Trigger Point

Therapy of the
Lower Extremity

Heel and Foot

Pain
Thomas Bertoncino, PhD, ATC

Introduction
Dr. Tom Bertoncino ([email protected])
Pittsburg State University (Bachelors)
Kansas University (Masters and Doctorate)

Professional Experience

Athletic Trainer, Pembroke Hill High School

Athletic Trainer, HealthSouth Rehabilitation
Head Athletic Trainer, Park University
ATProgram Director, Park University
Department Chair of AT, Park University
Associate Professor, Park University

Objectives
Discover the sources of heel and foot pain
Determine which intrinsic soft tissues of the foot provide
stability of the arch
Examine how muscle imbalances can lead to a
dysfunctional gait pattern
Discuss how trigger points are formed and how taut
muscle bands lead to heel pain syndrome
Identify ways to treat trigger points by using various
manual therapy techniques

Sources of Heel and Foot Pain

Heel pain is the most

common foot problem and
affects 2 million Americans
every year.
(New York Times, 2012)

Sources of Heel and Foot Pain

Heel Pain Syndrome occurs from:
Sudden increase in activity
Repetitive stress, impact on the foot

Inadequate flexibility in the foot & calf muscles

Biomechanical dysfunction (i.e. over pronation)

Lack of arch support
Worn out shoes
Obesity
Too much time on the feet

Referred Pain from TRIGGER POINTS!

Sources of Heel and Foot Pain

Description of Pain
Heel and foot pain typically
present as a cramping, tight or
sharp pain that develops along
the medial longitudinal arch and
at the insertion of the fascia and
intrinsic muscles of the medial
calcaneal tuberosity.

Stability of the Foot

Regions of the Foot
Rearfoot
Calcaneus
Talus
Midfoot
Navicular
Cuneiforms
Cuboid
Forefoot
Metatarsals
Phalanges
Sesmoids

Within these three regions are four arches!

Stability of the Foot

Four Arches of the Foot
Medial Longitudinal
Lateral Longitudinal
Transverse
Tarsalmetatarsal
Metatarsalphalangeal

v Basic function of the

arch is to provide shock
absorption and foot
stability during
propulsion.

Stability of the Foot

Muscles of the sole of the foot that support the arches
can be divided into four layers. (Bowden et al., 2005)

Superficial Layer

Flexor Digitorum Brevis

Third Layer

Flexor Hallucis Brevis

Adductor Hallucis

Abductor Hallucis

Abductor Digiti Minimi

Second Layer

Fourth Layer

Lumbricles

Interossei

Quadratus Plantae

Flexor Digiti Minimi

Stability of the Foot

Superficial Layer

Flexor Digitorum
Brevis

Abductor Hallucis

Abductor Digiti
Minimi

Stability of the Foot

Second Layer

Quadratus Plantae

Lumbricles

Stability of the Foot

Third Layer

Flexor Hallucis Brevis

Adductor Hallucis

Stability of the Foot

Fourth Layer

Flexor Digiti Minimi

Plantar Interossei

Dorsal Interossei

Stability of the Foot

Plantar Fascia
Gives shape to the arch by forming
a truss with calcaneus,
midtarsals, and metatarsals.
This truss prevents the spreading
of the calcaneus and the
metatarsals to maintain the medial
arch.
Creates a windlass mechanism
during weight bearing. During toe
off, toes extend and the plantar
fascia pulls the calcaneus forward
and lifting the arch even more to
give more stability.

Stability of the Foot

Other soft tissue that supports the arch

Deltoid Ligament

Plantar calcaneonavicular Spring Ligament

Short Spring Ligament
Intermetatarsal Ligaments

Stability of the Foot

Deltoid Ligament
Complex
Anterior Tibiotalar
Tibionavicular
Tibiocalcaneal
Posterior Tibiotalar

Stability of the Foot

Plantar Calcaneonavicular
Spring Ligament
Short Plantar Ligament

Stability of the Foot

Intermetatarsal
Ligaments

Treating heel and foot pain starts

with a thorough assessment of the
lower extremity!

