Over the past few weeks, I have reviewed some interesting articles on running.  While this article is not specifically on running, its subject matter is very near and dear to running.  Pain on the bottom of the foot.

This week I am going to review an article about plantar heel pain.  Plantar heel pain is very similar to plantar fasciitis.  What is the difference?  If you have pain on the plantar surface, i.e. the bottom, of your foot and it is in the heel that is plantar heel pain.   If you have plantar heel pain and you see a medical professional and they can diagnosis that plantar heel pain as plantar fasciitis.  However, plantar heel pain does not always equal plantar fasciitis!  In this article plantar fasciitis = plantar heel pain.  

The article is titled: Effectiveness of myofascial release in the management of plantar heel pain: A randomized controlled trial.  If you click on the title you will be taken to a page where you can read the abstract.  

 

Did you know that up to 10% of the general population may be affected by plantar heel pain (PHP) over their lifetime.  There is limited evidence for a number of management techniques of PHP including corticosteroid therapy, shockwave therapy and no evidence for low level laser therapy or therapeutic ultrasound.

 

Picture of the bottom of the foot. This shows the plantar fascia attaching at the heel coming up from the mid foot and attaching on the bases of the toes. The plantar fascia is surrounded by many different muscles

Plantar fascia on the bottom of the foot, the ‘white stuff’.
from: myhealth.alberta.ca

Myofascial release was defined as “… application of a low load, long duration stretch to the myofascial complex, intended to restore optimal length, decrease pain and improve function”.  

The authors want to see the effect of myofascial release on pressure pain threshold, pain and disability on people with PHP compared to a sham ultrasound control group.  The myofascial release was done specifically on the gastrocnemius, soleus and plantar fascia.     

There were inclusion and exclusion criteria listed.  This is a list of what limits the participants into the study.  It also gives reason to limit people, that are not appropriate, from entering the study.  The criteria set out by this group of researchers made sense, I thought.  

The intervention was provided 3 x/week for 4 weeks with a minimum of one day gap between sessions.  

 

The client has their foot hanging over the end of the bed, the knee is straight, and the therapist is using their elbow pushing into the calf muscle, in a superior direction.

Technique #1 for gastrconemius, superior direction of force. Client’s knee is straight
from: www.numss.com

Here was part of this paper that I really liked.  They actually described the myofascial release techniques that they used in the study.  Many studies, too many studies, I think, simply say that they are going to use this technique or that technique and that is it.  Not in this paper, no siree Bob!  They get right into the myofascial techniques.  In fact, three techniques were used on the gastrocnemius, one using a line of tension in the superior direction, one in the inferior direction (back of the knee) and another inferior technique around the Achilles onto the calcaneus.  There was one technique description for the soleus technique, similar to technique one for gastrocnemius but the knee is bent.  All of the above mentioned techniques were done with the client actively dorsiflexing and relaxing their foot as the techniques were being applied.  The technique for the plantar fascia was done just anterior of the calcaneus and the client’s toes were actively flexed and extended.  

The client has their foot hanging over the end of the bed, the knee is bent, and the therapist is using their elbow pushing into the calf muscle, in a superior direction.

Technique for soleus, superior direction of force. Client’s knee is bent.
from: www.numss.com

There were 66 people recruited for the study and 65 completed it.  That is great as dropout rates are concerned.  There were 32 people in the control group and 33 in the myofascial release group.  

 

What were the results…

 

“…the [myofascial release] intervention tested in this trial was significantly more effective than [sham ultrasound] over the pain, functional disability and pressure pain threshold of PHP”.  

 

They were unsure of the exact mechanism of how the PHP decreased with the myofascial release.  It was thought that possibly that ankle dorsiflexion was less restricted with the release of the two calf muscles.  

There were limitations in the study, for example, they did not know which myofascial technique, the gastrocnemius, soleus or plantar fascia brought on the improvement.  

 

Left = superficial gastrocnemius Right = deeper layer with gastrocnemius removed, we see the soleus and plantaris muscles

Left = superficial gastrocnemius
Right = deeper layer with gastrocnemius removed, we see the soleus muscle
from: www.personaleuphoria.com

I have my own thoughts on why these results may have occurred.  On the calcaneus, heel bone, the Achilles tendon attaches in the back and the plantar fascia attaches to the front of the bone.  If the Achilles tendon is tight, the Achilles tendon is made of the gastrocnemius, soleus and plantaris muscles, this rotates the heel bone downwards.  This slight downward rotation puts extra tension on the plantar fascia.  With this extra tension being placed on the plantar fascia all the time, it is easier for it to start to break down.  Or if you add more tension, starting running, or running for longer periods of time, that may start the further breakdown of the plantar fascia, leading to plantar fasciitis.

 

However, if you use a myofascial release technique on the musculature that turn into the Achilles tendon, then the calcaneus does not have extra pull on the plantar fascia.  This gives the plantar fascia some time to start to heal itself, instead of always being under tension.  

 

What practical tip does this give you, if you are seeing a medical professional for treatment of your plantar fasciitis?  If the medical professional is using ultrasound to treat it.  Tell them to stop it as there is NO evidence to support the use of ultrasound for this condition.  You might want to even start shopping around for a new medical professional…

In the next session, I will be reviewing a similar article on the treatment of plantar fasciitis and after that, I will write up a case study on a client of mine that had plantar fasciitis for a long time, a number of years and not find any relief until this mobile Kelowna physiotherapy service, came to his house and worked with him one-on-one.