Before we can discuss the potential of Thai Massage in relieving the discomfort of plantar fasciitis, we first need to discuss what it actually is. Unfortunately it is still a rather poorly understood condition, at least in terms of a strict understanding of its pathophysiology and a replicable mechanism for its development.
What Is Plantar Fasciitis?
What we do know is that it can be quite a painful condition that is usually felt towards the heel on the sole of the foot. Whilst heel spurs can commonly accompany it, they don’t always, and whilst it can definitely be seen more often in people with sedentary lifestyles it also isn’t always the case and in fact running (particularly on hard surfaces) is included as a risk factor for its development.
A Case of Mistaken Identity
From a more detailed examination of the condition (microscopy and ultrasonography) researchers have realized that in fact, what most people have shouldn’t even really be called fasciitis – it should instead be called fasciosis! (reference) We once believed it to be primarily an inflammatory condition, but we now understand that the pain present in a typically diagnosed case of plantar ‘fasciitis’ is more likely due to micro-tears and structural degeneration of the fascia, as opposed to the inflammatory process, because by the time most people seek assistance, there are no inflammatory mediators present within the area. [Clarification]: this doesn’t mean that plantar fasciitis isn’t a thing – it is – it’s just rarely what people truly have.
Some Proposed Pathophysiology Behind It:
When we think of the body as an integrated system of movement and tensional chains it helps us to think a little more holistically about the potential causes of plantar fasciitis/fasciosis. If we think about the pathophysiology of heel spurs which are in the same area and have some degree of association with plantar fasciosis, we see that bone is reformed in response to the stresses we place on the bone. In this instance there is an imbalanced force being loaded on the calcaneus with greater tension being applied to the plantar fascia attachment site, as opposed to the Achilles tendon attachment site, which is part of the posterior kinetic/fascial chain. In general, when one area of the body is tight we have that tension also passed around through our body in an effort to distribute it more evenly.
So with that in mind, the imbalanced tension found in the plantar fascia may actually be sourced from (or at very least influenced by) tension further up the posterior kinetic chain. This broadens the possibilities of what might actually be causing the issue, as there are many more structures involved than the immediately painful areas.
Additionally, when function of the intrinsic muscles of the foot is poor, we see additional collection of extra tension. So we do also need to keep an eye focused “locally” on the intrinsic muscles of the feet, albeit with a different lens.
What Does This Mean For Treatment?
In a treatment setting, what does this mean and what can we expect from someone with plantar fasciits/fasciosis? It generally means that structures such as the soleus, hamstrings and multifidi are tight and restricted. One of our first tasks in working with individuals with this condition should be a movement assessment to test exactly whether such an assumption holds true for them. If you’re reading this at home and you have plantar fasciitis/fasciosis stand with your legs straight (no bend in the knee at all) and fold forward from your hips – is that really uncomfortable/restricted?
For the manual therapists out there
If it does hold true, then we can start to structure a treatment plan that focuses heavily on lengthening and alleviating tension in the posterior chain of the body. Our work then should include heavier focus on movements that position our patients in hip and spinal flexion, knee extension and ankle dorsiflexion. So again for anyone at home who isn’t a practitioner of massage, you should know that you’ve got more work to do than simply loosening the connective tissue in your foot – you need to focus on a number of muscles that go up the back of your legs and into the back. This should be a point of focus in movement and strength practices as well.
Knowing also that inflammation is not a prominent feature as we once thought, we can and should work directly with the plantar connective tissues, with pain-free and gradual applications of massage pressure. Historically we may have avoided the area due to the concern of increasing the inflammatory response and inducing more discomfort. Enhancing the blood flow may indeed increase the amount of inflammatory factors present in the area, however when done slowly this is actually beneficial for the healing process.
A complete Thai Massage treatment with focus directed to the entire posterior chain will assist in the release of tension from a fascial chain that clearly has too much tension present. It therefore has the potential to help alleviate plantar fasciitis/fasciosis. And a complete treatment plan also would include self-massage and strength-work at home in order to speed up recovery. If you are experiencing plantar fasciitis/fasciosis, make sure you not only seek treatment, but that you remain dedicated to your homework exercises!
For the manual therapists reading this, we need to keep in mind is that it is outside our scope of practice to diagnose, and so a qualified medical professional must first identify any cases of plantar fasciitis/fasciosis before we can utilize the above notes for treatment and technique considerations.
Take good care of each other,
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Last Updated: April 25, 2019.