(Whyte-Ferguson et al., 2005)

Inspection of Mechanics
Inspection of Gait
Inspection of Joint and Soft Tissue
Restrictions

Inspection of Foot Mechanics

Historically, literature attributes plantar fasciitis to
excessive pronation, which increases stress applied to
medial musculofascial tissue. However, plantar fasciitis
with high arches have been reported.
(Bolgla et al., 2004)

Inspect Mechanics
Forefoot Valgus
Rearfoot Valgus
Forefoot Varus
Rearfoot Varus
Fick Angle

Inspection of Foot Mechanics

Forefoot Valgus

With rearfoot in the

neutral position, the 5th
MT is elevated relative
to the 1st MT.

Inspection of Foot Mechanics

Rearfoot Valgus

The calcaneus is everted

relative to the long axis of
the tibia and can be
associated with a valgus
tibial alignment. Rearfoot
valgus is rarely observed.

Inspection of Foot Mechanics

Forefoot Varus

The rearfoot is in a
neutral position, but
the 1st MT is elevated
relative to the 5th MT.

Inspection of Foot Mechanics

Rearfoot Varus

The calcaneus is inverted

relative to the long axis of
the tibia and may be
related to a varus
alignment of the tibia or
calcaneus.

Inspection of Foot Mechanics

Fick Angle

The angle of the foot is

approximately 5-18
degrees from the sagittal
axis of the body

Inspection of Gait
Two Phases of Gait

Stance Phase
Swing Phase

Inspection of Gait
Stance Phase

Heel Contact
Flat Foot
Midstance
Heel Off
Toe Off

Inspection of Gait
Heel Contact

Begins the instant the

foot touches the ground
Foot is slightly supinated
(~5 degrees)
Opposite leg is ending
with toe off

Inspection of Gait
Flat Foot
Starts when the entire plantar
surface of the foot comes in contact
with the ground.
The subtalar joint pronates to unlock
the midtarsal joints, allowing the foot
to become more flexible.

Metatarsal Break

During the Metatarsal Break,

weight is directed through the
midtarsal region: from the 5th
metatarsal, cuboid, navicular,
cunieforms and then to the
metatarsals.

Inspection of Gait
Flat Foot Continued

Also, during pronation the

talus slides anteriorly
increasing the distance
between the calcaneus and
metatarsals and applies a
tension stress to the plantar
fascia.

Inspection of Gait
Midstance
The point where the bodys weight
passes directly over the supporting
lower extremity.
The foot starts to slightly supinate
back occurs in the subtalar to
prepare for push off.
During supination, the talus moves
posterior into the ankle mortise.
The windlass mechanism begins.

Supination transforms the foot into a

rigid lever arm needed for propulsion!

Inspection of Gait
Heel Off

The instant the heel

comes off the
ground.
The body moves
ahead of supporting
joint.

Inspection of Gait

Toe Off
Transition period of
double support.
Involves a shift from
pronation to slight
supination as propulsion
is achieved.

Disorders result if the shift from

pronation to supination fails to occur!
(Whyte-Ferguson et al., 2005)

Inspection of Gait
A lack of shifting from pronation
to supination causes:

Weight-bearing to be placed on the

medial aspect of the heel.
Shearing forces that originate from the
medial calcaneal tubercle.
Eventually, the lack of toe off will
result in the entire limb to abduct
creating more stress on the medial
calcaneal tubercle.
The fascia and tendons of the intrinsic
muscles start to pull away from their
calcaneal origin.

Inspection of Gait

WHY?
The excessive pronation or lack of shifting
occurs because of shortened muscle groups.

Intrinsic Foot Muscles

Triceps Surae

Inspection of Gait
Lets Critically Analyze this Situation!

Normally:
The triceps surae stretches as the body weight pass
over the foot.
For Example: During Midstance

When the posterior muscle complex reaches its

normative reflex length, it contracts and affects
heel lift.

For Example: During Heel Off

There is a balance between supination and pronation.

All is Well!

Inspection of Gait
However!!!

A shortened posterior muscle complex

causes the heel to lift much sooner in
the gait cycle.
For example: During Flat Foot or Midstance

A lifting of the heel activates the

intrinsic foot muscles to stabilize the
foot.
A lifting of the heel activates the
windlass mechanism to stabilize the
foot as well.

