Show Notes:

24: Whitney and Til share a treasure chest of foot-pain ideas and techniques, packed full of assessments, anatomy, concepts, and hands-on tools. Download the free (optional) handout and follow along as Til and Whitney give an audio preview of their upcoming Plantar Foot Pain collaborative webinar (part of the ABMP CE Summit). 

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Resources discussed in this episode: 

Episode image from Advanced Myofascial Technique Vol 1, under license from Primal Pictures. 

References:

  • Insert comparisons: Bonanno, Daniel R., Karl B. Landorf, and Hylton B. Menz. 2011. “Pressure-Relieving Properties of Various Shoe Inserts in Older People with Plantar Heel Pain.” Gait & Posture 33 (3): 385–89. https://doi.org/10.1016/j.gaitpost.2010.12.009.
  • Slow heel raises vs stretching: Rathleff, M. S., C. M. Mølgaard, U. Fredberg, S. Kaalund, K. B. Andersen, T. T. Jensen, S. Aaskov, and J. L. Olesen. 2015. “High-Load Strength Training Improves Outcome in Patients with Plantar Fasciitis: A Randomized Controlled Trial with 12-Month Follow-up: HL Strength Training and Plantar Fasciitis.” Scandinavian Journal of Medicine & Science in Sports 25 (3): e292–300. https://doi.org/10.1111/sms.12313.
  • Arch height and other biomechanical factors: Warren, B. L. 1984. “Anatomical Factors Associated with Predicting Plantar Fasciitis in Long-Distance Runners.” Medicine and Science in Sports and Exercise 16 (1): 60–63.
  • Plantar fascia core/sheath anatomy: Zhang, Jianying, Daibang Nie, Jorge L. Rocha, MaCalus V. Hogan, and James H.-C. Wang. 2018. “Characterization of the Structure, Cells, and Cellular Mechanobiological Response of Human Plantar Fascia:” Journal of Tissue Engineering, October. https://doi.org/10.1177/2041731418801103.

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Your Hosts:

Til Luchau Advanced-Trainings        whitney lowe
Til Luchau                          Whitney Lowe

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Your Hosts:

Til Luchau Advanced-Trainings
Til Luchau

whitney lowe
Whitney Lowe

Thanks for listening and subscribing to the podcast! Make sure to connect with us on Twitter, Instagram and Facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

(The Thinking Practitioner Podcast is intended for professional practitioners of manual and movement therapies: bodywork, massage therapy, structural integration, chiropractic, myofascial and myotherapy, orthopedic, sports massage, physical therapy, osteopathy, yoga, strength and conditioning, and similar professions. It is not medical or treatment advice.)

Full Transcript:

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The Thinking Practitioner Podcast:
Episode 24: Plantar Foot Pain Crash Course

Broadcast date: 9/30/2020
©Copyright The Thinking Practitioner Podcast, Til Luchau & Whitney Lowe

Til Luchau:

Hey, Whitney. I'm looking forward to our conversation today, as always. We're focusing on plantar foot pain, and we're trying something different today. What are we up to?

Whitney Lowe:

Yeah, we're doing an interesting experiment today. This is, of course, our Thinking Practitioner podcast episode, but we're also letting everybody sit in on some video presentation as well. We're recording this on video and doing some other interesting things we're going to interject in here for the ABMP CE summit that's coming up very shortly, so looking forward to a great experiment, see if we can pull this off, and let everybody sort of sit behind the scenes with us on this recording and get some interesting things shared from us on plantar foot pain today.

Til Luchau:

Yeah, if you're listening to the audio, we'll do our best to describe it to you. If you're going to tune in to the ABMP summit, you're going to get some special video views and extras, especially later in the podcast when I try to actually show some hands-on techniques. That's going to be a real extra to check out.

Til Luchau:

Whitney, like I said, I am looking forward to our conversation, because I always learn something, and this is a subject you know a lot about. What do you think is important for us to know about plantar foot pain?

Whitney Lowe:

Well, we got a lot of things to potentially look at with plantar foot pain, and one of the things that I thought we could do, we sort of, in talking about how we might deal with this episode, said well, why don't we kind of split some of topic up into looking at how we might evaluate what's causing plantar foot pain, as sort of an assessment component. Then, also what can we do for it, because we obviously want to know what can we do to help our clients who are grappling with that. That sort of falls into our treatment component.

Whitney Lowe:

I'm going to sort of cover some of the anatomical background and assessment components, and then in the second half here turn it over to you and we're going to look at some key treatment strategies that would be helpful for people as well.

Til Luchau:

Sounds awesome.

Whitney Lowe:

Let's take a look at some key anatomical factors here that play a part in our assessment and evaluation of what's going on with the foot, with plantar foot pain. One of the things that I wanted to start off with discussing here is something I refer to as the lens of bias. This topic of plantar foot pain is a great place to address that. What I mean by that is that as massage and manual therapy practitioners, we tend to focus a great deal of our attention on muscle structures because that's what we tend to work with a lot. It's important I think for us all to realize that virtually every practitioner has this sort of lens of bias that they look at things through based on the way they're trained and based on the way we orient our practice.

Til Luchau:

Sorry to interrupt, but of course, I don't have a bias, because I was fascially trained.

