In my conversations with several leading massage therapists, some of whom are teachers of massage therapy, I learned that massage therapists often find it difficult to treat Plantar Fasciitis, which is a painful, foot problem. But, I have had some remarkable success utilizing a new approach that I have developed called Individualized Muscular Skeletal Therapy (IMST). This is a system of bodywork based on my experience treating a variety of maladies. The basic premise of this method is that each client with a muscular skeletal irregularity or dysfunction is not exactly the same as every other client with that same disposition. So, that, while two clients with plantar fasciitis may have pain in similar areas of the heel, each will compensate for that situation in different ways and IMST requires that treatment be adapted to each client's unique situation. Utilizing IMST the therapist looks at all the complex individual compensation patterns in the body. These include posture and movement patterns. The therapist must combine an understanding of anatomy on a deep level and the development of extreme tactile sensitivity. Manipulations must be done with extreme tactile sensitivity in the exact direction of correction and level of dysfunction.

Identifying Plantar Fasciitis*

Plantar Fasciitis is a painful inflammatory condition of the foot caused by excessive wear to the plantar fascia or plantar aponeurosis that supports the arches of the foot or by biomechanical faults that cause abnormal pronation.[1] The pain usually is felt on the underside of the heel, and is often most intense with the first steps of the day. It is commonly associated with long periods of weight bearing or sudden changes in weight bearing or activity. Jobs that require a lot of walking on hard surfaces, shoes with little or no arch support, a sudden increase in weight and over activity are also associated with the condition.

Plantar fasciitis was formerly called "dogs' heel" in the United Kingdom. It is sometimes known as "flip-flop disease" among US podiatrists. The condition often results in a heel spur on the calcaneus, in which case it is the underlying condition, and not the spur itself, which produces the pain.[1]

*From Wikopedia entries regarding Identification of Plantar Fasciitis and Conventional Treatment

Conventional Treatments of Plantar Fasciitis

Many different treatments have been effective. Without treatment resolution may be delayed for up to and over a year.[2] Initial treatment includes stretching of the Achilles tendon and plantar fascia, keeping off the foot as much as possible, weight loss, arch support, heel lifts, and taping.

There are a few simple maneuvers that may bring relief without need for further intervention.[3] Many sports medicine practitioners suggest placing a frozen bag of corn or even a cold beverage can under the affected foot and rolling it back and forth using the foot. This method provides a stretch and an ice massage simultaneously.

However, if these strategies are ineffective, the problem may require referral for Physiotherapy. The mainstays of Physiotherapy include myofascial release and scar tissue breakdown of the plantar fascia, and supervised stretching. People with plantar fasciitis should be careful to wear supportive and stable shoes. They should avoid open-back shoes, sandals, and flip-flops.

To relieve pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are often used but are of limited benefit.[4]. It's important to lessen activities which place more pressure on the balls of the feet because these increase tension in the plantar fascia. This is counter-intuitive because the pain is in the heel, and the heel is often sensitive to pressure which causes some people who have plantar fasciitis to walk on the balls of their feet.

Local injection of corticosteroids often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic and injected slowly with a small-diameter needle.[5] Recurrence rates may be lower if injection is performed under ultrasound guidance.[6] Repeated steroid injections may result in rupture of the plantar fascia. This may actually improve pain initially, but has deleterious long-term consequences.

In cases of chronic plantar fasciitis of at least 10 months duration, one recent study has shown high success rates with a stretch of the plantar fascia.

Pain with first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon before getting out of bed. Night splints can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease morning pain. These have many different designs, some of which may be hard and may press on the origin of the plantar fascia. Softer, custom devices, of plastizote, poron, or leather, may be more helpful. Orthoses should always be broken in slowly.

Recently, extracorporeal shockwave therapy (ESWT) has been used with some success for symptoms lasting more than 6 months. The treatment is a nonsurgical procedure, but is painful, and should be done either under sedation, or with local anaesthesia either with or without intravenous sedation (twilight sedation). Local anaesthesia by injection of drugs into the area can also be painful, and may incur the risks of neuritis, bleeding, and infection. ESWT re-inflames the area and in doing so increases blood flow to the area as a means to heal the area. It can take as long as six months following the procedure to see results. Results are variable, and one 2002 study reported ESWT for plantar fasciitis had no benefit.

