Stretching – The “Cornerstone” of Plantar Fasciitis Treatment
“Stretching is probably the top modality in treating plantar fasciitis, the number one commonly prescribed treatment and the cornerstone, essentially, of treating the foot,” according to Dr. Mark Vann, assistant professor of orthopedic surgery at the Baylor College of Medicine in Houston,Texas.
And according to pretty much every other plantar fasciitis expert you talk to.
“Some of the orthotics will put a lift in the heel enough that it takes the Achilles tendon out of it, and that’s why it makes it better,” says Dr. W. Hodges Davis, a Charlotte, North Carolina Foot and Ankle Surgeon and 2012-2013 President of the Outreach and Education Fund of the American Orthopaedic Foot & Ankle Society. “But ultimately, if you do stuff without stretching, it will come back. The vast majority of folks where it doesn’t go away completely, they’re the ones that don’t stretch.”
The two stretches with the most science behind them are heel-cord stretch [or, Achilles tendon stretching], and plantar fascia stretch, or dorsiflexion. These – and sometimes others – should be used in combination.
Stretching the Achilles tendon is an important part of as an important element in plantar fasciitis stretching exercises. The Achilles tendon, or “heel cord,” is tight in more than 90 % of plantar fasciitis patients. And that puts tremendous pressure on the plantar fascia. Stretching out the heel cord allows it to put less stress on the plantar fascia and helps make the plantar fascia able to heal. In fact, at least one group of physicians advocates, for surgery, not operating on the plantar fascia but operating to lengthen the Achilles tendon as a means of helping to heal the plantar fascia. Directly stretching the plantar fascia itself, of course, is extremely important as well.
My podiatrist gave me a number of stretches, but did not give me what many now think may be the most important stretching exercise: the non-weight-bearing plantar fascia stretch. One still finds this stretch left out of stretching instructions on some Web sites as well, because demonstration of its value is relative new. A 2003 article in the Journal of Bone & Joint Surgery reported a study of people who “had exhausted numerous other treatment methods, including a standard Achilles-stretching program,” in which plantar-fascia stretching was found to have superior results. The article describes, basically, as follows what you need to do:
- “The patient crossed the affected leg over the contralateral leg.” (the other leg) And what they didn’t say but showed in the photos in the AOFAS URL above, is that it’s ankle over knee.) “While placing the fingers across the base of the toes, the patient pulled the toes back toward the shin until he or she felt a stretch in the arch or plantar fascia. The patient confirmed that the stretch was correct by palpating tension in the plantar fascia.”
The idea of this stretch is to isolate the plantar fascia and work on that specifically.
“When you’re stretching the Achilles, you’re not necessarily stretching the plantar fascia,” says Debbie Nawoczenski, PT, PhD and professor in the Department of Physical Therapy at Ithaca College–Rochester Center, and a co-author of the 2003 article. “It’s most important that the (plantar fascia) stretch is done before you get out of bed. Once you’re upright, you have already set the pain cycle in motion. It gets better as you walk around, gets worse if you sit a long time and get up again. If you go for distance walking on hard surfaces it’s horrible again.”
“It’s not a lot of stretching,” she says. “Twenty to 30 seconds, five to ten reps. We don’t really know how many is optimal, but once the stretch is done before stepping on it, it seems to set the healing cycle in motion.”
People sometimes wear Night Splints for the same reason, she says. So the tissues are stretched out, and not contracted, when you step on the floor, when that morning pain comes from a tissue shock that aggravates inflammation and creates “micro-tears” in the tissue.
Of course, by the time many of us heave ourselves up from the pillow in the morning – or even during the night – we may be so ready to sprint for the bathroom that the time needed to perform this ten-times-the-count-of-ten maneuver may be hard to spare. Plus, we old fat boys can find it a difficult contortion, especially if we have an iffy lower back. Myself? I like to do the dorsiflexion by placing the front of my foot, in socks, with toes up against the wall, pressing it forward and down to stretch the toes up and, of course, holding that stretch for 30 seconds. Or when sitting at the kitchen counter, do the same thing with the little wall beneath the counter – whatever you have to do to do it a lot, any time during the day. Or, in sitting up on the edge of the bed in the morning, since my bed is next to a wall –separated only by the space needed to walk on that side — I use that wall. Whatever you have to do to dorsiflex the foot in the morning before getting out of bed, it’s certainly better than stepping immediately down to the floor and throwing your body weight on an un-stretched plantar fascia and causing pain and more damage.
Stretch #2: Achilles Tendon Stretch Against the Wall
Most commonly prescribed is the indirect stretching of the plantar fascia by the Achilles tendon stretch:
- Stand facing a wall, leaning into the wall with both hands, your affected foot stretched behind you with knee straight and keeping the heel on the ground, your unaffected foot beneath you with knee bent. It’s important to have your feet slightly “pigeon-toed,” the toes of your affected foot pointing toward the heel of your unaffected foot. Hold that stretch to a count of ten. Repeat this ten times. Do the whole thing three times a day.
How many reps eat time, and how many times a day — these aren’t magical numbers. My podiatrist said to hold the stretch 15 seconds, repeat three times, doing the whole thing three times a day. Dr. Davis says that when he himself was first hit with plantar fasciitis he “…started stretching immediately, aggressively, eight-nine times a day. I had one week of really bad pain, a week where it was better, and by three weeks it was back to no residual pain.”