Whitney Lowe:

Of course.

Til Luchau:

That's right.

Whitney Lowe:

That's good to know.

Til Luchau:

Okay, thank you.

Whitney Lowe:

Yeah. I always tell people that especially in the massage world we have a tendency to look at the world through muscle colored glasses, because it is something that we tend to a great deal. This topic of plantar foot pain is great because it lets us really say, "Hey, there's a lot of other things that we need to consider here that may be potentially relevant."

Whitney Lowe:

Let's take a little quick tour through some anatomical structures and things that might also be playing a role in plantar foot pain, and then we'll talk about how that plays a part in several of the conditions of things that we're going to get into.

Whitney Lowe:

First place we're going to start off here is with some of these deeper connective tissues around the foot and ankle, or excuse, in the plantar foot region in particular. We're looking here on the bottom surface of the foot at some of the deep connective tissues around here, such as the, again, we think a lot about like the plantar fascia, but there's a lot of other ligaments, tendons and muscles that are deep to that plantar fascial which may also be a source of many pain complaints.

Whitney Lowe:

For example, we have this long plantar ligament that also attaches to the anterior facet of the calcaneus, and pain that might be caused from excessive load on that ligament, for example the arch of the foot when somebody's bearing weight, the arch helps spread that weight out, and that long plantar ligament takes some of that tensile load, so if there's pulling on the attachment side, so that plantar ligament on the anterior calcaneus, that can give pain that could be mistaken for plantar fascia pain.

Whitney Lowe:

The other thing I want to call attention here, this is an interesting group of ligaments and structures, the transverse metatarsal ligaments. These ligaments span between the distal end of the metatarsal heads, and they play a very prominent role in some nerve impingement problems in the foot, surprisingly. A lot of people don't think about them and their potential role here, but let me just give you a brief explanation of why.

Whitney Lowe:

If we put on some of the nerve tissues that are around here, we'll take a look at the in particular digital plantar nerves, these small, thin nerves that go all the way down into the toes. You'll notice they are superficial to the transverse metatarsal ligament, meaning they're closer to the surface on the bottom of the foot.

Whitney Lowe:

Now, the reason that that is particularly important is, when people are in certain positions, for example, a runner who is in this toe-off position, and their foot and toes are hyperextended, when they're in that position, and this is the same thing that's true for anybody who's walking, running, or doing anything when they push off with their foot, that sort of bow strings those digital plantar nerves against the transverse metatarsal ligament, so if there is some type of nerve irritation or irritability in these nerves, when you pull the toes into hyper extension, you're bow stringing those nerves against that very firm and stiff transverse metatarsal ligament.

Whitney Lowe:

That can be a cause of pain that's usually pain into the toes, but it also sometimes can be felt on the plantar surface of the foot. These are some of the key ligamentous structures that we want to pay attention to and their role in a number of foot complaints that may happen in that area as well.

Til Luchau:

That's great. I just want to make sure I'm following. Your first distinction was between the plantar ligament, and this will be especially helpful for our audio listeners. The plantar ligament and the plantar fascia. Is that right? You were distinguishing those two?

Whitney Lowe:

Yeah.

Til Luchau:

Which one is deeper?

Whitney Lowe:

The long plantar ligament is very deep. Think about it, the underside of the calcaneus and all the tarsal bones, and there are numerous layers of tendinous and muscle tissues over the top of that, and the most superficial just under the skin is the plantar fascia.

Til Luchau:

A broader, fascial sheet just under the skin, that's the planter fascia per say.

Whitney Lowe:

Exactly.

Til Luchau:

Then, your second interesting distinction was the transverse metatarsal ligaments, right around those joints in the midfoot there, and you're saying that's the target area where the smaller nerves can get impinged or compressed, especially in toe-off position.

Whitney Lowe:

Yeah. Exactly. Yes, so it's more like they're getting bow strung across [crosstalk 00:08:06]. We talk about neural tension sometimes as opposed to compression. We think most commonly of nerve compression problem, but nerves can be exposed to excessive pulling or tensile stress, and this is a place where they get sort of pulled and bow strung against the underside of that ligament there, and that causes plantar foot pain, but also frequently pain into the toes as well, with those ligaments.

Whitney Lowe:

Now, if we go a little bit more superficial from those deep structures, let's begin looking at a couple of the other muscle tissues that are in here that we want to focus on. We have these short interosseous muscles running in between each of the metatarsal heads, and remember any time we have any of these muscles in here, they could be a potential cause of pain from myofascial trigger points, irritability, over stressing. It's difficult to isolate these muscles because they are so deep, they run in between those metatarsal bones, so they're hard to kind of specifically palpate and identify, but it's really important to keep in mind that they do exist in this area and that they are something that we may want to be paying attention to.

Til Luchau:

Now, for our audio listeners, this again would be, you said right between the metatarsals, the set of bones just behind the toes, the long bones of the foot that aren't toes. You're saying deep in there are muscular myofascial structures that could be a source of [inaudible 00:09:24] input.

Whitney Lowe:

Exactly. Yeah, and it could be from their attachment points. It could be just you could have strains to these muscles, it's not particularly common, but they could have just chronic ongoing pain trigger points, strains, any of those things that effect muscles or myofascial tissues could impact those as well.