Most often plantar fasciitis improves within one year of beginning non-surgical treatment, without any long-term problems. Surgery is sometimes required, and is successful about 95% of the time.

Surgery

Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure of the pain to improve. Surgical procedures, such as plantar fascia release, are a last resort, and often lead to further complications such as a lowering of the arch and pain in the supero-lateral side of the foot due to compression of the cuboid bone. An ultrasound guided needle fasciotomy can be used as a minimally invasive surgical intervention for plantar fasciitis. A needle is inserted into the plantar fascia and moved back and forwards to disrupt the fibrous tissue.

Coblation surgery (aka Topaz procedure) has been used successfully in the treatment of recalcitrant plantar fasciitis. This procedure utilizes radiofrequency ablation and is a minimally invasive procedure.

An Individualized Approach

The Individualized Muscular Skeletal Therapy (IMST), as applied to the treatment of plantar fasciitis is an alternative to the complex, long term and sometimes dangerous conventional procedures, described in this article. IMST requires the therapist to look at all the complicated compensation patterns in the body that have emanated from this condition.

To determine the obstacles to foot healing in the body I begin each therapeutic session with an evaluation. This assessment is done with palpation and observing posture and movement patterns. I discuss with my clients what I see and let them know about some of the less obvious causes of plantar fasciitis that may be at the root of this condition. For example, there is the possibility that the lower leg muscles are very involved in plantar fasciitis, which is true in many cases.

It is not uncommon in the treatment of Plantar Fasciitis to find there are problems to be addressed in tendons, connective tissues, muscles, ligaments and joints. The techniques I commonly use are connective tissue manipulations, deep tissue massage, trigger point therapy, joint placement and alignment techniques and joint mobilization all done with extreme tactile sensitivity and an understanding of anatomy and anatomical relationships in the body.

I have found that this new individualized approach can be different for people with the same plantar fasciitis condition. Every client's plantar fasciitis has a unique quality to it and the therapist's choice of technique has to be adapted to it. The direction of stroke and the depth of dysfunction should be very precise, which means the therapist's determination of exactly which direction to stroke in a given area and how deep needs to be individualized to the specific needs of the client.

For example, some people can develop plantar fasciitis due to a functional leg length discrepancy. This means the client has one leg which is longer than another thereby causing a trauma on the foot when walking because one leg is longer than the other leg. Another client may have a problem with plantar fasciitis due to a fall which results in pain in the foot thereby causing the foot to be dysfunctional. Should this happen walking on it will become painful.

In these two different very typical kinds of situations there is the same diagnosis, i.e. plantar fasciitis. But, treatment to rectify this condition will not be the same in each case due to their different causes and the variations in the extent and depth of each client's dysfunction. To illustrate how this happens in real life, I have provided a couple of case histories from my practice. Client A: Plantar Fasciitis due to a fall

Client A, who is a 57 year old mother of three children, came to see me a year after the symptoms of plantar fasciitis started. She had fallen down badly while going down a flight of stairs. I started therapy on her plantar fasciitis a year after the trauma occurred. She mentioned to me that, for a year prior to the fall, she had been wearing one of her shoes one size bigger than the other due to the pain and the inflammation of her foot during that time. When she fell she hit her right glute region and her right foot forcefully with great impact. When her foot hit the ground, all five of her toes were flexed.

I started the sessions with her by mobilizing the shoulder region because there was compensation causing shoulder rotations from the trauma when the right glute was hit. I then did some connective tissue manipulation of pectoralis major, pectoralis minor, and subscapularis. Also, I utilized some joint alignment techniques to the head of humeris on an agle to take the shoulder and put it back in alignment in the exact direction of correction and level of dysfunction.

At this point I did work to take her out of a right anterior rotation of ilium (rari) to relieve trauma to tissues caused by the fall. I began with psoas lift doing connective tissue manipulations on superior portions of muscle to help set up glutes for the work in the exact depth of dysfunction and direction of correction needed. I then did some deep tissue and connective tissue manipulations on glute medius.

