Master Plantar Fasciitis By Working With Trigger Points and Functional Pairings

Plantar fasciitis. The term alone can send shivers down the spine of even the most experienced manual therapist. This common complaint, characterized by sharp heel and plantar pain, often presents as a frustrating, treatment-resistant puzzle, with standard treatments yielding poor results. Traditional approaches typically focus on the plantar fascia itself – stretching, rolling, icing – but the Coaching The Body® approach invites us to look deeper, to understand the intricate web of muscular relationships that are likely the true root of this discomfort. The payoff for this insight is the ability to get great results when other approaches fail. 

My own feelings about this diagnosis evolved when I was first learning trigger point therapy from head-scratching confusion to a sense that this condition had been grossly misunderstood and mishandled.

By applying the concepts that I had developed for Coaching The Body®, working with functional pairs, movement and neurological distraction, I found that I could restore ankle mobility and have a huge impact on plantar fasciitis in a single session. Today's article and video show how you can get those kind of results with your own clients.

Traditional approaches typically focus on the plantar fascia itself – stretching, rolling, icing – but the Coaching The Body® approach invites us to look deeper, to understand the intricate web of muscular relationships that are likely the true root of this discomfort. The payoff for this insight is the ability to get great results when other approaches fail.

The CTB Lens: Plantar Fasciitis as a Symptom of Muscular Imbalance

The CTB philosophy centers on several key principles:

• Protection: The CNS is a protector, always seeking stability and safety above all else. Pain is a manifestation of the CNS protecting the body against perceived threats. Trigger points and taut fibers can be used by the CNS in a well-meaning but misguided attempt to stabilize joints under threat, 
• Interconnectedness: Muscles do not work in isolation. They are intricately linked through functional relationships, creating chains of influence throughout the body. This network interacts with a separate network of satellite pain referral.
• Neuroplasticity: The brain can change and adapt. We can influence the nervous system through carefully selected interventions.
• Satellite Referral: Pain often refers from one area of the body to another via trigger point pain referral. This can be easily misinterpreted as local injury, if the therapist isn't aware of referral patterns. When a direct referral from a trigger point lands over another muscle, it creates a hidden, remote influence that can be difficult for inexperienced practitioners to trace. 
• Perpetuating Factors: These are the chronic stresses, often structural and habitual, that create an environment where muscles are more likely to develop trigger points.

Applying these principles, we view plantar fasciitis not as an isolated disease condition but as a symptom of imbalance. The plantar fascia, that thick band of connective tissue running along the bottom of the foot, is often the victim, not the villain. 

The term plantar fasciitis is an example of a diagnosis in which the name presumes the cause - and therefore the treatment. This is very misleading, because it encourages an assumption that we should treat the fascia itself to resolve the pain, which is not an effective strategy. There are three ways in which trigger points in muscle can lead to the condition that we call plantar fasciitis:

• Several muscles exhibit a pattern of direct pain referral over the heel and plantar fascia, leading to a diagnosis of plantar fasciitis even without any actual inflammatory tissue response in the area. The phenomenon of trigger point pain referral demands that we separate the experience of a pain sensation from the assumption of local tissue inflammation, because the latter is usually absent. 
• The chronic occurrence of referral over the fascia may lead over time to autonomic changes and actual local inflammation - although this must be viewed as a symptom, not a cause.
• Taut fibers from trigger points cause muscles to shorten and lose range due to protective splinting. In the complex, carefully orchestrated balance of the ankle stirrup, this can alter foot mechanics and cause overload in local muscles. Trigger points in some muscles may cause excess tension on parts of the plantar fascia.

Key Muscular Contributors: Untangling the Foot-Calf-Hip Connection

While the plantar fascia may be the site of discomfort, several muscles, located both distally and proximally, are often implicated in plantar fasciitis, creating a complex web of dysfunction. Let’s break down the key players:

1. Soleus: A primary offender in many cases, the soleus is the deeper calf muscle that provides most of the foot's propulsive power. When stressed, it can cause pain that radiates into the heel and Achilles tendon, mimicking plantar fasciitis. Trigger points in the soleus can develop from overuse, hyperpronation, and biomechanical imbalances.
2. Gastrocnemius: While the gastrocnemius is a more superficial calf muscle, it works with the soleus in plantar flexion. Its involvement often exacerbates tension in the plantar fascia and contributes to limited ankle dorsiflexion (a critical factor in plantar fasciitis) and heel pain through referral patterns.
3. Tibialis Anterior: An antagonist to the calf muscles, the tibialis anterior runs along the shin. Chronic tension in the soleus inevitably causes trigger points in the tibialis anterior, making it difficult for that muscle to shorten. Both tib anterior and soleus will then limit ankle dorsiflexion, placing more stress on the plantar fascia. This will affect weight transfer from heel to forefoot and limit toe clearance during swing phase of gait.
4. Peroneals (Longus and Brevis): These muscles run along the outside of the lower leg and provide lateral stability to the ankle. They are often compromised by hyperpronation. Peroneal trigger points cause lateral ankle pain.
5. Long flexors and extensors of the foot: The direct referral from the long flexors lands in the plantar fascia, and these muscles are often stressed by hypermobile ankles and feet in an attempt to claw the toes to provide stability.
6. Intrinsic Foot Muscles: The small muscles within the foot itself play a crucial role in supporting the arches and plantar fascia. They are vulnerable to satellite referral from larger muscles, such as the soleus, long flexors, and glutes.
7. Gluteus Medius and Minimus: A seemingly distant connection, the glutes can be a primary factor. Trigger points in glutes contribute to poor stabilization throughout the kinetic chain, especially in the lower leg and foot, leading to excessive load on the plantar fascia. Gluteus medius is the most common source of low back pain and refers to the glutes, lateral hip, and posterior lateral leg, sometimes with referral down to the plantar surface. Gluteus minimus, the “sciatic muscle,” causes referral down the leg, sometimes stopping before the ankle, or sometimes down to the plantar aspect of the foot.
8. Quadratus Lumborum (QL): This deep back muscle, which stabilizes the pelvis and connects to the ribs, is often a silent instigator. The QL is a powerhouse muscle that will develop trigger points when the pelvis is laterally tilted. Its referral patterns often include hip, low back, and lateral leg pain, which can contribute to the symptoms and pain patterns we see in plantar fasciitis. QL also has a functional relationship with the glutes and is very sensitive to effective leg length discrepancies.
9. Adductors (Longus and Magnus): These inner thigh muscles, especially adductor magnus, have a strong influence on the hip and contribute to pelvic stability, but they are also a powerful influence on the lower leg and foot. Adductor longus may be shortened due to pelvic rotation, and adductor magnus refers pain into the medial leg and foot and is a primary antagonist of the TFL.