Til Luchau:

Great.

Whitney Lowe:

Yeah. now, moving a little bit more superficially from that, we've got another group of muscles on the bottom surface of the foot, the lumbricals, which are also sort of long muscles on the bottom surface of the foot. Quite difficult to palpate individually because of the other tissues that overlie this area, but do keep in mind we have each of these single, individual lumbrical muscles on the bottom surface of the foot, and again, they could be subject to potential myofascial injury, tightness, hypertonicity, trigger point activities, or possibly even strains. Impact trauma is another thing to think about. If you step on something sharp or really pointed, that can cause some degree of potential damage, inflammatory reaction and irritation of those muscles on the bottom surface of the foot, so that is certainly something [crosstalk 00:10:29]

Til Luchau:

Bruising, contusions. Yeah.

Whitney Lowe:

Exactly.

Til Luchau:

Absolutely.

Whitney Lowe:

Yeah.

Til Luchau:

Now, these lumbricals, we're deep to the plantar fascia. Are we as deep as the long plantar ligament?

Whitney Lowe:

Yeah, so these are about the same level as the long plantar ligament. For those of you on the video feed here, you can see there's sort of attaching, got some fibrous attachments into that ligament, so pretty close to the same level as that deep plantar ligament in there, but a bit more superficial with their location there.

Til Luchau:

Now, I hope this is an okay time for this question. How important do you think it is for me as a practitioner to really know, say individual lumbricals or individual muscle structures?

Whitney Lowe:

I would say, personally, because we can't really identify them individually very well, it's probably not a crucial thing for you to know and recognize each of those individually. The thing that I think is really important is for everybody to realize, there's a lot of stuff deep to the plantar fascia. Just keep that in mind as a general guideline, because we tend to frequently jump to those things that are most familiar, so a person comes in and says, "I got a pain on the bottom surface of my foot," and your mind immediately goes, "Oh, plantar fascia," because that's what you hear about all the time, that plantar fascitis, but it's really important to remember there's a lot of stuff underneath there, and that's just kind of what I want to hit on today, is just noting there's a number of other things to think about that may also be potential problems in there.

Til Luchau:

I love it that you named the lens of bias, and our named muscles set us up for that kind of bias toward muscles. Now, from the fascial bias, we say it's probably the wrappings that are more sensitive even, and it might be the intermuscular septa or the paramecium around those muscles that could have innervation levels, but in any case, those are useful concepts to know there's lots of little structures, lots of little layers, lots of little bundles and envelopes there throughout the foot.

Whitney Lowe:

Yeah, absolutely. Next, I want to point to an interesting muscle that you don't hear about this muscle very often, but it plays a role, I think, in a number of foot pain complaints that we don't see so frequently, and that's the quadratus planti. This is a muscle that attaches to the calcaneus near where the plantar fascia does, so an irritation of this muscle's attachment point right on the anterior calcaneus can easily mimic what we see as symptoms with plantar fasciitis very frequently, but also if you note the attachment point of this muscle, it's actually on the tendon of the flexor digitorum longus muscle.

Whitney Lowe:

This muscle's function is actually to help pull these other individual tendonous slips that go out to each one of the toes here, but this muscle can be injured from, again, overuse, from impact trauma, from all kinds of things on the bottom surface of the foot, and it also plays a role in some other nerve entrapment problems in this area as well. Let me just highlight that a little bit here, too, for those visually. This other muscle that is right next to it here, the abductor minimi muscle. There are nerve structures that go right in between the quadratus planti and the abductor digiti minimi muscle, and they can get compressed and trapped right in this area, and again, this is a nerve entrapment problem that might mimic the symptoms of something like plantar fasciitis with plantar foot pain, but in reality what you've got is a nerve compression problem going on right on the bottom of the surface of the foot, in between those two muscles.

Whitney Lowe:

This is actually-

Til Luchau:

That's really great. That's so important, I'm interrupting you, but I don't have your visual either, so this is kind of cool, I get to do this auditorily, and just from memory, that abductor house just goes from the big toe, back toward the medial malleolus, maybe tucking underneath the foot a little bit. If I'm feeling the medial side of my own foot, it kind of starts at the big toe, and then wraps up toward the ankle bone. Is that more or less right?

Whitney Lowe:

Yeah, and this particular muscle here, where that nerve compression is, can be a little bit more toward the lateral aspect of the foot over here, too, so that quadratus planti is right down the middle, and then moving a little bit toward the lateral side tends to be where that nerve compression problem is occurring in there. This is, again, it's a little bit difficult to isolate, because if you do have a nerve compression problem in this area, if you press on it, it could mimic the exact symptoms of somebody who's got a plantar fasciitis, because it's usually quite sore and tender in that area, but this is one of the things that gets back to the integration of history with the evaluation process, because we always want to try to identify in our history taking with our client, what are the kind of symptoms that they're expressing. If they're really sharp, almost electrical kind of sensations, or they're getting the sensations in position that would stress maybe the neural structures but not necessarily the muscle tendon structures, that could be a clarifying distinction to determine which one of those things might be a potential problem in there.