The foot becomes locked or rigid much sooner than it should!

It is locked in a pronated position, never moving back into supination,
thus causing medial heel and foot pain!

Inspection of Gait

When the foot becomes locked in this

pronated position, the first MPJ does not
fully extend for normal toe off. Then, the
foot must evert as well as the entire limb
must abduct abnormally to accommodate
the restriction of motion at the first MPJ.
Stress is placed on the medial side of
foot.
Medial weight bearing is de-stablizing
which often causes subtalar and
midtarsal joints to collapse and create
flat feet.
Thereby increasing risk of trigger
points and plantar fascia tears.

Inspection of Gait
As problem continues to persist and pain worsens, the
patient will naturally move away from pain.
They start to walk on the lateral side of foot.
Walk on toes to avoid heel contact.
Form calluses on the lateral side of foot.
All of which further shorten muscles that further place
you in eversion.
Lateral intrinsic foot muscles
Peroneal muscles
Biceps femoris
TFL

Inspection of Joint and Soft

Tissue Restrictions

Joint Mobility

Talocrural joint
Subtalar joint
Midtarsal joint
First metatarsal
phalangeal joint

Soft Tissue Mobility

Intrinsic foot
muscles
Triceps surae
Peroneals
Hamstrings
Deep hip rotators
TFL

End Feel Restrictions

Abnormal Joint End Feels
Muscle Spasm

Caused by movement with a sudden dramatic stop of movement often

accompanied by pain.

Capsular

Very similar to tissue stretch, however, occurs earlier in the ROM and
tends to have a thicker feel.

Bone-to-Bone

Similar to the normal bone-to-bone type but restriction occurs before the
end of ROM would normally occur (e.g. osteophyte formation).

Empty

Detected when considerable pain is produced by movement. Movement

cannot be performed because of the pain, although no real mechanical
resistance is being detected. (e.g. subacromial bursitis).

Springy Block

Occurs where one would not expect it to occur; found in joints with
menisci. There is a rebound effect.

Treatment of Heel and Foot Pain

v Treatment of TRIGGER POINTS
often will improve mobility as well as
correct gait mechanics.

Treatment of the locked foot involves

delaying heel lift until later in gait!
(Whyte-Ferguson et al., 2005)

Treatment of Heel and Foot Pain

What are trigger points?

Palpable, hyperirritable, tender knots or

taut bands in muscles.
(Lo, 2010)

Treatment of Heel and Foot Pain

What contributes to trigger point formation?

Emotional stress and tension

Postural strain
Biomechanical dysfunctions
Trauma
Fatigue
Sleep deprivation
Prolonged immobility
Infections
Initiating factors of trigger point formation include excessive
mechanical forces, overload, repetitive loading which damages
fibers throughout the muscle.
(Gerwin, 2008)

Treatment of Heel and Foot Pain

Where are trigger

points found?

Muscle

Can also be found in:

Trigger points in skeletal

muscles usually develop
at the origins , insertions
and bellies of muscles,
particularly at the
neuromuscular junction.
(Grace, 2011)

Fascia
Ligaments
Tendons
Periosteum

Treatment of Heel and Foot Pain

Three Types of Trigger Points
1. Active
Ongoing and persistent muscular pain
Tender to the touch
Causes pain to be referred to other body parts
Leads to muscle weakness and may prevent them from fully stretching
2. Latent
Only painful when compressed
Do not refer pain to other parts of the body
Thought to cause of joint stiffness and reduced range of motion as we age
3. Satellite
Develop at the point of referred pain of an active trigger point
For example, an active trigger point in the calf muscles can create leg pain
and eventually a satellite trigger point in the referred pain area of the heel

Treatment of Heel and Foot Pain

Increased tension of the taut muscular bans associated
with TrP can maintain displacement stress on the
joint. Alterna;vely, joint hypomobility may reflexively
ac;vate TrPs. It is also conceivable that TrPs provide a
nocicep;ve barrage to the dorsal horn neurons and
facilitate joint hypomobility.