I found that the direction of correction was very complicated. So, I did almost J hooking technique commonly used for spine on glutes because there was a very deep depth of dysfunction. I then did trigger point work on piriformis and the quadradus femoris muscle which referred all the way down the leg into the foot on the dorsal surface. I followed this with work on the interossium membrane to create a proper balance between the tibia and fibula in order to prepare the foot for the work to come.

The foot was very inflamed but the treatment on the other areas I just described was necessary to set up the direct foot work in order to rectify the plantar fasciitis. After this preparation I focused on the injury itself by working on the peronial tendon on the ankle. The ankle felt sticky from connective tissue dysfunction. On the foot itself I worked on the dorsal surface to create the proper space between all toes in an exact direction of correction to put the bones in the right position.

The plantar surface of the foot felt like an adhesive pad from very dysfunctional connective tissues. I did connective tissue work on the plantar surface as I was working in the exact direction and layer of dysfunction. At times I did straight strokes other times I went a little left or right.

By doing the proper preparation before attending to the injury itself, I achieved amazing results and the tissue returned to health quickly. The outcome of these sessions was, as follows:

1) after 2 months of weekly treatments the pain was gone and
2) after 2 ½ months of weekly treatments the inflammation was completely gone.
3) The client 2 years later feels very good. The problem never returned and she can wear any type of shoe and do any activity without any problem.

Client B Plantar fasciitis due to leg length Discrepancy

Client B is a 47 year old nurse who came to me 6 months after the symptoms of plantar fasciitis began. But, she did not know the cause of these symptoms. They just seemed to start suddenly one day. She went to a physician who diagnosed plantar fasciitis.

I started therapy on her 6 months after the pain started. When I was doing my evaluation of her condition I found a functional leg length discrepancy. Client B's plantar fasciitis resulted from the trauma that occurred when she walked for a long period of time with one leg longer than the other.

I started Client B's sessions working on gluteus medius which was very short. I did connective tissue manipulations in an exact direction of correction and level of dysfunction with an extremely detailed focus. Then I found periformis shortened and did very detailed and precise connective tissue strokes medial to laterial in an exact level of dysfunction and direction of correction. Next, I directed the client to lie down on her sides where I worked on connective tissue and did deep tissue manipulations on the quadradus lomborum muscle on the attachments to the iliac crest in a very precise detailed manner going to the deep portion of the muscle in an precise direction and level of dysfunction. I used my knuckles to deeply manipulate the muscle and at the same time positioned the crest of the pelvis. It was a very complicated type of manipulation.

I followed this with work on bicep femoris which was very short on the right side in a very detailed precise deep tissue manipulation with an exact depth and direction of correction. I then did work around the ankle to prepare the feet for manipulations so it could be as efficient as possible.

The foot work was extremely detailed and precise with connective tissue strokes on the plantar side of the foot and on the entire foot from the laterial side to the medial side. The direction of correction was several directions and very complicated. The level of dysfunction was deep.

It took 5 months to correct the leg length discrepancy. The plantar fasciitis was completely gone in 7 months and after about 3 years it has yet to return.

CONCLUSION

Bodywork is the combination of science and art. Creativity is very important just as understanding the relationships of anatomical structures is very important. We as bodyworkers need to master science and the art of manipulation. We need to learn what happens to the function of the body when it is dysfunctional so we can understand compensation patterns and rectify problems as efficiently as possible. This applies to plantar fasciitis as well as many other injuries and pain problems that clients can have.

In this article I demonstrated that plantar fasciitis can be rectified with IMST (Individualized Muscular Skeletal Therapy) which means that the treatment is different for every person with the same condition, in this case plantar fasciitis.

Some of the key elements to rectify and evaluate plantar fasciitis are postural analysis, palpation, and gait .Treatments are precise detailed in an exact depth of dysfunction and direction of correction and extreme tactile sensitivity is needed .Every injury or pain condition has a unique quality to it and it is up to the skilled therapist to find the best treatment for each of his or her clients' injuries or dysfunctions as efficiently as possible.