Til Luchau:

Something I keep in mind as I'm working in those zones, if there's a quality of pain that's being evoked that suggests nerve pain, like that sharpness you mentioned, or hot, electric pain, then I think, "Okay, there may be a nerve entrapment issue, as well as any tissue generated [inaudible 00:15:56].

Whitney Lowe:

Yeah. Absolutely. A couple other things to look at here. We've got some other deep tendons, or deep tendons along this area that come right down through here. They're part of the major tendons that are in the deep posterior compartment and come around the medial side of the ankle. There's three main ones here: the flexor hallucis longus, flexor digitorum longus, and tibialis posterior. Those main tendons that come around the medial side of the ankle also have tendon sheaths surrounding them, and for those of you watching visually, let's see if we can take a look at that.

Whitney Lowe:

These tendon sheaths are designed to help reduce compression underneath the flexor retinaculum, which is the structure on the medial side of the ankle. It's just like the retinaculum on your wrist where carpal tunnel syndrome occurs. You have this thick, binding, connective tissue that spans between the medial malleolus and the calcaneus, and those tendons have to take a right angle turn as they go right around the medial side of the ankle and course down into the foot. Those tendons are surrounded by a sheath in this area, and you can have an inflammatory irritation that develops between the tendon and the sheath from usually biomechanical problems of the foot like over pronation, where a person is over pronating their foot, and those tendons are exposed to excessive tensile loading, and that may cause an irritation of that tendon sheath, that inflammatory reaction in there, so the various foot shapes or biomechanical positions of the foot can cause those tendons to become more susceptible to some of chronic overuse things that we see happening with tendons.

Til Luchau:

The territory, you're talking about the medial side of the ankle, the wrapping around of those three muscles around the medial side, how they have tendons sheathed around them, there's tons of movement in there. They're under the retinacula, and there are places that there can be irritation, there can be sensitivity, like a lot of other tendonous places.

Til Luchau:

Now the biomechanical connection to pronation, I should just say, is debated. There are things that have shaken my belief in that point of view enough that I'm agnostic on that question about whether pronation is a contributing factor or not.

Whitney Lowe:

Okay.

Til Luchau:

I can share some of those references in the show notes if you want.

Whitney Lowe:

Yeah, do we have time for you to give us a brief share of your thoughts on that?

Til Luchau:

Yeah.

Whitney Lowe:

I'm curious to know.

Til Luchau:

In the study and I believe it's Warren, 1984, there was not a big correlation between these different factors, being arch height or degree of subtalar pronation, and planter fascia pain, in this big study of different people with that symptom, that didn't seem to be a big factor. There is a point of view that takes that as an accepted approach, that it's less related to say, pronation and supination and more towards some other factors, but again, that's under debate, and the conventional wisdom says, yeah, if you show a lot of pronation, that's going to stress that ligament. It just goes intuitively to think that, and it could be. Certainly in some cases I wouldn't argue that at all.

Whitney Lowe:

Yeah, so again, these are really great concepts because it makes us recognize that this is a very biomechanically complex area, and there's numerous things that can play roles in here. You can have one person that's got really poor arch structure, chronic over pronation and all kinds of other apparently problematic biomechanical issues, and no pain in their foot or no apparent disfunction in there. Again, the presence of that is sometimes a factor, and sometimes not a factor. This is, again, I think where thorough and detailed client history becomes really important because we have to determine when is that a problem for each individual, because for some people it is and other people it's not as much of a problem.

Whitney Lowe:

Let's keep coursing a little bit more superficially. We got a number of other structures that we're going to contact as we move more superficially. You had mentioned some things here, too, with the abductor hallucis muscle. This is a big one. It's pretty easy to palpate pretty superficially on the medial side of the foot here. We also have the flexor digitorum brevis, which is a smaller muscle intrinsic to the foot attaching to the calcaneus and also blending in with the tendons that go to the flexor digitorum longus, all the way into the toes, so these are, again, two more muscles deep to the plantar fascia which could be potentially problematic with pain sensations that people are having on the base of their foot.

Whitney Lowe:

Then, more superficial to that, and again, this is a little bit challenging visually for people when you talk about things being superficial, but it's moving down toward to ground surface, because superficial in the foot means closer to the skin surface, so just underneath the skin is where that thick plantar fascia is. Now, we come up with all these different layers, and the most superficial layer under the skin is the plantar fascia itself, going from, of course, the interior calcaneus and spanning into each of these individual digits with fascial connections that go all the way through here.

Whitney Lowe:

One thing I want to call our attention back to something you were mentioning, Til, a moment ago, too, is that some of the other muscle tendon attachment points can be the source of pain complaints in this area. For example, the tibialis posterior has attachments to almost every one of the bones on the bottom surface of the foot, the tarsal bones. I think there's one of them that it skips, and so attachment sites for that tibialis posterior is constantly pulling if it's under excessive tensile loading from various maybe mechanical distortions or something like that, can cause a condition called enthesitis which is an inflammatory irritation of the attachment point of those tendons. That's another thing that could potentially cause pain on the bottom surface of the foot that would be really deep because those tendon attachments are on the bones of the foot muscles and not superficial in those tissues, so that would be another factor that we'd want to take into consideration as we do our evaluation of what might be potentially causing some pain complaints in there.

