Plantar Fasciitis and Stretching, by Dr. Perry Julien, DPM, courtesy of FootFlex¹
TREATMENT OF PLANTAR FASCIITIS WITH TRICEPS SURAE STRETCHING
Robert M. Goecker, DPM
Perry H. Julien, DPM
The clinical condition known as plantar fasciitis is characterized by pain and inflammation secondary to strain on the intrinsic musculature and plantar fascia at their origin from the medial calcaneal tubercle. The classic physical examination finding is point tenderness at the anterior edge of the fascial attachment to the medial calcaneal tubercle. This usually coincides with a history of pain upon rising in the morning, pain after periods of non-weight bearing or pain after prolonged weight bearing. Several potential etiologies of heel pain exist which are beyond the scope of this paper. The primary etiology of heel pain relevant to this paper are biomechanical abnormalities of the foot which lead to increased strain on the tissues that originate from the medial calcaneal tubercle.
The plantar fascia, or aponeurosis, is composed of central, lateral, and medial bands that originate along the medial tubercle of the calcaneus. The plantar fascia courses anteriorly along the arch of the foot, where the fascia divides into slips which eventually insert into the sides of the proximal phalanx in each toe. At toe-off, hyperextension of the metatarsophalangeal joints results in tightening of the plantar fascia and assists with resupination of the foot. The plantar fascia functions through the windlass mechanism to depress the metatarsal heads and elevate and stabilize the longitudinal arch of the foot during gait. Therefore, with every step from heel rise to toe-off the plantar fascia is placed under tension.1 In some patients, the tension within this structure can become debilitating.
Multiple treatments have been recommended with various degrees of success for plantar fasciitis. Conservative modalities used to treat plantar fasciitis have included heel pads, orthotics, padding, strapping, stretching, physical therapy, non-weight bearing, NSAIDís, corticosteroid injections, etc. The majority of patients will improve or be fully relieved by nonsurgical treatment. However, even with appropriate treatment, plantar fasciitis may become chronic and recalcitrant in nature eventually leading to surgery. There is no definitive surgical treatment of recalcitrant plantar fasciitis that is without complications. Therefore, a continued search for an effective conservative modality useful in the treatment of plantar fasciitis exists. In today's healthcare environment there is a tendency towards active mobilization and rehabilitation. A review of recent literature has shown an increase use of aggressive stretching of the gastrosoleal complex for the treatment of plantar fasciitis.
Articles documenting the outcomes of nonoperative treatment of plantar fasciitis have for the most part shown excellent results.2-4 However, there is no panacea in the treatment of plantar fasciitis.
One of the easiest and most cost-effective conservative modalities in the treatment of this condition is stretching. It is well accepted that an important contributing factor of plantar fasciitis is equinus.5, 6 Tightness within the Achilles tendon and gastrosoleal complex results in compensatory increased dorsiflexion of the first metatarsophalangeal joint during gait. Dorsiflexion of the first metatarsophalangeal joint via the windlass effect stretches the plantar fascia at its insertion. If the foot fails to resupinate at toe-off, increased strain is placed on the plantar fascia due to the windlass effect. Equinus has also been linked to an increased amount of pronation of the foot which causes prolonged eversion of the calcaneus during gait resulting in pathologic stretching of the plantar fascia. Therefore, it would only make sense that decreasing the tightness within the triceps surae would eventually have a positive effect on the plantar heel pain.
