Plantar Fasciitis and Massage Therapy

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Plantar Fasciitis and Massage Therapy

Many years ago – in what seems like the Dark Ages, I was in school to become a registered massage therapist (RMT) in Ontario, Cananada and was taught a standard massage treatment for plantar fasciitis and runners. 

The massage therapy mostly focused on the foot. It involved stretching the plantar aspect of the client’s foot by cranking the toes into extension forcefully and pulling the bottom of the foot tight. Then while your client was face down and you had this position achieved, you were to take your thumbs or even an elbow and dig away at the tissue until you had eradicated all of the ‘granular’ scar tissue. 

I quite clearly remember my teacher saying that we needed to then ice the bottom of the foot immediately, as he slapped an ice pack on my friend who was a runner and triathlete. I remember her gingerly limping off post-treatment. I can’t remember how long it was before she ran again after that. Who knows?  No explaination was ever given for the method of treatment. They never explained that the purpose was to break down tissue and re-injure the site to facilitate healing. But it surely stank of that mode of treatment, and it did not make sense. 

Why do we need to hurt someone to make a massage work? 

Now let me ask you a question, a question that I will likely repeat in multiple blog posts: If you come to me, as a medical practitioner, and you complain of a black eye, and I punch you in the same eye and tell you it will facilitate healing, does that make sense? No! So why is it acceptable in massage? Certainly it applys to plantar fasciitis and massage. 

Massaging the leg for runners
Photo by Adam Ninyo

Years later, I now teach a very different method to address runner’s issues to the therapists at Body Mechanics. It is far more gentle, treats the entire lower leg as well as upper (depending on time constraints), engages the brain by moving the body, and involves a referral to PT or exercise depending on the level of experience the runner or athlete has. 

The Plantar Fasciitis Massage Treatment

When assessing, we are looking at a far wider spectrum of dysfunction than simply plantar fasciitis. Indicators that there might be an issue or impending problem include heel pain, pain in the bottom of the foot, and sometimes calf pain. Of course with any assessment, we screen to rule out red flags as well. The symptoms listed above can also correlate with a recent increase in mileage or speed work for runners, or a weight change, plyometrics or recent changes in health. If there is no connection to the assessment you’re probably going to want to refer out regardless to check for bone Spurs and tendon issues. 

For the purposes of this blog let’s focus on the lower leg. I generally combine in-prone, general massage with gentle pin and stretch. Having the patient flex and extend the ankle as well as pronate and supinate. I am looking to see a full articulation of the foot and ankle. Often you will see that those with foot pain also have poor articulation. Resistance in these areas can be added to help cue the body into moving better. Once we have warmed the area with massage and movement, adding resistance to those movements is helpful. While many massages focus on the muscles, at Body Mechanics Orthopedic Massage I like to include tendon work, like “bowing,” as well. We want soft supple moving parts so practicing flexibility is helpful. 

When treating the bottom of the foot, I no longer use that awful stripping technique that requires an ice pack. Instead, I use a hot towel to warm the foot and then use a deeper gliding technique across the sole, while I have the patient flex and extend the toes, or spread them and let them fall to neutral. Here, if things are still not moving well we would add in some mobilizations between the tarsals and resisted exercises for the toes. 

As for home care, if the problem persists, we will refer you to a physical therapist and if it does not, then we would advise you to a program of foot and calf strengthening as injury prevention. As a massage therapist, I am not rehabbing you.  My job is to get you more comfortable while your body does what it does and what it was designed to do. It is adaptive. It will adapt, with or without me.

Summing up…

A warm towel? Simple exercises? No digging thumbs or elbows into the client’s foot? This is a far cry from the painful techniques that I was taught! No one is limping painfully off our tables before a run. The clinical outcomes seem just as effective and I’d say are more beneficial. If you are looking for a therapist who will not hurt you to help you, ask questions before you book. Look for someone who listens well and has a wide variety of techniques at their disposal. It would be a shame to miss your next run due to foot pain… especially if it was caused by the person trying to help you.

Check out more on plantar issues

 

Body Mechanics Orthopedic Massage

1 W 34th St
#204,
New York, NY 10001
Phone: 212-600-4808
Email: info@bodymechanicsnyc.com

Massage Therapy and Pain (Continued)

FullSizeRender (1)Massage Therapy and Pain

Working with Clients in the Pain Zone

This is a continuation of the last pain blog which offered some history on pain science and also some really general guidelines on massage therapy and pain.

If your client has no red flags in assessment and you have decided it is safe to touch, working with clients experiencing chronic pain not associated with an injury has its own challenges. For many people, pain has the distinct effect of stopping us from moving, regardless of its cause, and so getting your client back to a place where they feel that they can move can be considered a success. To work safely as a massage therapist with an understanding of this, you are going to want to switch from the treatment model where massage is passively received by a client into one where the client has full control of the experience, both physically and mentally.