Til Luchau:

Okay, there's so much detail here. You have such a wealth of information, I want to make sure that you have time to get at the things you think are most important for us to know. I won't slow you down any more, but tell us what you think are the most important things you want to make sure we cover are.

Whitney Lowe:

A couple of the things that I want to also focus some attention on here, are what are the types of problems that we want to look for and that might be potentially problematic, as we've looked at these different anatomical structures. Clearly, as we talk about muscle tendon complaints, we have the common types of problems to look for, such as myofascial trigger points, simple hypertonicity problems at the attachment points of those muscles, the enthesis, and again our history is going to tell us a lot about those.

Whitney Lowe:

We tend to see a lot of the problems in the foot region being associated with chronic overuse. Exercise activities, aerobics, dance classes, or just starting a new running regimen or something like that. Usually, there's something in the history that will point to a sudden increase in activity loads, or it may be a particular type of footwear that you're wearing, some of the other types of biomechanical challenges that the foot is exposed to. Our feet take a huge pounding on a day-to-day basis. If you look at a lot of the sort of force plate studies that they do in biomechanics, that the foot is exposed to something like three to four times the body weight on each foot strike when you're running, so take your body weight and multiply that by three or four times, and then multiply that by the number of foot strikes when you take a quick little mile run around the block or something like that. That's a lot of cumulative load that's in there.

Whitney Lowe:

That's something to certainly think about with the muscle tendon complaints. We mentioned earlier, too, a lot of those deep ligamentous structures, and remember, every one of those tarsal bones in the foot has ligaments that span between them. A lot of sudden injuries of the foot may sprain those ligaments, either overstretching them just a little bit, or overstretching to the point of there being some tearing in there, but that's certainly likely to kick off the inflammatory response so that you going to have chemical mediators in there floating around in the foot that are possibly going to irritate the nociceptive nerve endings. Lots of potential things could cause pain complaints from ligament sprains that are in there.

Whitney Lowe:

We spoke earlier, too, about some of the nerve tissues that are coming down through this area, especially the tibial nerve as it comes down around the side of the ankle, and splits off into the medial and lateral nerves and goes down into the foot. Pain from compression of that tibial nerve, especially around this area here, which is called the tarsal tunnel. This is on the medial side of the ankle, just underneath that flexor retinaculum. Compression of that nerve or irritation of that nerve in this region can easily produce pain on the bottom surface of the foot that is frequently mistaken for plantar fascia pain.

Whitney Lowe:

One of the things from an assessment perspective that we will try to do to make some distinction is, because of the location of this nerve on the side of the ankle, you can come up and sort of press your thumbs just inferior to the medial malleolus and press on the neural structures in this area and if that aggravates the plantar foot pain, that is a lot more likely to be a cause of tarsal tunnel or tibial nerve compression than it would be plantar fasciitis, because again, you're not pressing on the plantar fascia, not irritating it any further, so pressing or palpating those areas where they're likely to be particularly tender is going to enhance a lot of what we can find.

Whitney Lowe:

There's a number of different key strategies here that include visible things that we might see. Do we see any particularly visible inflammation? Do we see discoloration? Do we see some indicators of other major tissue trauma or tissue injury? Those things will be particularly important, along with [crosstalk 00:25:54].

Til Luchau:

Swelling, for example.

Whitney Lowe:

Swelling, a big one there, especially for the ligament sprains. Any of those things will be important indicators that will help us identify when some of those things are particular problems. There are a number of sort of special orthopedic tests that are sometimes used to help identify some of the problems around this area, and you can look a lot of these tests up in some of the orthopedic manuals, but I will also say, I'm a big advocate of not getting too wrapped up in trying to memorize and perform a lot of these procedures, because the basic evaluation of active movement and passive movement and some of the manual resistive tests and palpation that you do on this area to really, specifically investigate some of those soft tissues can give you a whole lot of really valuable information in many instances without having to feel like you have to memorize or perform all of these special testing procedures.

Whitney Lowe:

As we had noted earlier, because we do have so many of these different tissues on the bottom surface of the foot, it can be different to isolate particular movements of the foot and ankle region like you do in, let's say, another joint like the arm or the shoulder or the knee or something like that. Much easier to isolate the movements there than it is between all of these individual foot bones.

Whitney Lowe:

Those are some of the key things that we want to focus our attention on from sort of an assessment perspective, and I'm sure we'll delve into this in a little bit more detail. Til, you're going to run us through now some treatment concepts that will be helpful for addressing some of our key plantar foot pain issues, right?

Til Luchau:

I am, and I just want to say, is it okay if we put your outline into the handout, here?

Whitney Lowe:

Sure. Absolutely.

Til Luchau:

You have it so clearly outlined here.

Whitney Lowe:

Yeah. Absolutely. We'll do that.

Til Luchau:

There's so much great detail there, that I think that's something I'd really recommend, is go download the optional handout from the link where you got this, either the podcast or the webinar, and you'll get to see Whitney's clear outline of the different structures he's talking about and how they can contribute, one of the key points there being, we don't know if it's the plantar surface per se, that is the irritated zone, or if there's a nerve, perhaps, that's being entrapped.

Whitney Lowe:

Yeah.

Til Luchau:

That palpation around the side of the ankles is a key way to know that we can actually suspect nerve entrapment, say if it's tender around those ankles.