Designing An Effective Treatment

With a clear picture of the potential muscular culprits, therapists face the daunting task of creating a treatment plan that covers all of the necessary muscles and assessments in a reasonable amount of time. We know from many years of teaching our method that treatment design is one of the most challenging hurdles faced by new therapists.

We have created protocols for the major pain areas of the body that guide the therapist through the muscles relevant to a complaint. This is an immense time-saver, because trying to design a treatment of this sophistication on the fly would take many hours. 

Using the CTB Protocols With Plantar Fasciitis

The CTB Core Protocol for the Lower Body, which is taught as part of our Foundation Bundle, is a great starting point for treating plantar fasciitis complaints. It covers the distal referral muscles that set up lower leg pain, along with a simplified treatment section for soleus and tibialis anterior. 

The Core Protocol can be expanded to a more detailed foot/ankle treatment very easily. Our Advanced and Complete Bundles cover the complete Foot/Ankle Protocol, inserting a more detailed section in addition to the brief initial work with tib anterior and soleus. This makes a complete plantar fasciitis treatment possible in approximately 90 minutes for an experienced CTB practitioner.

CTB Treatment Cycle for Individual Muscles: We adapt a general cycle of treatment steps to the unique character of each muscle. 

• Palpation: Assess for taut bands, tenderness, and twitch responses.
• Initial Softening: Use manual compression, therapeutic vibration (like the Muscle Liberator), or EPS (Electronic Point Stimulator) over the trigger point area to reduce hypersensitivity.
• Work Into Short: Gently move the muscle into a position of shortening, applying compression or vibration to minimize any protective muscle engagement as it shortens.
• Work through Range: Move the muscle through its full range of motion, maintaining gentle compression or vibration, allowing the CNS to see the muscle working without pain.
• Contract/Relax (MET): Engage the muscle against mild resistance and allow a gentle stretch.
• Reassess and Repeat: Continuously evaluate progress and repeat the cycle as needed, moving from muscle to muscle as is appropriate.

The Treatment Cycle is ideally applied to a muscle in combination with its functional antagonists (“working both sides of the joint”). We’ve spent many years coming up with useful treatment positions that accomplish this for each muscle grouping. 

Here is a summary of a typical CTB treatment for plantar fasciitis: 

1. Assessment: History, palpation for trigger points, range of motion for the ankle, knees, hips, and pelvis, gait analysis, and assessment of LLD, hyperpronation, and breathing mechanics. Many of these assessments can be done during the bodywork session.
2. Initial Treatment (Supine): Many of the initial assessments are done in supine - for example, the Crossover Stretch is likely to reveal any long referrals from the hips that may be contributing to pain in the lower leg. We assess and treat the adductors and any hip flexor or hip extensor compensations. 
3. Side Position Treatment for Glutes and QL: Move to side position and focus on the hip and gluteal muscles using the "Hip over Knee" positions. Then use the extended leg position and address the QL and TFL if needed. 
4. Detailed Lower Leg Treatment (Supine): Return to supine, treating the contributing lower leg muscles in detail using the CTB Treatment Cycle.
5. Resolving Stretches: Finish by combining deeper stretches and contract/relax, such as a version of the “crossed legged forward fold” to target the glutes, adductors, QL, and spinal erectors.
6. Address Perpetuating Factors: Suggest corrective lifts to compensate for LLD, hyperpronation management with appropriate footwear and the CTB Hyperpronation Correction System.
7. Self-Care Education: Empower clients to maintain the new state of homeostasis with home-based strategies using compression balls, therapeutic vibration and contract/relax stretching.

Conclusion: Empowering Clients Through Understanding

Plantar fasciitis, while frustrating, presents a wonderful opportunity for us to apply the holistic, interconnected principles of Coaching the Body®. Inflammation doesn’t just magically appear. As a CTB Membership student, you will learn to quickly move past the mistaken assumptions that tend to keep clients stuck, and restore the muscular balance that clients need to once again walk normally, and live, work and play without pain.

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