Soft Tissue Restrictions
1) tenderness and restriction along the plantarfascia in a distal to proximal or proximal to distal direction.
This often feels like rice crispies and more so than other areas of the body (except thoracolumbar fascia and/or ITB)
2) along the bony contours of the superior medial and lateral calcaneal borders
this is often tender and restricted, limited calcaneal rocking and tilting
3) the proximal lateral posterior calf - pt's with lower quarter muscle imbalances often have a restriction here, and it can refer distally into the foot, plus limit dorsiflexion
1) the talocrural joint is normally restricted in posterior glide, and more often than not, the medial portion of the talus is not moving posteriorly, but the lateral is. This causes toe out and compensatory overpronation, overstretching the plantarfascia during stance phase
2) the lack of dorsiflexion and the "too many toes sign" then lead to a decrease or complete lack of push off with the first ray, the longer this goes on, the more likely the restrictions in great toe extension, which should be up to 90 degrees passively
3) the subtalar joint may be restricted in medial/lateral tilt, upward rotation (dorsiflexion osteokinematically), or internal/external rotation (vertical axis)
1) Functional Release and TASTM to the plantarfascia
2) Functional release and TASTM to the posterior calf
3) some finishing touches of TASTM/functional release to the bony contours of the calcaneus to free up calcaneal rock
4) joint distraction and posterior glides to the talocrural joint, thrust as a progression for distraction
also remember to restore great toe extension with 1st MTP distractions and posterior glides if necessary, this will make #6 easier on the pt, thus increasing compliance.
5) home program of runners stretch with an emphasis on heel pushing into the ground and forward facing foot - no too many toes sign allowed!
6) the KEY to the home program is the The Strassburg Sock
If a patient wears this nightly, it will keep them in dorsiflexion and most importantly continue to activate the windlass effect which will keep their plantarfascia on stretch. They have to wear it at least 6 hours!
7) Progress on TASTM and joint mobilization - they should be better within 6 visits no matter how chronic their condition was!