Massage therapy can ease chronic heel pain caused by plantar fasciitis and plantar fasciosis, but it’s essential to understand how both conditions differ.
By Donna Shryer, November 1, 2019
Massage therapy can ease chronic heel pain caused by plantar fasciitis and plantar fasciosis but first, it’s essential that you understand how both conditions differ. Why is this important? Because plantar fasciitis and plantar fasciosis call for the exact opposite approach to massage therapy.
Both conditions involve the plantar fascia, the thick ligament that runs across the bottom of your foot and connects your heel bone to your toes. This band of tissue supports the arch of your foot and acts as a shock absorber. When the plantar fascia experiences repetitive tension and stress, it can suffer small tears and become painfully irritated.
Podiatrists use the umbrella term plantar fasciopathy when referring to plantar fascia-related conditions in general. Plantar fasciopathy is common, affecting 1 in 10 people during their lifetime. Fortunately, nonsurgical treatments, including massage therapy, are shown to resolve 90 percent of all cases within 12 months.1, 2
Plantar fasciopathy is described as an overuse or repetitive strain injury, like carpal tunnel syndrome or tennis elbow.3 The root cause of the condition is varied, including high arches, flat feet, pronation, obesity, menopause, pregnancy, middle-age, older age, shoes lacking support, tight Achilles tendon, tight calf muscles, foot trauma and standing, running, hiking or walking for long periods of time.4
Plantar fasciitis and plantar fasciosis fall under the plantar fasciopathy umbrella, with both conditions characterized by a stabbing pain near the heel and usually most painful with the morning’s first few steps or after extended inactivity. But that’s where the similarity between the two conditions ends.
Plantar fasciitis involves chronic inflammation of the plantar fascia. Remember those small tears from repetitive tension and stress discussed earlier? The body’s natural response to these injuries—as with most injuries—is inflammation, which triggers plantar fascia stiffness and heel pain.
Plantar fasciosis is a somewhat recently identified condition, first described in 20035 and previously lumped together with plantar fasciitis. Plantar fasciosis is a noninflammatory degeneration of the plantar fascia—but despite this striking difference, the name is still often used interchangeably with plantar fasciitis.
“Plantar fasciosis is a condition in which dysfunctions that result in plantar fasciitis symptoms are left untreated for a long time,” explains David Edwards-Smith, licensed massage therapist in Soldotna, Alaska, and founder of Structural Assessment Algorithm Seminars. “So, one of my first questions for a client with chronic heel pain is, ‘How long has this been going on?’ If the answer is six months, we’re strongly considering plantar fasciosis. If it’s only been a few weeks, it’s probably plantar fasciitis and, therefore, directly reducible with manual therapy.”
Plantar fasciopathy is an umbrella term to describe overuse injuries that harm the plantar fascia and cause chronic, stabbing heel pain. There are two plantar fascia conditions—each representing a distinct phase of damage.
Plantar fasciitis is phase 1, distinguished by inflammation. The benchmark inflammation is caused by small tears in the plantar fascia due to repetitive tension and stress on the plantar fascia. Massage therapy, with a focus on stretching and strengthening techniques, is associated with improved function in plantar fasciitis clients and may reduce heel pain.2
Plantar fasciosis is phase 2, characterized as non-inflammatory. At this point, the plantar fascia has begun to degrade. This advanced stage can result if plantar fasciitis is not properly treated in a timely manner. There are no conclusive studies to prove that massage therapy can remodel the degrading ligament, although it is anecdotally reported that techniques meant to soften and shorten the plantar fascia do help. The goal is to increase the flow of nutrient-rich, oxygenated blood to the area and thus create a healthy environment to slow or stop tissue degradation.
Both conditions are manageable, but with a caveat, emphasizes Doug Nelson, licensed massage therapist in Champaign, Illinois, and founder/president of Precision NMT seminars. “As massage therapists, we have the hands-on capacity to treat the plantar fascia—but only if we understand he problem,” Nelson says. “That’s key, since plantar fasciitis often involves stretching the plantar ascia, which only further irritates plantar fasciosis.”
Here’s a look at how massage therapy needs to be adjusted for these two distinct plantar fasciopathy disorders.
Plantar fasciitis calls for massage techniques that stretch the client’s foot and posterior calf muscles, particularly the soleus and gastrocnemius muscles. “Damage to the plantar fascia is minimal at this point, so massage therapy can bring very quick results,” says Garry Adkins, licensed massage therapist and massage therapy educator in Southfield, Michigan.
Historically, a combination of myofascial and deep tissue massage have been used to treat plantar fasciitis and relax painfully tight muscles back into a normal posture, explains Erin Revels, licensed massage therapist in Clayton, North Carolina. Revels, who works beside a physical therapist and chiropractorat the Goldsboro Spine Center, cautions against treating plantar fasciitis with a primary focus on the pain source. “I’ve never had a plantar fasciitis client who didn’t have tight fascia in other areas of the leg, especially in the calf. These muscles are normally tight because they’re trying to balance out the soleus and gastrocnemius muscles, which are also too tight.”