(Penas, 2009)

Treatment of Heel and Foot Pain

v Start with Joint Mobilization Techniques to realign joints and to correct tissue length.

Common sites of joint restriction

1. Talus may be anterior (reduced posterior glide).

2. Calcaneus may be posterior (reduced anterior
glide); hypermobility in a posterior direction
increases the tension placed on the plantar fascia
and intrinsic muscles.

3. First cuneiform-navicular joint maybe dropped

rather than maintaining the normal arch.

Treatment of Heel and Foot Pain

Other joint restricted sites

1. Cuboid may be dropped

2. Tarsalmetatarsal joint
3. Metatarsalphalangeal joint

Treatment of Heel and Foot Pain

Joint Mobilization

Talocrural

Tarsals (Cuboid/Navicular)

Treatment of Heel and Foot Pain

Joint Mobilization

Subtalar

MP Joint

Treatment of Heel and Foot Pain

v Next, apply Trigger Point Release Techniques to get taut tissue to release.

Trigger Point Release Techniques

1. Ischemic Compression slow, progressive pressure

until taut band subsides, followed by a gentle
stretch.
2. Stripping deep, firm stroking pressure along the
length of the taut band

The application of IC is a safe and effective method

to successfully treat elicited myofascial trigger points.
The purpose is to deliberate the blockage of blood in the
trigger point area in order to increase local blood flow.
This washes away waste products, supplies necessary
oxygen and helps the affected tissue to heal.
(Montanez-Aguilera et al., 2010)

Treatment of Heel and Foot Pain

Trigger Points and Pain Referral Patterns

Flexor Digitorum Brevis

and Abductor Digiti Minimi

Treatment of Heel and Foot Pain

Trigger Points and Pain Referral Patterns

Abductor Hallucis

Treatment of Heel and Foot Pain

Trigger Points and Pain Referral Patterns

Adductor Hallucis
and Flexor Hallucis Brevis

Treatment of Heel and Foot Pain

Trigger Points and Pain Referral Patterns

Quadratus Plantae

Flexor Digiti Minimi

v An isolated pain pattern is not established for flexor digiti minimi;

however it is similar to abductor digiti minimi.
(Travell et al., 1992)

Treatment of Heel and Foot Pain

Soft Tissue Mobilization

Intrinsic Muscles

The patient is long sitting. The

clinician presses on or strips the
intrinsic muscles under medial
border of the plantar fascia, while
extending and adducting the big
toe.

Treatment of Heel and Foot Pain

Soft Tissue Mobilization

Deeper Layers of Intrinsic

Muscles
The patient is prone with the knee
flexed and the ankle dorsiflexed. The
clinician applies deep pressure with
the elbow to tender trigger points,
while the forefoot is slightly
dorsiflexed.

Treatment of Heel and Foot Pain

Soft Tissue Mobilization

Triceps Surae
The patient is prone with the
knee flexed. Ischemic pressure is
performed on the trigger point
within these muscles while
rocking the ankle into plantar
flexion and dorsiflexion to stretch
the taut bands of the muscles.

Treatment of Heel and Foot Pain

Soft Tissue Mobilization

Triceps Surae

With the patient prone and the

knee straight, pressure is
performed on the gastrocnemius
trigger points while rocking the
ankle into plantar flexion and
dorsiflexion, thus stretching the
taut bands of the muscle.

Cross Country Education

Copyright 2013 Thomas Bertoncino

60

Treatment of Heel and Foot Pain

Soft Tissue Mobilization

Soleus, Gastrocnemius,
Posterior Tibialis

The clinician strips and

performs localized tissue
traction along the entire length
of the muscles.

Treatment of Heel and Foot Pain

Other Muscles that Contribute to Heel and Foot Pain
Peroneal Longus and Brevis
Triceps Surae
Hamstrings
Tensor Fascia Latae
Deep Hip Rotators

These shortened muscles contribute to valgus

at the knee and pronated position of the foot!

