TREATMENT OF PLANTAR FASCIITIS WITH TRICEPS SURAE STRETCHING

Robert M. Goecker, DPM
Perry H. Julien, DPM

Introduction

The clinical condition known as plantar fasciitis is characterized by pain and inflammation secondary to strain on the intrinsic musculature and plantar fascia at their origin from the medial calcaneal tubercle. The classic physical examination finding is point tenderness at the anterior edge of the fascial attachment to the medial calcaneal tubercle. This usually coincides with a history of pain upon rising in the morning, pain after periods of non-weight bearing or pain after prolonged weight bearing. Several potential etiologies of heel pain exist which are beyond the scope of this paper. The primary etiology of heel pain relevant to this paper are biomechanical abnormalities of the foot which lead to increased strain on the tissues that originate from the medial calcaneal tubercle.

The plantar fascia, or aponeurosis, is composed of central, lateral, and medial bands that originate along the medial tubercle of the calcaneus. The plantar fascia courses anteriorly along the arch of the foot, where the fascia divides into slips which eventually insert into the sides of the proximal phalanx in each toe. At toe-off, hyperextension of the metatarsophalangeal joints results in tightening of the plantar fascia and assists with resupination of the foot. The plantar fascia functions through the windlass mechanism to depress the metatarsal heads and elevate and stabilize the longitudinal arch of the foot during gait. Therefore, with every step from heel rise to toe-off the plantar fascia is placed under tension.¹ In some patients, the tension within in this structure can become debilitating.

Multiple treatments have been recommended with various degrees of success for plantar fasciitis. Conservative modalities used to treat plantar fasciitis have included heel pads, orthotics, padding, strapping, stretching, physical therapy, non-weight bearing, NSAID’s, corticosteroid injections, etc. The majority of patients will improve or be fully relieved by nonsurgical treatment. However, even with appropriate treatment, plantar fasciitis may become chronic and recalcitrant in nature eventually leading to surgery. There is no definitive surgical treatment of recalcitrant plantar fasciitis that is without complications. Therefore, a continued search for an effective conservative modality useful in the treatment of plantar fasciitis exists. In today's healthcare environment there is a tendency towards active mobilization and rehabilitation. A review of recent literature has shown an increase use of aggressive stretching of the gastrosoleal complex for the treatment of plantar fasciitis.

Literature Review

Articles documenting the outcomes of nonoperative treatment of plantar fasciitis have for the most part shown excellent results.^2-4 However, there is no panacea in the treatment of plantar fasciitis.

One of the easiest and cost effective conservative modalities in the treatment of this condition is stretching. It is well accepted that an important contributing factor of plantar fasciitis is equinus.^{5, 6} Tightness within the Achilles tendon and gastrosoleal complex results in compensatory increased dorsiflexion of the first metatarsophalangeal joint during gait. Dorsiflexion of the first metatarsophalangeal joint via the windlass effect stretches the plantar fascia at its insertion. If the foot fails to resupinate at toe-off, increased strain is placed on the plantar fascia due to the windlass effect. Equinus has also been linked to an increased amount of pronation of the foot which causes prolonged eversion of the calcaneus during gait resulting in pathologic stretching of the plantar fascia. Therefore, it would only make sense that decreasing the tightness within the triceps surae would eventually have a positive effect on the plantar heel pain.

To learn more about the FootFlex Performance Stretching Device, visit www.footflex.com, call 704-948-1002, or write to SelfSource, 11515 Vanstory Drive, Suite 135, Huntersville, NC 28078