Davis et al in a review of 105 patients with 132 symptomatic heels noted an 89.5% success rate of nonoperative treatment for plantar fasciitis. Their treatment protocol consisted of nonsteroidal anti-inflammatory medications, relative rest, viscoelastic heel cushions, calf muscle stretching exercises and occasionally, injections. The patients reviewed in this study indicated that the stretching program was the most helpful treatment prescribed.2
A prospective randomized trail of several nonoperative treatments of proximal plantar fasciitis revealed a 72% success rate in those patients who underwent stretching exercises only (control group).3 The stretching program utilized in this study effectively targeted both the gastrocnemius and the soleus muscles. Although the percent improvement of some of the other groups with additional foot support was higher, the degree of improvement with stretching alone is impressive. Other authors have also advocated stretching. 4,7-13
Several recent reports have shown excellent success with the use of tension night splints in the treatment of plantar fasciitis.8-13 Overall, the success of night splints in the treatment of plantar fasciitis has ranged from approximately 80% to 90%.8-13Night splints maintain a constant, consistent stretch on the Achilles tendon and plantar fascia. When you think about it, both night splints and stretching are attempting to accomplish the same net result utilizing different means.
Stretching of tight soft tissues can be supported by the physical property of creep. Creep is plastic deformation in response to strain. Consistent stretching of the gastrosoleal complex applies an important strain to the tight posterior muscle/tendon group, which not only maintains functional length but also eventually provides a net gain in length due to soft tissue remodeling laws.14
These soft tissue adaptation laws are the reason that stretching is beneficial. Stretching the triceps surae over a period of time results in a decreased tightness within the gastrosoleal complex. This avoids the many deleterious effects of equinus during the gait cycle. In a large percentage of cases, pronation secondary to equinus is at the root of chronic heel pain. With equinus, the foot attempts to compensate for the lack of ankle joint dorsiflexion just before heel lift, by subtalar and midtarsal joint pronation. During pronatory gait, every step leads to an unstable forefoot because of unlocking of the midtarsal joint.5 In an effort to compensate for this instability, greater intrinsic muscle activity is required to stabilize the foot, resulting in excessive stress on the intrinsic muscular origins from the calcaneus inferiorly and particularly the medial tubercle of the calcaneus, leading to inflammation.15 Pronation also results in abnormal and prolonged eversion of the calcaneus leading to flattening of the medial longitudinal arch which increases the strain within the plantar fascia.6 Continued strain and increased stress to the plantar fascia and intrinsic musculature leads to the enthesopathy. This is sometimes radiographically evidenced as an inferior calcaneal spur of various sizes. When the local subclinical irritation secondary to faulty biomechanics exceeds a certain point then inflammation and pain begin.
Many patients will try almost any conservative regimen in an effort to avoid surgery. The authors utilize an aggressive stretching program in the treatment of plantar fasciitis. A few positional modifications during stretching have added to our patients success. It is very important to avoid pronation during calf stretching because of the resultant compensatory mechanism of an unlocked midtarsal joint that destabilizes the foot decreasing the effectiveness of the stretch and possibly increasing the strain on the plantar fascia. Therefore, the authors have instructed their patients to stretch their calf muscles with a traditional wall stretch holding the foot in a slightly supinated position. Recently, a prefabricated device (FootFlex P.S.D.) available on the market helps accomplish this position during stretching by utilizing the windlass mechanism. This device dorsiflexes the hallux which places the plantar fascia under tension elevating the arch of the foot into a more supinated position. Stretching with foot in proper biomechanical alignment allows a more effective stretch of the gastrosoleal complex and at the same time also is gradually stretching the plantar fascia. This effectively stretches both the triceps surae and the plantar fascia at the same time. There is no study, to our knowledge, documenting the effectiveness of this modification of traditional stretching exercises. Success noted at this time is purely anecdotal. However, stretching has been shown to be helpful in reducing the symptomatology of plantar fasciitis, and, the authors believe an even higher percentage of success could be achieved with proper foot positioning during stretching. A prospective outcome study comparing the two different stretching modalities would help determine the efficacy of this type of stretching in the treatment of plantar fasciitis.
Recent literature has shown stretching to be an effective adjunctive therapy in the treatment of plantar fasciitis. A review of the literature and theories behind stretching are presented. A stretching program of the gastrocnemius and soleus should be considered a cornerstone of any effective treatment plan.
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¹ FootFlex is a stretching device for plantar fasciitis, shin splints, heel pain, and much more.