Treatment of Heel and Foot Pain

Trigger Points and Pain Referral Patterns

Peroneal Longus and Brevis

Treatment of Heel and Foot Pain

Trigger Points and Pain Referral Patterns

Triceps Surae

Treatment of Heel and Foot Pain

Trigger Points and Pain Referral Patterns

Hamstrings

TFL

Treatment of Heel and Foot Pain

Trigger Points and Pain Referral Patterns

Deep Hip Rotators

Treatment of Heel and Foot Pain

v If more manual therapy is needed, apply Muscle Energy Techniques to improve
ROM and decrease muscular hypertonicity.

Muscle Energy Techniques

1. A technique that uses voluntary
muscle contraction(s) in a controlled
direction, at varying levels of intensity,
against a counter force.
2. Based on the premise that joint
misalignments occur when the body
becomes unbalanced due to muscle
spasms, weak muscles being
overpowered by a stronger muscle, or
restricted mobility of a joint.

Treatment of Heel and Foot Pain

Application of Muscle Energy Techniques

Isometric Contraction involves very little force.

Isotonic involves using just enough force to allow motion at an
even, controlled speed.

1. Joint is moved to its pain-free end range and held by the

therapist
2. Patient performs a pain-free sub-maximal isometric contraction
for 5 seconds
3. Patient takes a deep breath and relaxes
4. Patient actively (or passively) moves joint toward new limit of
motion
5. Repeat the sequence 3-5 times

MET of Dorsiflexion Restriction at

the Talocrural Joint

The patient is short sitting.

Therapist sits in front of the patient and
supports the plantar surface of the
forefoot with one hand while placing the
webbing of the other hand against the
talus.
The dorsiflexed barrier is engaged by a
combination of dorsiflexing the foot and
applying posterior force to the talus.
The patient then plantarflexes against the
therapist unyielding resistance, for 5-7
seconds, utilizing no more than 25% of
available muscle strength.
On complete relaxation, the therapist
engages a new restriction barrier.

MET for Shortened Gastrocnemius

and Soleus

The patient is long sitting.

The heel lies in the palm of the hand.
The other hand is placed so that the
fingers rest on the dorsum of the foot
(these are not active and do not apply
any pulling stretch), with the thumb on
the sole.
Starting at the restricted barrier, the
patient is asked to plantarflex against
unyielding resistance.
The contraction is held for 7-10 seconds
or up to 15 seconds for chronic
conditions.
On relaxation, the foot is dorsiflexed, with
patients assistance, to a new restriction
barrier.

Treatment of Heel and Foot Pain

Home Treatment Program of Trigger Points

Treatment of Heel and Foot Pain

Myofascial Entrapments

Treatment of Heel and Foot Pain

Nerve Tissue Mobilization
Stretching and weakening of the medial
plantar structures can inflame:
Posterior tibial nerve
Calcaneal or superficial branch of the
lateral branch of the posterior tibial nerve
v (Baxters Nerve)

Treatment of Heel and Foot Pain

Trigger Points and Pain Referral Patterns

Posterior Tibial

Flexor Digitorum Longus

and Flexor Hallucis Longus

Treatment of Heel and Foot Pain

Nerve Tissue Mobilization

Technique #1
The clinicians active contact is in the
arch, more dorsal and higher in the
arch than the calcaneal tubercle.
Initially, the foot is relaxed, and then
it is dorsiflexed and pronated to
stretch the tissues entrapping the
nerve. The stretch during contact is
repeated three or four times.

vDone both passively and actively!

Treatment of Heel and Foot Pain

Nerve Tissue Mobilization

Technique #2

The clinician contacts the points along

a line in the medial calf that are tender.
Contact is maintained while the nerve
is stretched by dorsiflexing the ankle
and pronating the foot. This is
repeated three or four times. Multiple
points of contact are treated by
advancing the contact up the medial
calf a few centimeters at a time, until
the whole extent of the nerve in the
calf has been treated.

vDone both passively and actively!

References

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R., Barrios-Pitarque, C., & Bosch-Morell, F. (2010). Changes in a patient with
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References

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References

Penas, C. (2009). Interaction between trigger points and hypomobility: A clinical

perspective. The Journal of Manual & Manipulative Therapy, 17(2), 74-77.
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Questions
& Answers