Whitney Lowe:

Yeah.

Til Luchau:

You agree with the, it's probably oversimplification, that the nerves around the medial side are more like to cause the plantar fascia area to be sensitized, while the lateral side would tend to show up more as a heel sensitivity?

Whitney Lowe:

Yes, absolutely, and that's just because of the pathway of those nerves, and the similarity that they have to those other sensations. I would say that's definitely true.

Til Luchau:

Okay.

Whitney Lowe:

Yeah.

Til Luchau:

Well, thanks again for that. Let's go ahead and shift gears, and then we'll get set up to show you a couple of these concepts as well.

Whitney Lowe:

Sounds great.

Til Luchau:

Okay, so before we go to the table, let me just give you a couple of concepts. This is a little overlap of what you've presented, Whitney, so clearly, but I like to think of there being four main stressors that could be part of that plantar foot pain. The first one being mechanical stress. That's the conventional explanation for a lot of what used to be called almost exclusively plantar fasciitis, and then, by the way, went to “fasciosis,” where the inflammatory aspect was being debated. Now, the pendulum has swung back, and many people are saying, "Well, there actually is an inflammatory initiation to a lot of that pain."

Til Luchau:

Whether it's inflammatory or just injury, that was the basic debate, there's a mechanical stressor there. When I'm thinking mechanical stressors, it's basically a stress coming from outside of the foot into the foot, often, and it could be as simple as just having your knees locked. That could stress the back side of the body such that that Achilles tendon transmits the force either around the calcaneus, if you think of the calcaneus like a knee cap, which is an interesting concept that I just shared with you, Whitney, in that study we saw. A knee cap within the tendon of the conjoined Achilles tendon and the plantar fascia. Or, whether you think of the continuity of the bone as a puller on that plantar fascia, but the back of the body seems to mechanically pull on the plantar surface of the foot and so there's definitely something to think about in terms of its contributors there, mechanically.

Til Luchau:

Dorsiflexion limitations have been pretty strongly correlated with plantar foot pain, and whether it's cause or effect, it's a little hard to say, but there seems to be a therapeutic benefit to helping people have more dorsiflexion. That's ease of pulling their toes and foot up. As well as general foot adaptability. Really high, stiff arches could be thought to be a contributor as much as low, un-springy arches, the question being a difference in adaptability. How much are the foot bones able to adapt to each heel strike or each foot strike, and how much can they adapt to the different demands we put on them.

Til Luchau:

If they can't adapt, then it may be that the plantar tissues themselves get demanded upon too much.

Whitney Lowe:

Yeah.

Til Luchau:

Overuse, a huge factor, you mentioned that, and then contusions, you mentioned that as well. Those are the mechanical stressors.

Whitney Lowe:

One of the things, too, you were mentioning that I think is really important for people to remember, especially that whole concept of the role of the gastroc and soleus and they're pulling on the Achilles tendon is that often times a key factor of addressing something like pain on the bottom surface of the foot really involves working somewhere else, because of the relationships of how that, like you mentioned, is pulling on the calcaneus and that's altering mechanics, again, not only of the plantar fascia but those other tissues that we saw, like the quadratus planti, the deep plantar ligament, all those other tissues that are attached to that calcaneus as well.

Til Luchau:

Then, the most direct and obvious connections, I said, are on the back of the leg, like the Achilles complex, the gastroc soleus, fascial, crural fascia, that kind of stuff, but there's bigger connections, like, even I mentioned knee position, but even your pelvic mobility, your spinal curves, the amount of head forward position, perhaps. All those things could be thought to contribute to a lack of adaptability along the back side of your body there. It could manifest to sensitivity at the bottom of the foot.

Whitney Lowe:

Yeah.

Til Luchau:

Okay, you mentioned nerve stress, and gave us some nice, clear indicators about that. I mentioned inflammatory stress, that's the role of inflammation is debated in say plantar fasciitis or fasciosis, but a lot of it seems to at least start that way, or be aggravated by inflammatory factors. The short version of that story is it could be local inflammation from, say, a bruising or an injury or a repeated strain, or it could be systemic. If you have any systemic contributors to your inflammatory load, including just getting older, that could make you more likely to have plantar foot pain with an inflammatory contributor.

Til Luchau:

I have a lot to say about inflammation, and I'm going to save that for some other time.

Whitney Lowe:

Right.

Til Luchau:

Except that you'll see it embedded in the way that I'm working at the table when we get in there.

Whitney Lowe:

Yeah.

Til Luchau:

Then, we should for sure bookmark psychosocial stress, too, as we learn more and more about how pain is not just a biological but a psychosocial phenomenon, and this harkens back to the view that the feet are a source of support, perhaps. Our emotional support, physical support but also emotional support. They're certainly tied really clearly to our mobility, our ability to exercise and manage stress, those kinds of things, so if there's pain in the foot, that could have all sorts of psychosocial factors that tie in with isolation or sleep disruption.

Til Luchau:

Then, it goes the other way, too. The stressors in your life or stressors in the world could be a factor toward this sensitivity on the bottom of the foot. Can you think of any stressors in the world right now? I'm having a hard time thinking.

Whitney Lowe:

It's pretty mild right now.