“I tell my patients,” he says, “I’d rather they stretch for 30 seconds six or seven times a day than one time for three minutes. I’d rather have people stretch all day.”
This seems to work well for me. When I try to making an extensive and time-consuming ceremony of doing all the stretches for long periods of time, doing the whole thing once in morning, once inmiddayand once at night, I often start cutting the process because of how long it takes. If I take short stretching episodes whenever I have the chance, it seems easier to work them in.
Stretch #2-A: Achilles Tendon Squat Stretch
Another commonly prescribed version of the Achilles stretch is described with illustration on FootCare MD, a Web page of the American Orthopaedic Foot & Ankle Society (AOFAS) using material co-developed by the American Academy of Orthopaedic Surgeons:
- “…lean forward onto a countertop, spreading your feet apart with one foot in front of the other. Flex your knees and squat down, keeping your heels on the ground as long as possible. Your heel cords and foot arches will stretch as the heels come up in the stretch. Hold for 10 seconds, relax and straighten up. Repeat 20 times.”
Stretch #3: The Stair-Drop Stretch
This was the third stretch my podiatrist gave me. Stand backward on one step of some stairs (holding the walls or railings to keep yourself steady upright), or any other drop-off point where you can steady yourself with your arms. Front of foot on step, heels extended in space off the step. Lower heels until back of leg and Achilles are stretched as much as is not uncomfortable. Hold it for a 15-second count, said podiatrist, then rise up on front of foot until foot is level. Then drop down again and hold, then rise up again. Do this three times, podiatrist said, and do the whole thing three times a day. (Magic numbers? Nah, but like Dr. Davis advises, I tend to do this off and on throughout the day rather than just three times, and maybe I’ll just do it once or twice when I do.)
This stretch gives a special emphasis to calves and hamstrings as well as the plantar fascia, and that’s worthwhile, according to Dr. Davis.
“I do believe that stretching both the hamstrings and calf muscles as well as the plantar fascia is a first line of treatment and works in the majority of cases,” he says.
Stretching, Orthotics and Footwear…across the spectrum of self-cure, a common piece of expert advice is to choose what works for you and, if it hurts, don’t do it. However, best is to proceed with expert guidance.
Physical therapists, for example, will “spend a little time with you and show you the appropriate stretches,” says Nawoczenski. “If you do the stretch wrong, it will stress tissues you shouldn’t be stressing.”
“There are other things that physical therapists do that have also been shown to work,” she says. “Really nice manual therapy techniques to get really deep into the soft tissues. People who have had that kind of ‘trigger-point’ myofascial release in combination with stretching do even better than the stretch alone, but there are not a lot of people who know or do that.”
Physical therapists at outpatient or private practices with an orthopedic specialty – the Orthopedic Certified Specialist, or OCS – will know all the aspects of plantar fasciitis care, Nawoczenski says.
I do the Achilles tendon stretches, the plantar fascia stretch and the stair-drop stretch, a minimum of three times a day. I don’t always do all the reps, as many times and holding them as long as suggested. I DO do at least one of them whenever I have the chance throughout the day, amounting all together to more times than the minimum.
I follow the advice of Dr. Davis: start stretching “immediately, aggressively” throughout the day. You want to get better, right?
“It goes away completely, but it takes a while,” Dr. Davis says. “It’s not a lifetime sentence or a career-ender.”
Stretching Tip #1
A lot of the illustrations that show how to stretch show people doing it barefoot. NO BAREFOOT stretching and, in fact, no barefoot at all. When you get out of bed in the morning – even if you’ve had a night splint or done the plantar fascia stretching – you must not walk barefoot, says Ithaca College’s Debbie Nawoczenski. Step into a supportive piece of footwear, a slipper or slip-on shoe with arch support and cushioning.
“You have to be in something supportive,” she says. “Get good slippers and put insoles in the slippers, and inserts that you can get over the counter at a good running store. You want to stretch the plantar fascia but you don’t want it to micro-tear by barefoot walking. I even tell people to put on flip-flops or Crocs when they go into the shower, so they’re still not stressing the plantar fascia.”
When you are doing the Achilles stretch or other stretches (except for the bedside plantar fascia stretch), do it as you do the rest of your day: wear shoes with orthotics. Nawoczenski recommends eliminating barefoot altogether. Everybody likes to walk around the house in socks, but that’s equivalent to walking barefoot. And if you use house slippers, don’t – unless they’ve got good ach support or you first put orthotic arch supports in them.
And just to clarify, she adds, “shoes with orthotics” does not necessarily mean a custom arrangement, it can be an over-the-counter insole, just something supportive of the sole of the foot.
Stretching Tip #2
Also not made clear in many instructions, and some illustrations: stretching should be done slightly pigeon toed, or toe-in. During the Achilles stretches and during the stair-drop stretch.
According to Nawoczenski, “Toe-in during the stretch helps keep the arch from collapsing or dropping – and that is important for the Achilles. Otherwise, if the arch collapses (a person becomes ‘flat-footed’ during the stretch) then the stretch may occur in the midfoot/arch rather than the Achilles tendon. This may place increased stress on the soft tissues of the foot itself, and that is problematic for someone who already has foot pain.”
Reader Input: We welcome any comments on your own experience and insights, things you’ve tried and how it worked, etc.