Take a Stand Against Plantar Fasciitis

By Whitney Lowe

Many occupations require people to be on their feet throughout the day. Consider, for example, airline workers, assembly line workers, cashiers, cooks, soldiers, store clerks, and waitresses. These are just a few occupations where the primary tasks require workers to place enormous stress and strain on their feet. 

One of the most perplexing, painful, and disabling conditions of the feet is plantar fasciitis. This elusive condition confounds even the most experienced health-care provider. Fortunately, new ideas and research regarding condition etiology and emerging treatment concepts are quite promising, and both the practitioner and the client will benefit. 

Key Biomechanical Aspects

Newton’s third law—for every action there is an equal and opposite reaction—is a fundamental component of many soft-tissue injuries. Gravity exerts a continual downward force on the body that we experience as our weight. A 160-pound person exerts 160 pounds of force on the ground when in a standing position. However, the “equal and opposite reaction” law predicts that there will be a similar force exerted on the body from the ground pressing against the body, which is referred to as the ground reaction force. This force is magnified when walking or running; it is estimated that, when running, 3–4 times the body weight is experienced with each foot strike.

This force is absorbed through the structural design of the body, particularly the joints and the flexible, pliable, soft-tissue, shock-absorbing structures. Foot pain and other cumulative trauma disorders can result when this force is not properly mitigated. Often, there are biomechanical causes, such as poor posture, gait issues, or even footwear.

The foot and ankle complex is structurally designed to help mitigate daily impacts. The longitudinal arch of the foot acts like a curved archway to spread compressive loads across the base of the foot (Image 1). The plantar fascia acts like a spring, with the ends of the arch tethered at the heel and ball of the foot. That means there is a strong tensile load, caused by body weight, pulling on the two ends of the plantar fascia. 

The plantar fascia is a narrow band at the anterior calcaneal attachment, but broadens under the arch and then splits into several attachment sites on the metacarpal joints. Long periods of static load or high tensile forces can lead to chronic overload of this connective-tissue structure. Inflammation at the calcaneal attachment is thought to result. 

Inflammation or Not?

Plantar fasciitis has traditionally been treated as an inflammatory problem, with the primary focus being the attachment site into the anterior calcaneus. However, new research indicates that inflammation may not be as much of a problem as previously thought. There has been a paradigm shift in the understanding of tendon-overuse disorders in recent years. Research shows that tendon problems traditionally thought of as inflammatory (i.e., tendinitis; “itis” refers to inflammation) appear to result from collagen degeneration instead (i.e., tendinosis, which refers to pathology of the tendon). 

In 2003, a podiatrist named Harvey Lemont reviewed specimens of plantar fascia from patients who had undergone surgery for the condition.1 He found no evidence of inflammatory activity in any of these specimens. What he did find was widespread evidence of chronic degeneration and necrotic tissue in the plantar fascia. 

Since the tissue samples came from those with severe plantar fasciitis, there is still a question as to whether inflammation is a factor in early onset of the condition. However, cortisone injection treatments generally do not last and only provide short-term relief, which indicates that, at least for those with chronic conditions, inflammation may not be a persistent factor.2 

New Concepts in Etiology

Ray McClanahan, DPM, a podiatrist in Portland, Oregon, suggests that the primary problem in plantar fasciitis is biomechanical dysfunction in the foot—along with footwear that impedes natural function. This leads to improper circulation, chronic tissue overload, and the resultant degenerative process that produces plantar foot pain and plantar fasciosis (heel pain).3

Restricted blood flow to the tissue caused by wearing improper shoes is a key issue, according to McClanahan. He points to the common narrow toe box that bunches the toes together, the often seen “toe spring” that raises the hallux and toes into extension, and the elevated heels found in most shoes. Unfortunately, the vast majority of shoes people wear today contain these elements. 

Tightness and/or spasm in the abductor hallucis muscle is another key issue, as this muscle can pull on the flexor retinaculum and decrease blood flow to the plantar fascia, leading to tissue necrosis and dysfunction.4 The abductor hallucis muscle is located on the medial side of the foot. The medial plantar artery passes under the abductor hallucis muscle before supplying blood to structures on the bottom surface of the foot, including the plantar fascia (Image 2). 

McClanahan’s points are well taken. One of his tests is quite insightful: pull the insole out of your shoe and stand barefoot on it. It is remarkable how much the natural foot simply does not fit today’s narrow styles, even in athletic footwear. Of course, years ago there were more options for narrow, medium, and wide shoes. 

Benny Vaughn, an expert in the massage profession and an athletic trainer who has worked with a diverse abundance of sports professionals for 40 years, points to problems along the entire chain of the vastly complex fascial connections of the lower body that he believes also lead to plantar fasciitis. What is apparent to Vaughn is that the condition is not confined to the bottom surface of the foot and calf.

Vaughn’s conclusions and treatment successes make sense. There are fascial connections extending from the bottom surface of the foot through the posterior calf and thigh region that continue up the back and neck to the head. Thomas Myers identified these interconnections as the superficial back line and illustrates and describes these in his work.5 Tensile forces generated in tissues anywhere along this path can adversely affect the tensile load on the plantar fascia. Consequently, plantar fasciosis can routinely be linked to dysfunctional biomechanical patterns during gait, upper-body muscle tension from long static loads, or biomechanical imbalance in other portions of this kinetic chain. 