Til Luchau:

Then, we can pretty much assume it's mechanical if someone's foot hurts.

Whitney Lowe:

Always. Yeah. Okay.

Til Luchau:

Thanks. Let's go to the table and I'm going to show you a couple of these ideas.

Whitney Lowe:

Great. Look forward to seeing it.

Til Luchau:

All right. If you haven't got the handout, that will help you a lot, but I'll go ahead and talk you through this little set of ten techniques that I've put together as emblematic or representative techniques of how I might work with plantar fascia pain. The first one, on page one in the handout, is called the dorsiflexion test. That's just looking to see how much dorsiflexion someone has, comparing left and right. If there's not a lot of dorsiflexion, or especially if there's pain in the sole of the foot during dorsiflexion, then we can suspect that's a factor, either correlative or contributive to that plantar foot pain.

Til Luchau:

Easy way to do a dorsiflexion test is have your client walk up to the wall and touch their knees to the wall with their heels on the ground and find the distance from the wall where that's comfortable and then gradually back that off, centimeter by centimeter, until you get to a place where the heels either need to lift, or there's enough discomfort that let's you know that you've found something that might be contributing to that pain.

Til Luchau:

Number two in the handout is the crural fascia retinacula technique. In that technique, I'm using a gentle touch and actually fingernails to slide the stockings of the crural fascia and the retinacula around the ankle and around the lower leg. It's actually a fairly light touch to begin with. It's thinking about just like sliding someone's socks around. The crural fascias are wrapping around the entire lower leg and blends in with the fascial wrappings of the plantar fascia of the top of the foot as well as the bottom of the foot. I'm sliding those layers with a beginning, a light touch and then using a little more fingernail to grab that layer, a little more of a glide.

Til Luchau:

That might have mechanical effects of letting things slide easier, under it. Certainly it could help any nerve entrapment there around the medial or lateral ankle, be a little easier as well.

Til Luchau:

Number three in the sequence was gastrocs with plantar and dorsiflexion. That's indicated when there has been a dorsiflexion restriction, a type one, where you're not able to go as far because of something tight in the back of the leg. In that technique I have my soft fist under the client's leg, on the table. They're face up on the table. My soft fist is under the gastroc and I'm using my knuckle to gently feel up into the gastroc complex as they plantar flex and dorsiflex the foot, throughout the entire length of that gastroc soleus Achilles complex, just making sure that's differentiated and springy, is the theme there.

Til Luchau:

Then, I might follow that up with in some clients, if there was a dorsiflexion restriction with some interosseus membrane of the legwork, because that lack of adaptability between the tibia and fibula can inhibit dorsiflexion right there where the tib and fib clamp around the talus, the web shaped talus. There's a technique in that handout that's helpful for more adaptability you can say between the tibia and fibula, helping the talus move a little freer.

Til Luchau:

The plantar foot itself, on number five if you got the handout, is me using my thumbs to gently press and release into the entire surface of the foot, initially to warm it up and prepare it, get it used to my touch and the pressure there, but also to assess and map out any sensitivity, any tender places. I'll combine that with my client's active movement of the toes, lifting and curling the toes, say, to begin to elicit some movement and gliding at those deep structures. Once things warm up and get a little easier, I can actually feel down pretty deep, maybe even between the bones, there where Whitney was describing, and feel for the tissue qualities and tissue sensitivity there, and even perhaps as far as lumbricals, but certainly into the deep plantar flexors, the toe flexors there on the plantar surface of the foot.

Til Luchau:

The plantar fascia itself, number six in the handout, is a more superficial structure, it's just under the skin. It has its own layering, it has it's own sheath and core. The core is very dense and aligned collagen structures. The sheath, fairly thick on a lot of people is more interconnected collagen fibers. Most of the vasculature and enervation of that plantar fascia is in those outer layers. I'll throw a reference to that, and some cool pictures into the show notes for this as well, because you can feel for layering within just the superficial layers of the foot.

Til Luchau:

The goal there is normalizing sensation, not scraping it clean, as much as helping someone actually move there in a comfortable way, so my pressure isn't that deep, honestly. It doesn't have to do much beyond hook a layer and have someone move, because my goal in this approach is gliding, hydration, restoration of natural perfusion, those kinds of things, more than say, mechanically stripping or even a pin and stretch kind of approach where it's aiming for some tissue lengthening effect. We don't have a lot of evidence that we can do that, tissue lengthening in any lasting way, for sure. We do have evidence that glide changes with good manual therapy work, and that that improves pain. It helps pain be better when there's better glide there, from a bunch of different mechanisms.

Til Luchau:

The calcaneus medial side is a place to work. I show some, in the ABMP webinar, if you go tune in for that, when that appears on Whitney's site, or my site later, you can go see me working with some of those ideas around the heel, but in the handout, it's page seven, shows some gentle ways to work around that malleolus where there could be some tendon sheath irritation or some of that nerve entrapment that could contribute to plantar foot pain.

Til Luchau:

The transtarsal techniques on page eight and nine, I have my client on the side and I'm bending the foot over a rolled towel, or the rolled edge of the table. If you could imagine a rolled towel under the edge of your foot and someone bending your foot in a flat plane over that, so essentially it's like a bear paw or a duck foot, curving the foot in two directions, both inward and outwardly, then you get a sense of that technique. We'll try to post, again, in the handout, they'll be a picture of that, and try to post a little bit of instructions there, because it's a very unusual movement for the foot to make, but that really does help liberate those deep structures that Whitney was describing where those nerves can become [inaudible 00:40:49] around the metatarsal ligaments.

