Plantar Foot Pain Series
To read the first part of this two-part installment on plantar foot pain, check out “Exploring Plantar Foot Pain, Part 1,” page 22, in the January/February 2023 issue of Massage & Bodywork magazine.
Key Points
• The feet and legs are sometimes ignored in massage treatment. Yet, lower-extremity massage has resounding effects throughout the kinetic chain of our body.
• With foot pain, choosing the most appropriate treatment strategy for that particular condition is necessary.
In the first installment of this two-part series, we looked at a group of common soft-tissue disorders of the foot. Unfortunately, clients can ignore foot pain until it creates a functional disability. Yet, massage therapy and addressing biomechanical function early can resolve pain and prevent dysfunction.
Understanding foot pathologies and recognizing their key signs and symptoms allows us to intervene earlier. For 30 years, I have stressed how important it is to match the physiology of the condition with the physiology of the treatment. With foot pain, choosing the most appropriate treatment strategy for that particular condition is necessary.
In this installment, we explore a few techniques to address these conditions. In creating a treatment plan, it is essential to consider the condition’s degree of severity and stage of development (for example: recent versus chronic). How treatments are applied also depends on these factors. There is far more to understand about foot pain than this overview can provide. But the following will get you started.
First, I cover the basic soft-tissue treatments, numbered for quick reference. Next, I provide guidelines for which techniques to use with particular conditions.
Treatments
1. Deep Gliding with Broad Contact Surface (Plantar Surface)
Use the back side of the fist, palm, or forearm to perform a slow, broad, gliding stroke on the foot’s plantar surface. The client may be more comfortable with the treatment applied in one direction versus the other. Your work will not have the force to pull the plantar fascia farther from the calcaneal attachment.
2. Deep Gliding with Small Contact Surface (Plantar Surface)
Similar to the technique above, except a small contact surface is used. Use the fingertips, thumb, knuckle, or pressure tool to apply a long, slow, gliding technique to the soft tissues on the plantar surface of the foot (Image 1).
3. Active Engagement Lengthening: Deep Compartment Muscles
This method employs massage along with active muscle contraction. It’s an effective way to access the leg’s deep compartment muscles, which have tendons that extend into the foot. Use a small contact surface such as a fingertip or thumb to apply a slow, gradual stripping along the medial border of the tibia. The client is instructed to move the foot back and forth in dorsiflexion and plantar flexion. The stripping technique is applied as the foot moves into dorsiflexion (scan the “Active Engagement Stripping: Tibialis Posterior” QR code).
4. Sweeping Cross-Fiber and Broadening Strokes: Triceps Surae Group
The gastrocnemius and soleus muscles are collectively referred to as the triceps surae group. Use a sweeping motion of the thumb or surface of the palm to apply long, broad, cross-fiber strokes. Pressure levels can be varied depending on the severity of the condition and the client’s pain (Image 2).
5. Positional Release Applications: Foot/Ankle Complex
Positional release is a technique that works primarily at the neurological level. Placing tissues in a position that decreases adverse input from nociceptors helps decrease pain. Results are usually most effective when the target tissue is brought into a shortened position. However, with nerve conditions, this may not be the case. Since no specific position guarantees pain relief for every client, finding the best position is often a trial-and-error process.
Find a position that decreases discomfort the most. Sometimes it helps to press on tender areas first and then ask the client which position decreases pain more. Hold the position for 30–60 seconds, then slowly move the foot into a neutral position. This strategy can often reduce pain in a severe condition.
6. Myofascial/DNM Strategies
Myofascial therapy and dermoneuromodulation (DNM) are beneficial with neural sensitization and severe conditions. In this technique, a superficial force is applied to the skin that gently pulls it over the underlying fascia and connective tissues. Try pulling the skin in different directions to find the position that decreases most pain; hold that position for 30 seconds or so.
7. Metatarsal Spreading
This technique addresses a variety of pain complaints in the foot that affect the short intrinsic muscles between the metatarsal bones. It also reduces nerve entrapment between the heads of the metatarsals in Morton’s neuroma. Grasp the forefoot with both hands while the thumbs are on the plantar surface of the foot. Use the thumbs to produce a sweeping motion back and forth that encourages spreading and broadening of the metatarsals (Image 3, page 25).
8. Metatarsal Mobilization
Metatarsal mobilization treats nerve compression in Morton’s neuroma, but also has applications for other foot pain complaints. Grasp the forefoot with both hands, as in metatarsal spreading. Begin by holding the last four metatarsals with one hand and the first metatarsal with the other. Shift the metatarsals in relation to each other back and forth. Then move to the next metatarsal, so the one hand grasps three metatarsals and the other hand grasps two. Repeat the mobilization technique, shifting the metatarsals back and forth. Repeat the procedure through the metatarsals until you have worked each of the four joint spaces (scan “Metatarsal Mobilization” QR code).
9. Neural Mobilization: Tibial Nerve
Neural mobilization techniques apply a gentle tensile load on the affected nerve, along with dorsiflexion and plantar flexion movements. This action can encourage movement in the nerve where it may be compressed or compromised through narrow channels. Mobilization can affect the tibial nerve branches that extend down into the foot. To perform, pull the foot into simultaneous dorsiflexion with toe extension (adding neural tension). Then move the foot into plantar flexion (reducing the tensile load). Knee extension and hip flexion can be added into each stretch to enhance the effect but can add discomfort, so check in with the client (scan “Neural Mobilization: Tibial Nerve” QR code).
Conditions
The techniques described before address a variety of foot pain complaints discussed in the first installment of this series. However, it’s important to remember that no technique will work in every situation. Below are guidelines to consider for each condition.
