Massage & Bodywork

July/August 2013

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Want more treatment options? Visit the Online Education Center at www.abmp.com to see Whitney Lowe's webinars, where he explores specific treatment approaches for common pathologies. Medial plantar artery 2 traditionally thought of as inflammatory (i.e., tendinitis; "itis" refers to inflammation) appear to result from collagen degeneration instead Abductor hallucis (i.e., tendinosis, which refers to pathology of the tendon). The abductor hallucis and the In 2003, a podiatrist medial plantar artery. 3D anatomy named Harvey images. Copyright of Primal Pictures Lemont reviewed Ltd. www.primalpictures.com. specimens of plantar fascia from patients who had undergone surgery for the condition.1 He found no evidence of inflammatory activity in any of these specimens. What he did find was widespread evidence of chronic degeneration and necrotic tissue in the plantar fascia. Since the tissue samples came from those with severe plantar fasciitis, there is still a question as to whether inflammation is a factor in early onset of the condition. However, cortisone injection treatments generally do not last and only provide short-term relief, which indicates that, at least for those with chronic conditions, inflammation may not be a persistent factor. 2 New Concepts in Etiology Ray McClanahan, DPM, a podiatrist in Portland, Oregon, suggests that the primary problem in plantar fasciitis is biomechanical dysfunction in the foot—along with footwear that impedes natural function. This leads to improper circulation, chronic tissue overload, and the resultant degenerative process that produces plantar foot pain and plantar fasciosis (heel pain).3 Restricted blood flow to the tissue caused by wearing improper shoes is a key issue, according to McClanahan. He points to the common narrow toe box that bunches the toes together, the often seen "toe spring" that raises the hallux and toes into extension, and the elevated heels found in most shoes. Unfortunately, the vast majority of shoes people wear today contain these elements. Tightness and/or spasm in the abductor hallucis muscle is another key issue, as this muscle can pull on the flexor retinaculum and decrease blood flow to the plantar fascia, leading to tissue necrosis and dysfunction.4 The abductor hallucis muscle is located on the medial side of the foot. The medial plantar artery passes under the abductor hallucis muscle before supplying blood to structures on the bottom surface of the foot, including the plantar fascia (Image 2). McClanahan's points are well taken. One of his tests is quite insightful: pull the insole out of your shoe and stand barefoot on it. It is remarkable how much the natural foot simply does not fit today's narrow styles, even in athletic footwear. Of course, years ago there were more options for narrow, medium, and wide shoes. Benny Vaughn, an expert in the massage profession and an athletic trainer who has worked with a diverse abundance of sports professionals for 40 years, points to problems along the entire chain of the vastly complex fascial connections of the lower body that he believes also lead to plantar fasciitis. What is apparent to Vaughn is that the condition is not confined to the bottom surface of the foot and calf. Vaughn's conclusions and treatment successes make sense. There are fascial connections extending from the bottom surface of the foot through the posterior calf and thigh region that continue up the back and neck to the head. Thomas Myers identified these interconnections as the superficial back line and illustrates and describes these in his work.5 Tensile forces generated in tissues anywhere along this path can adversely affect the tensile load on the plantar fascia. Consequently, plantar fasciosis can www.abmp.com. See what benefits await you. 103

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