The Theory and Practice of Massage and Exercise for Plantar Heel Pain

Original Editor - Merinda Rodseth based on the course by Bernice Saban


Top Contributors - Merinda Rodseth and Wanda van Niekerk  

Introduction[edit | edit source]

Manual therapy is commonly used by Physiotherapists for improving mobility and reducing pain.[1] Myofascial restrictions of the posterior calf muscles have been implicated in the development of plantar heel pain (PHP) as it interferes with the extensibility of the muscles and fascia, impeding optimal muscle functioning.[2][3] The manual therapy referred to in the “New Protocol” for Plantar Heel Pain Syndrome (PHPS) refers to Deep Friction massage therapy based on the teachings of Dr James Cyriax.[4]

The teachings of Dr Cyriax are based on three principles:[5]

  • All pain arises from a lesion
  • All treatment must reach the lesion
  • All treatment must have a beneficial effect on the lesion


The two attributes of muscles that enable them to function effectively include the ability to:[5]

  • contract - shorten and widen
  • relax - lengthen and narrow


Damage to the muscle during injury will result in disruption of both of these attributes and prevent optimal contraction (widening) and relaxation (lengthening). Following trauma where there is damage to the muscle which results in healing. Healing of the muscle tissue is through the means of scar tissue, which is less elastic and more fibrous than muscle tissue. Scar tissue is also prolific and attaches to the adjacent muscle fibres that are not damaged, causing pain and limited movement because of the adhesions between the muscle fibres.

Deep friction massage enables the separation of these adhesions to create movement in the tissues while simultaneously causing traumatic hyperaemia that stimulates blood supply and promotes healing (Figure 1).[5][6][7] The massage will support the muscle to contract and widen effectively as it breaks the adhesions between the muscle fibres limiting the contraction.

Effect of DTM.jpg

Figure 1. Impact of Deep Friction Massage and Exercise [5]


Shortening of the muscles and fascia are involved in the pathology of PHPS [2] and hence, the muscle fibres also need to lengthen which can be achieved through the disruption of adhesions as well as the use of stretches. Stretches have been shown as beneficial for patients with PHPS, but not as a stand-alone treatment as it only addresses one aspect of the muscle’s functioning - its ability to lengthen.[8] That is where the deep friction massage compliments its use, enabling the muscle to recover its ability to contract.

Deep Friction Massage of the Posterior Calf Muscles[edit | edit source]

Deep friction massage (DFM) was developed by Dr Cyriax as a technique to stimulate the regeneration process of the soft tissues.[9] DFM  involves passive mobilisation of the soft tissues to:[9]

  • enhance fibroblastic activity
  • break disorganised and dysfunctional adherences between collagen fibres
  • realign and elongate collagen fibres
  • decrease pain
  • re-establish blood supply

In order to maximise the effects of DFM it is necessary to adhere to the basic principles of application provided by Dr Cyriax (Figure 2).[5][6][9]

Technique of Deep Friction Massage.jpg

Figure 2. The Principles of Application of Deep Friction Massage [5]

The approach to the DFM of the posterior calf muscles should be systematic, ensuring that all the tight parts of the posterior calf muscles are identified and treated. One systematic approach is to start on the (Figure 3): [5]

  • Lateral side of the leg
    • place the thumbs on the lateral border of the lateral belly of the gastrocnemius muscle assessing for tightness not only in the superficial Gastrocnemius muscle but also the deeper muscles
    • Move fingers to the lateral border of the medial belly in the centre of the calf
  • Medial side of the leg
    • Place fingers on the medial border of the lateral belly
    • Move fingers to the medial border of the medial belly


Move down the length of the muscles on both sides of the leg, starting proximally at the popliteal fossa and moving distally to the sides of the Achilles Tendon in order to identify all the painful and incompliant areas. Treatment should be continued for at least 10 minutes.[5]

Approach to Deep Tissue Massage of Post Calf Mucles.jpg

Figure 3. Approach to the deep massage of the posterior calf muscles [5]