Til Luchau:

I'll ask for a little bit of client toe movement there once they get their foot into one of those adducted or abducted positions as well. The sequence ends, this lighting sequence that might take me more than one session to get through, but the sequence ends with some foot and knee awareness. Getting your client up and having them stand and describe some of what they feel in their foot now that you've worked on it, and maybe playing with softening the knees, tightening the knees, so they get a comparison of what happens in their foot with each of those positions. A lot of times that makes some lights goes off or connects some dots for clients where that knee locking or lack of spinal adaptation could be a factor in their foot pain. Just playing with that and standing now that their sensitivity has been heightened can really help them feel sometimes how those connections are very obvious and tangible.

Til Luchau:

That's the verbal description of some of those techniques. I do encourage you to download the handouts or check out the video, but hopefully that gives you even just enough ideas just with the verbal part. What do you think, Whitney? Anything you want to add there?

Whitney Lowe:

Perfect. That's really helpful to get some ideas of how we can best address some of these potential problems with our clients here.

Til Luchau:

Great. In summary, think about the whole body, the whole foot, and the whole person. Think about adaptability through those whole things. Even if their pain is just the front of their heel there, front of the calcaneus, it more than likely has contributors and certainly ways into that system by thinking of the whole. Track for flaring, especially if you use pressure in your work. Don't keep flaring it up. There's an approach that says we can be high stakes and flare it up on purpose, once or twice. I'm not recommending this, I'm just saying there are approaches that take this point of view, that flaring it up once or twice can actually reset the inflammatory cycle and help it resolve. That's a high stakes maneuver, because your client is going to be less comfortable afterwards. That will be a lot of instrument assisted methods and things like that.

Til Luchau:

Not inevitably insensitive, but that's a risk, and what I see really common, say in massage therapy circles or even structural integration circles is the constant working of that sore sole of the foot and essentially keeping it inflamed. Same thing with ball work, like I mentioned there at the table, so avoid the flaring once or twice, maybe, but beyond that, change your approach if someone feels worse or there's no improvement after your sessions.

Til Luchau:

The general principles for those tests usually have to avoid compression, thus avoiding the ball. Encourage glide. Loading. There's a lot of interesting self-care that we didn't get into at all involving, say, gentle heel raises. I'll often refer my clients to their PT if they're working with a PT, for some customized advice, or even a personal trainer can really help them. Custom advice on heel raises, because that can really help someone's plantar fascia pain, but it's not the kind of thing without really being able to customize it to the client, I would just recommend across the board.

Til Luchau:

Perfusion and sensation, helping people feel the sole of the foot and helping there be fluid flow through there is going to be helpful as well. Mostly, we're going to make it safe for people to move, get out there and walk and do stuff. Walking helps a lot of people's plantar foot pain. Again, if it's flaring, then something needs to change, but walking is an acute pain reliever for a lot of people as well.

Til Luchau:

That's what I got, Whitney.

Whitney Lowe:

That sounds great, and thanks so much for those suggestions and the wrap-up. I think we've done a good number of things to hit on some key components to look for in identifying causes of plantar foot pain and some great strategies for addressing that with our clients as well.

Til Luchau:

Okay, well let us know if you have questions. You can contact us through our sites. Enjoy the rest of your day, the rest of the ABMP event if you're doing it online. Go check out those handouts for sure.

Whitney Lowe:

ABMP is a proud sponsor of the Thinking Practitioner podcast. All massage therapists and body workers can access free ABMP resources and information on the coronavirus and the massage profession at ABMP.com/covid19, including sample release forms, PPE guides, and a special issue of massage and body work magazine, where Til and I are frequent contributors.

Whitney Lowe:

Also check out the ABMP podcast, which is available at ABMP.com/podcasts, or wherever you prefer to listen.

Til Luchau:

Yep, thanks to ABMP and to Books of Discovery, our sponsors for today's podcast episode. Stop by thethinkingpractitioner.com for show notes, handouts, transcripts and extras. Those are also available on Whitney's site. What is your site, Whitney?

Whitney Lowe:

They can find that also over at the academyofclinicalmassage.com. Til, where can they find your resources there?

Til Luchau:

My site is advance-trainings.com. We post all of the transcripts and everything there as well. If you have questions, you can email us both at info@thethinkingpractitioner.com, or look for us each on social media. I'm @TilLuchau, my name. How about you, Whitney?

Whitney Lowe:

Also, I'm at @WhitLowe and also on Facebook under my name as well. You can follow us on Spotify, rate us on Apple Podcast and wherever else you listen. Do tell a friend, and thank you all so much for listening. We really do appreciate the listeners and the great feedback from everybody as well.

Whitney Lowe:

That will wrap our discussion on plantar foot pain and we'll look forward to another interesting discussion with some fascinating topics here in another couple weeks.

Til Luchau:

Thank you, Whitney.

Whitney Lowe:

All right. Sounds good. We'll see you then.

 

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