Treatment Strategies

Due to complex biomechanical relationships, it is important to keep in mind that no single intervention is likely to be effective on its own. A variety of treatment approaches is most beneficial. Also, the various treatments do not work for everyone; treatment should be tailored to the specific needs of the client. 

Traditional treatments for plantar fasciitis include: biomechanical remedies for improper gait or foot function, Botox injections, changes in footwear, extracorporeal shockwave therapy, ice for pain, medications and cortisone shots, orthotics, physical therapy, particular stretching regimens, and rest from offending activities. Acupuncture also shows positive results, and naturopathy can cover overall health issues that may be impeding tissue healing. 

The importance of proper shoes should not be underemphasized. Traditional treatments focus on supporting the arches with orthotics or shoes with greater support. They also call for shoes with hard insoles. If there is a blood-flow issue, however, these treatments seem contraindicated. An arch support could potentially shorten or bowstring the abductor hallucis muscle, compressing the tissues and thus the medial plantar artery, and lead to further problems with blood flow. It is highly recommended that sufferers change to shoes with a wide toe box and a relatively level heel and forefoot position to decrease stress on the affected structures. 

Another type of treatment that needs more consideration is soft-tissue therapy applications—but not just to the foot. Because the fascial connection pathway of the superficial back line extends from the cranium down to the bottom of the foot, soft-tissue treatment methods need to focus on all of these regions. Vaughn has found the most benefit in treating plantar fascia problems by performing soft-tissue therapy on all of the muscles along the superficial back line— from the foot all the way through the neck. 

In addition to specifically targeted massage treatments, such as active engagement methods, Vaughn finds fascial mobilization methods using tools, such as the gua sha technique, to be highly effective. This same approach has been popularized in the chiropractic profession under the name Graston Technique, which uses specially shaped tools to perform scraping movements on the skin and superficial fascia and encourage full fascial mobility. (Special training is required for proper use of these tools and techniques. See Massage & Bodywork, November/December 2012, “Smooth Movement,” page 94.) 

Vaughn also points out that the hip rotator and abductor muscles play a major role in proper gait mechanics that can result in plantar foot pain when they are not functioning properly. Therefore, soft-tissue treatment and stretching methods should include the deep lateral hip rotators like the piriformis, as well as the gluteus medius and minimus, which function during medial hip rotation and abduction.

The soft tissues that have received the most attention in terms of stretching protocols are those contained in the superficial and deep posterior compartments. Massage to these muscles can also be very effective in releasing tightness. One of the best ways to encourage pliability and mobility in these tissues is to perform movement simultaneous with the soft-tissue treatment methods. This is done most effectively with active engagement techniques. 

An effective method for addressing the superficial posterior compartment (gastrocnemius and soleus) is to have the client actively plantarflex and dorsiflex the foot. During dorsiflexion, as the muscles are elongating, perform a deep and specific stripping technique on those posterior compartment muscles (Image 3). You can enhance the effectiveness of this technique by adding additional resistance to the muscle as you perform the stripping technique. Resistance is added in a way that has the muscle working eccentrically and elongating as the stripping technique is performed. Use one hand on the bottom surface of the client’s foot to push the foot into dorsiflexion, while the other hand applies a long stripping technique to the posterior calf muscles. 

A similar approach can be used in addressing the deep posterior compartment muscles: tibialis posterior, flexor hallucis longus, and flexor digitorum longus (Image 4). You can use the same methods of adding eccentric resistance to the muscle by pressing on the plantar surface of the foot as you slowly push the client’s foot into dorsiflexion (while the client slowly resists that movement). Apply a deep stripping technique along the posterior tibial border during this movement to reach the deep posterior compartment muscles. 

While it appears that massage focused solely on the plantar fascia has limited effectiveness, plantar foot work should not be completely ignored. As mentioned earlier, the abductor hallucis muscle may play a prominent role in reducing tightness, and deep longitudinal stripping methods applied along the medial surface of the foot may be very beneficial. In addition, general treatment of the foot may be beneficial for encouraging blood flow, helping to reduce tightness in the intrinsic foot muscles and providing pain relief. 

Managing the static and distributed loads on all these structures is essential for reducing chronic overload and debilitating foot pain. Massage therapy is a treatment that naturally focuses on numerous connections between different regions of the body. It is a highly beneficial approach that should be integrated into any treatment plan for plantar fasciitis. 



1. H. Lemont et al., “Plantar Fasciitis: A Degenerative Process (Fasciosis) Without Inflammation,” Journal of the American Podiatric Medicine Association 93, no. 3 (2003): 234–7.

2. Y. Z. Tatli and S. Kapasi, “The Real Risks of Steroid Injection for Plantar Fasciitis, with a Review of Conservative Therapies,” Current Reviews in Musculoskeletal Medicine 2, no. 1 (2009): 3–9. 

3. G. Ingram and R. McClanahan, “Treatment of Plantar Fasciosis,” Naturopathic Doctor News and Review (March 2007): 8–9; accessed June 2013, http://quoindesign.com/nwfootankle/FasciosisTreatment.pdf.

4. Northwest Foot and Ankle, “Plantar Fasciosis,” accessed June 2013, https://nwfootankle.com/foot-health/drill/3-Problems/31-Plantar%20Fasciosis.

5. T. Myers, Anatomy Trains (Edinburgh: Churchill Livingstone, 2001).

Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. You can find more plantar fascia treatment ideas in Lowe’s next free enewsletter—and his books, course offerings, and DVDs—at www.omeri.com. 

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