More force might be necessary for patients with exceptionally stiff or developed muscles. Start by using the fingers to locate the incompliant areas and continue to treat using the elbow in order to generate more force and penetrate at a sufficient depth (Figure 4).[5]

Deep tissue massage using elbow.jpg

Figure 4. Deep friction massage of the calf using the elbow [5]

Following the dry DFM, continue with: [5]

  • A massage with cream/oil to locate additional stiff areas
  • skin rolling


Massage is a safe technique that is widely used for the treatment of soft tissues. It is however important to keep some contraindications to massage in mind:[5][10]

  • Fever
  • Under the influence of alcohol or drugs, including prescription medication
  • Skin diseases/lesions
  • Contagious diseases
  • Unusual and undiagnosed lumps or bumps
  • Undiagnosed pain
  • Cuts
  • Sunburn
  • Varicose veins - it might be beneficial for venous return to work around the varicose veins but avoid working over the swollen veins themselves


Keep in mind the anatomy of the muscles of the posterior calf when considering DFM.[5]

Figure 5. Superficial Layer of the Posterior Calf Muscles

The superficial layer of the posterior calf (Figure 5):

Many of the superficial muscles also have a deeper portion where they are located behind those more superficial.

Figure 6. Deep Layer of the Posterior Calf Muscles

The deep muscles of the posterior calf (Figure 6):[5]

The deep muscles are continuous and go into the foot, but they bypass the heel and attach more distally to the foot.

Dysfunction in the plantarflexion muscles will have an impact on the antagonist muscles as well, creating an imbalance in functioning. Hence, even though not necessarily indicated in the initial treatment of PHPS, the eventual assessment and treatment of these antagonist muscles are necessary to enhance the optimal resolution of PHPS.[5] These muscles include the lateral muscles of the lower leg consisting of (Figure 7):

Lateral calf muscles.png

Figure 7. Lateral calf muscles

Treatment of these muscles can be performed with the patient in supine or in side-lying with a pillow between the legs. The fascia covering these muscles are also often very stiff and might necessitate increased pressure to reach the muscle tissue.

Figure 8. The Windlass Test

The discussion of the muscles of the posterior calf necessitates a discussion of the findings of the Windlass Test. As previously discussed, the Windlass Test:

  • Only identifies around 30% of individuals with PHPS [11], and is
  • Unable to support stress on the plantar fascia as a cause of PHPS


However, the symptoms experienced in some individuals with PHPS during the Windlass test might be explained by stress on the calf muscles, specifically the Flexor Hallucis Longus muscle considering the mechanics of the movement (Figure 8). Since patients are not all affected in all of the posterior calf muscles provides a possible theoretical explanation of why the Windlass test is not positive in all patients complaining of PHPS.


Exercises for Plantar Heel Pain[edit | edit source]

Exercise is an important aspect of managing any musculoskeletal injury as it involves the cooperation and involvement of the patient. From the research and discussions about PHPS, we know that:[5]

  • Stretch exercises are an effective treatment for PHPS, but not as a stand-alone treatment [8][12]
  • Many patients with PHPS are sedentary and would benefit from moving more [13][14]
  • Deep massage to the calf muscles have a positive effect on heel pain which implies dysfunction of the muscle [3]
  • Massage restores the ability of the muscle to contract (broaden/widen) [15]
  • Stretch exercises have the capacity to restore the length of the muscle
  • Strength and proprioception training need to also be included in order to restore the full function of the muscle
Figure 9. Lunge stretch


When considering exercises for PHPS, it is necessary to consider :

  • the muscles crossing the knee as well as the ankle, necessitating a long stretch of the calf, such as commonly used lunge exercise (Figure 9)
  • The muscles only crossing the ankle demanding  exercises with a bent knee
  • Including a variety of exercises in order to stretch the posterior calf muscles in various different ways


Exercises should include stretching into dorsiflexion in order to lengthen the posterior calf muscles (Figure 10) as well as into plantar flexion  (Figure 11) in order to lengthen the antagonists and restore full function to these muscles.[5]

Dorsiflexion Stretch Exercises.png

Figure 10. Dorsiflexion stretch exercises [5]