Adkins has recently been putting an indirect, gentler spin on this traditional therapy—with strong results. “You still elongate, or stretch, the area, but you gently sink into one layer at a time. I’ve had clients get off the table after one session and say their heel pain is 80 percent better. This is after they’ve had cortisone injections and physical therapy, and still no relief.”
Giving massage therapists a heads up, Adkins adds that this gentler approach is physically demanding. “It takes 30 minutes to treat just one foot. But seeing such relief on a client’s face when they realize their heel pain is better—that’s amazing.”
Plantar fasciosis often calls for a very different approach than the one typically applied to plantar fasciitis, Nelson says. “Your goal is to soften and shorten the plantar fascia to increase blood flow to the area. If you can increase the flow of nutrient-rich, oxygenated blood, you’re creating a healthy environment to slow or even stop tissue degradation. Overly aggressive treatment and stretching can potentially undermine this goal.”
Your focus, Nelson adds, needs to be on the abductor hallucis muscle, a foot muscle that participates in the abduction and flexion of the big toe. “That muscle can put pressure on the medial plantar nerve, and if that muscle is in any way restricted, blood flow to the plantar fascia is restricted—which invites degradation of the tissue.”
Edwards-Smith points to another distinct plantar fasciosis characteristic, which is time. “With fasciosis, the condition has progressed to degenerative and you need to reverse tissue damage. The tissue will remodel, and the client is not permanently impaired, but increasing circulation to the area takes time and load management. You have to go slowly and avoid grinding into that ligament. It’s trying to heal.”
To this end, the goal is to unload the tissue around the plantar fascia and make sure everything has optimal movement to encourage blood flow. “That’s where I feel a manual therapist plays an important role, although there are no studies to my knowledge that confirm a link between massage and plantar fasciosis,” Edwards-Smith says.
The fine line between plantar fasciitis and plantar fasciosis is complicated by the fact that no gold standard tests for diagnosing either condition exist. So to help identify the problem, Edwards-Smith relies on an evidence-based assessment algorithm. “You look at the entire foot—beyond the heel—as well as the calf. Does your client’s foot move fluidly? Is there pronation? Supination? Proper plantar flexion extension? Can you identify a lack of movement between foot bones? I’m not talking about a diagnosis. This is an assessment to determine a technique relevant to the presented condition.”
As for whether or not the massage therapist chose the right technique, there’s no definitive test for that, either. “Podiatrists, physical therapists, massage therapists—we all must use clinical reasoning skills to guide our approach to treatment,” Nelson explains. “If a client says they have plantar fasciitis and they’ve done everything that every health care provider asked them to do to treat inflammation but nothing helps, that’s a good indication that, in fact, inflammation is not the problem. Maybe the condition has progressed to fasciosis and as a massage therapist, I need to look at therapies that restore optimal circulation to the plantar fascia.”
Regardless of the diagnosis and appropriate therapy, plantar fasciitis and plantar fasciosis are treatable—although both can return. “I think it’s important to warn clients that the pain relief massage therapy brings isn’t permanent—not unless they figure out the original cause and find a solution,” Revels says. “That’s a discussion that needs to happen with a doctor.”
When the plantar fascia is restored to good health, the original injury’s cause is addressed and, if necessary, massage therapy sessions for maintenance are scheduled, then it’s very likely that heel pain got the boot.
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1. Monteagudo M, de Albornoz PM, Gutierrez B, Tabuenca J, Álvarez I. Plantar fasciopathy: "A current concepts review." EFORT Open Rev. 2018; 3(8): 485–493. Published 2018 Aug 29. doi:10.1302/2058-5241.3.170080; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134886
2. Fraser JJ, Corbett R, Donner C, Hertel J. "Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review." J Man Manip Ther. 2018;26(2):55–65. doi:10.1080/10669817.2017.1322736. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901427
3. Karabay N, Toros T, Hurel C. "Ultrasonographic evaluation in plantar fasciitis." J Foot Ankle Surg. 2007; 46(6):442–446.
4. Monteagudo M, de Albornoz PM, Gutierrez B, Tabuenca J, Álvarez I. "Plantar fasciopathy: A current concepts review." EFORT Open Rev. 2018; 3(8): 485–493. Published 2018 Aug 29.doi:10.1302/2058-5241.3.170080; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134886
5. Lemont H, Ammirati KM, Usen N. "Plantar fasciitis: a degenerative process (fasciosis) without inflammation." J Am Podiatr Med Assoc. 2003;93(3):234–7; https://www.ncbi.nlm.nih.gov/pubmed/12756315