Plantar Fasciitis
With plantar fasciitis, the client is likely to report pain when first putting weight on the foot in the morning. If the onset is recent or the pain is not severe, treatment may be more aggressive or use more significant pressure. However, keep pressure levels within the client’s comfort tolerance.
There may be compensatory tightness in the intrinsic foot muscles or the leg muscles, such as the tibialis posterior, which extends into the foot. So, it is beneficial to address the long muscles of the lower leg that extend into the foot near the plantar fascia.
The condition is likely to be considerably more painful in the later stages. As a result, treatment choice should be less intensive at the outset. Adjust pressure levels accordingly, and avoid aggravating the client’s pain.
A primary concern at the later stages of the condition is that chronic ongoing pain may increase neural sensitization (increased sensitivity of the sensory nervous system). Sensitization may gradually cause hypersensitivity and pain in other areas of the foot and lower leg. To address sensitization, general relaxation massage techniques throughout the lower limb are beneficial, even if they do not target the plantar fascia itself.
Beneficial techniques: 1, 2, 3, 4
Nerve Entrapment
Tarsal Tunnel Syndrome and Baxter’s Neuropathy: The treatment goal for both conditions is to relieve pressure on the affected nerve(s). The primary problem involves nerve compression, so avoid techniques that put additional pressure directly on the nerves on the medial side of the ankle or bottom surface of the foot. The best treatment approaches are indirect. A key strategy is to address tightness and irritation in the soft tissues contributing to biomechanical distortion or nerve compression.
Three tendons from the muscles in the deep posterior compartment can compress the tibial nerve in the tarsal tunnel area: tibialis posterior, flexor hallucis longus, and flexor digitorum longus. Massaging the tendon is not likely to accomplish much, but working on the contractile elements of the muscle in the deep compartment can help tarsal tunnel syndrome. This is an instance in which remote work away from the tarsal tunnel is beneficial.
In the early stages of tarsal tunnel syndrome and Baxter’s neuropathy, treatment can focus on the biomechanical factors leading to the nerve entrapment. Effective treatments address the leg’s superficial and deep posterior compartment muscles and soft tissues on the foot’s plantar surface. These lower-leg muscles can impair neural movement and frequently contribute to pain.
A concern at the later stages is the development of neural sensitization. Continual irritation of the nerves can cause localized or even generalized neural hypersensitivity. As a result, any sensory irritation can exacerbate the pain beyond what should be normal. It may also cause the increased sensitivity to extend up the lower leg and potentially up through the lower extremity. There is no easy way to combat neural sensitization, but smooth, easy gliding and myofascial techniques can relax and calm the tissues. Positional release is particularly helpful as well.
Beneficial techniques: 3, 4, 5, 6, 9
Morton’s Neuroma: The main issue with Morton’s neuroma is that the distal metatarsal heads are squeezed together, thereby pinching the digital plantar nerves. Shoes with a narrow toe box that squeeze the metatarsal heads together are the primary culprit. The best treatment strategy for this nerve compression is to relieve the pressure by choosing a shoe or boot with a wider toe box. A simple footwear change can resolve the issue.
Neural mobilization, metatarsal spreading, and metatarsal mobilization will help to decrease pressure on the nerve. However, if the individual experiences the same biomechanical factors that caused the nerve compression in the first place (shoes with a narrow toe box, for example), the compression and pain will continue. The same concerns about neural sensitivity in later stages or severe conditions are applicable here.
Beneficial techniques: 1, 2, 7, 8, 9
Muscle-Tendon Pathology
Muscles in the posterior leg have tendons that extend into the bottom of the foot. When these muscle-tendon units are under high tension, they can pull on their attachment sites on the plantar surface of the foot, causing plantar foot pain. This pain is often due to hypertonicity and dysfunction of the muscles. Any muscles in the lower leg or foot that act on the bones of the foot may be involved in muscle or tendon pathology.
Treatment often involves working on the lower-leg muscles, as the contractile portion of these muscles is in the lower leg, even though their tendons reach into the foot. Massage techniques should aim to address not only the directly affected muscles but also other muscles in the kinetic chain. Reducing symptoms helps calm the nervous system, even if long-term physical changes to the tissues are not being made.
As mentioned earlier, chronic irritation from nerve compression can lead to neural sensitization. It is also feasible that continual irritation from muscle-tendon pathology, trigger points, or unresolved pain could lead to neural sensitization. The most helpful massage strategies will address the affected muscles and other associated muscles that are part of the kinetic chain in the region.
Keep in mind that the key rehabilitation goal is to reduce symptoms and settle the nervous system. We don’t need to make long-term physical changes to these tissues to have beneficial treatment effects.
Beneficial techniques: 1, 2, 3, 4, 6
In Sum
Foot pain can be debilitating and lead to serious conditions that limit physical activity. We put extraordinary loads on the lower extremities daily. The simple act of walking or running can put several times our body weight on each foot strike. These cumulative loads can lead to any foot and leg complaints discussed in this article series.
Unfortunately, the feet and legs are sometimes ignored in massage treatment. Yet lower-extremity massage has resounding effects throughout the kinetic chain of our body. Pain that we might think is in the upper back and cervical region may have initiated in the lower extremities.
We help our clients the most when we address the entire body and appreciate the role of the lower extremity. Massage is a powerful treatment for lower-body conditions, bringing clients back to function after severe pain and dysfunction.
Whitney Lowe is the developer and instructor of one of the profession’s most popular orthopedic massage training programs. His text and programs have been used by professionals and schools for almost 30 years. Learn more at academyofclinicalmassage.com.