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

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Top Contributors - Merinda Rodseth, Kim Jackson, Wanda van Niekerk, Jess Bell and Ewa Jaraczewska  

Introduction

This lecture investigates manual therapy - the practical side for the treatment of Plantar Heel Pain Syndrome (PHPS). Manual Therapy for PHPS refers to deep friction massage therapy and the massage techniques used in this unit are based on the teachings of Dr James Cyriax.

The teachings of Cyriax are based on three principles:(Saban 2021)

• 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:(Saban 2021)

• 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) (Chaves 2020, Saban 2021, Farooz 2019). The massage will support the muscle to contract and widen effectively as it breaks the adhesions between the muscle fibres limiting the contraction.

Figure 1

Shortening of the muscles and fascia are involved in the pathology of PHPS  (Pollack 2017) 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 standalone treatment as it only addresses one aspect of the muscle’s functioning - its ability to lengthen (Katzap 2018). 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

Deep friction massage was developed by Dr Cyriax as a technique to stimulate the regeneration process of the soft tissues (Chaves 2017). DFM  involves passive mobilisation of the soft tissues to:

• enhance fibroblastic activity
• break disorganised and dysfunctional ahderences between collagen fibres
• realign and elongate collagen fibres
• decrease pain
• re-establish blood supply (Chaves 2017).

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) (Chaves 2020, Chaves 2017, Saban 2021).

Figure 2. The technique of Deep Friction Massage (Saban 2021)

The approach to the DTM 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): (Saban 2021)

• 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 (Saban 2021).

Figure 3. Approach to the deep massage of the posterior calf muscles (Saban 2021)

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) (Saban 2021).

Figure 4. Deep tissue massage of the calf using the elbow (Saban 2021)

Following the dry deep tissue massage, continue with: (Saban 2021)

• 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:(Saban 2021, Stasinopoulos 2004)

• 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 deep tissue massage:(Saban 2021)

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

• Medial and lateral heads of the Gastrocnemius muscle
• Plantaris (with its belly crossing the popliteal fossa)
• Popliteus
• Soleus
• Peroneus Longus
• Flexor Digitorum longus
• Tibialis Posterior
• Flexor Hallucis Longus

Figure 5. Superficial Layer of the Posterior Calf Muscles

Many of the superficial muscles also have a deeper portion where they are located behind those more superficial. The deep muscles of the posterior calf include (Figure 6):(Saban 2021)

• Semimembranosus tendon
• Tendon of Biceps Femoris
• Popliteus
• Tibialis Posterior
• Flexor Hallucis Longus
• Flexor Digitorum Longus
• Peroneus Brevis
• Peroneus Longus

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

Figure 6. Deep Layer of the Posterior Calf Muscles

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. (Saban 2021) These muscles include the lateral muscles of the lower leg consisting of (Figure 7):

• Peroneus Longus
• Peroneus Brevis
• Peroneus Tertius

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.

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 (De Garceau 2003), 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.

Figure 8. Windlass Test

Exercises for Plantar Heel Pain

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:(Saban 2021)

• Stretch exercises are an effective treatment for PHPS, but not as a stand-alone treatment (Katzap 2018, Sweeting 2011)
• Many patients with PHPS are sedentary and would benefit from moving more (Thomas 2019, Riel 2017)
• Deep massage to the calf muscles have a positive effect on heel pain which implies a dysfunction of the mucle (Saban 2014)
• Massage restores the ability of the muscle to contract (broaden/widen) (Chamberlain 1982)
• 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

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

Figure 9. Lunge stretch

Exercises should include stretching into dorsiflexion in order to lengthen the posterior calf muscles (Figure 10) as well as into plantarflexion  (Figure 11) in order to lengthen the antagonists and restore full function to these muscles. (Saban 2021)

Figure 10. Dorsiflexion stretch exercises

Figure 11. Plantarflexion stretch exercises

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: (Saban 2021)

• 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)

Figure 12. Toe mobility exercises

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

Figure 14. Rehabilitation and Proprioception exercises

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