Plantar flexion stretches.png

Figure 11. Plantar flexion stretch exercises [5]

In order to restore full function to the foot, all aspects of muscle function should be considered and it is therefore also necessary to consider and incorporate:[5]

  • Mobility of the toes (Figure 12)
  • Lengthening of the short muscles of the foot (Figure 13)
  • Various rehabilitation exercises in order to restore athletes to their full function  (Figure 14)
  • Proprioception, as pain and inactivity negatively impacts the proprioception of the foot (Figure 14)


Stretches for toes.png

Figure 12. Toe mobility exercises [5]

Stretch of short muscles of foot.png

Figure 13. Stretch of plantar flexors and short muscles of the foot [5]

Rehab exercises.jpg

Figure 14. Rehabilitation and Proprioception exercises [5]

References[edit | edit source]

  1. Mischke JJ, Jayaseelan DJ, Sault JD, Emerson Kavchak AJ. The symptomatic and functional effects of manual physical therapy on plantar heel pain: a systematic review. Journal of Manual & Manipulative Therapy. 2017 Jan 1;25(1):3-10.
  2. 2.0 2.1 Pollack Y, Shashua A, Kalichman L. Manual therapy for plantar heel pain. The Foot. 2018 Mar 1;34:11-6.
  3. 3.0 3.1 Saban B, Deutscher D, Ziv T. Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial. Manual therapy. 2014 Apr 1;19(2):102-8.
  4. Cyriax J. Textbook of Orthopaedic Medicine - Volume 1. 8th Edition. London: Bailliere Tendal; 1982.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 5.23 Bernice Saban. The Theory and Practice of Massage and Exercise for Plantar Heel Pain. Physioplus Course. 2021
  6. 6.0 6.1 Chaves P, Simões D, Paço M, Pinho F, Duarte JA, Ribeiro F. Pressure Applied during Deep Friction Massage: Characterization and Relationship with Time of Onset of Analgesia. Applied Sciences. 2020 Jan;10(8):2705.   
  7. Farooq N, Aslam S, Bashir N, Awan WA, Shah M, Irshad A. Effectiveness of transverse friction massage of Flexor digitorum brevis and Calf muscle stretching in Plantar fasciitis on foot function index scale: A randomized control trial. Isra Med J. 2019;11(4):305-9. 
  8. 8.0 8.1 Katzap Y, Haidukov M, Berland OM, Itzhak RB, Kalichman L. Additive effect of therapeutic ultrasound in the treatment of plantar fasciitis: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2018 Nov;48(11):847-55.     
  9. 9.0 9.1 9.2 Chaves P, Simoes D, Paco M, Pinho F, Duarte JA, Ribeiro F. Cyriax's deep friction massage application parameters: Evidence from a cross-sectional study with physiotherapists. Musculoskeletal Science and Practice. 2017 Dec 1;32:92-7.
  10. Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. British journal of sports medicine. 2004 Dec 1;38(6):675-7.
  11. De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot & ankle international. 2003 Mar;24(3):251-5.
  12. Sweeting D, Parish B, Hooper L, Chester R. The effectiveness of manual stretching in the treatment of plantar heel pain: a systematic review. Journal of foot and ankle research. 2011 Dec;4(1):1-3.
  13. Thomas MJ, Whittle R, Menz HB, Rathod-Mistry T, Marshall M, Roddy E. Plantar heel pain in middle-aged and older adults: population prevalence, associations with health status and lifestyle factors, and frequency of healthcare use. BMC musculoskeletal disorders. 2019 Dec;20(1):1-8. DOI:10.1186/s12891-019-2718-6
  14. Riel H, Cotchett M, Delahunt E, Rathleff MS, Vicenzino B, Weir A, Landorf KB. Is ‘plantar heel pain’ a more appropriate term than ‘plantar fasciitis’? Time to move on. Br J Sports Med. 2017; 15(22):1576-1577.
  15. Chamberlain GJ. Cyriax's friction massage: a review. Journal of Orthopaedic & Sports Physical Therapy. 1982 Jul 1;4(1):16-22.