First lets look at the physical aspects of a client having control

This can be challenging, especially considering that most massage therapy programs teach massage as a passive activity that is ‘done’ to the client. In this role the massage therapist acts more as a facilitator to touch. Consider that touch is not a one way experience and that every time you gently “rub” a muscle, you also have the ability to instead have that muscle and skin move gently under/against you. If someone is in pain, you have the option of saying “I am going to gently put my hand here on your back, why don’t you try breathing up into that feeling”, or “I will never press harder, why don’t you try pressing gently into me?”, or “I am going to hold your arm gently, why don’t you just tense the muscle a little and then relax or wiggle your fingers?”. There should be a direct relationship to the amount of pain present and the amount of control the client has. The more pain present, the more the patient should be in control of what is happening.

This does 3 things in my opinion:

1. Lowers the anxiety associated with treatment, and the anticipation of pain, and possibly dropping their pain level.
2. Facilitates change in the body by signaling normal function and behavior as the patient moves.
3.Protects you the therapist from stepping over a boundary. If the client has control, they only go as far as they want, and no further. 

I want to be clear that if you are using this kind of treatment with someone who is in pain, you never want to cause pain. Their may be pain associated with the treatment, but it should not be from a new stimulus you are providing, such as pressure or forced movement. The pain associated with treatments of this nature should be caused by a patient moving through their own pain signal. What does that mean? It means that if someone has had long standing neck pain, and they are completely cleared for treatments, with no red flags, you should never aggressively treat with traditional deep massage. Instead I should gently guide the person to the edge of their painful experience and create a safe, controlled, comfortable setting in which they can explore going further-if they choose to do so. If the feeling of pain does not abate, you should, discontinue and refer out, but often reducing the anticipation of pain and giving the client control is the first step in the pain management in Massage Therapy.



How do you do it?

It all sounds pretty simple-give the client the control and they might get past their pain, but its actually a bit more complicated than that, because you don’t want to be randomly trying techniques. I divide my techniques up into graded categories to help me organize the treatments.

  • Low pain– resisted eccentric/concentric contractions and dynamic stabilization, and holding the tissues muscle while the muscle moves beneath
  • Medium pain– gentle active resisted techniques, holding the skin while the muscle moves underneath, simple isolated muscle movements
  • Higher intensity pain– tense and relax exercises for muscles or groups of muscles, breathing exercises that activate accessory breathing muscles

You will notice the different categories of pain could also be explained as acute, sub acute, chronic, or you could use a pain scale to divide them up. The important thing is that you know where you with the person you are treating. I use LP, MP and HP for short hand charting proposes. Lets look again at that client with the neck pain so we can get a better idea of the application of these techniques for the different pain categories.



Lets look at some examples to make things clearer

Client with HP  neck –  This client is afraid to move and has pain on movement of any aspect of cervical spine or upper thoracic, with a history of whiplash. Does not go about normal activities.

Treatment– Is a gentle skin deep gliding massage. The goal is just to get used to the client getting used to touch. Once the client is relaxed we are going to begin graded breathing exercises to see if we can get them to reduce the bracing in the accessory breathing muscles. I isolate a muscle by gently touching it and say “can you make this expand and contract by moving air?” We go though each and every muscle that would be effected by breathing. Then we switch to tense relax and do the same. Isolate the muscle, or muscle group by gently touching it, ask the client to control it by tensing up and then relaxing. I finish by going back to very gentle surface treatment of gliding massage.

Client with MP neck -Client has some movement but feels very limited by their pain. Range of motion is reduced to about half, and some of the ranges are less quality than others. Goes about normal activities but has stopped participating in any sports or anything unnecessary to their day.

Treatment– General massage with light to medium pressure. Once the client is comfortable I begin holding isolated areas skin in areas of pain and asking the client to gently pull away from me. If the client experiences pain we go back to the above treatment. We reverse the technique and this time I isolate muscles and have the client push into me (essentially bowing the muscle) If the clients pain level keeps dropping we then move to full simple isolated muscle movements. I hold the muscle and they run though a full rang of motion. (Video example of type of activity)I often do this by saying “ok now try to squish my fingers with your neck”. I correct any movement where they are recruiting another unnecessary muscle to complete the movement or avoid moving through the whole range. At the end of the treatment we return to gentle massage.

Client with LP neck-This client has pretty much full range of motion, but experiences pain at the end range. In their words “I just feel I can’t get past the final stage of the injury”. They are going about their daily lives, and participating in sports with occasional flairs. (this is the client you should most often be treating and seeing unless you are an advanced practitioner)

Treatment–  A general massage with light to medium pressure. You can use any of the above mentioned techniques to warm the tissues. As the treatment progresses, I move to holding the muscles firmly while they go through a range of motion. If no pain is present I ask the client to gently resist the movement for the selected muscle. (Video example of activity)If still no pain is present, I ask the client to resist with movement and move on to eccentric concentric moments. All of these activities are still gentle (the client need only meet you with enough force to activate the muscle)We end the treatment with the same general massage. If at any point the pain or the tone of the muscle rises, we go back to a previous treatment plan.

Wait!!!

But we have gotten ahead of ourselves…before you can do any of this cool stuff, you have to talk to your client about exactly what you will be doing with them and why you think it is the best choice!!!! And that’s exactly what we will go over next time.