5 minutes: Attendance and Breath of Arrival

  50 minutes: Problem Solving Ankles and Feet

Punctuality- everybody's time is precious:

o  Be ready to learn by the start of class, we'll have you out of here on time

o  Tardiness: arriving late, late return after breaks, leaving early

The following are not allowed:

o  Bare feet

o  Side talking

o  Lying down

o  Inappropriate clothing

o  Food or drink except water

o  Phones in classrooms, clinic or bathrooms

You will receive one verbal warning, then you'll have to leave the room.

Plantar fasciitis Pain in the plantar fascia due to collagen degeneration (tearing or softening of collagen fibers in connective tissues).

Plantar fascia Tough band of irregular fibrous connective tissue that supports the medial longitudinal arch of the foot.

Proximal attachment •  Bony matrix and periosteum of the anterior calcaneus •  Note: because this is a much smaller attachment site,

there is a higher concentration of tensile force per square millimeter leading to a much greater likelihood of plantar fasciitis here

Distal attachment •  Fascia of the metatarsals and toes

Function •  Maintain plantar foot stability and absorb shock in the foot

High tensile forces are generated in the plantar fascia: •  At the end of the push-off phase of gait •  During normal weight-bearing

Excessive tensile forces can cause: o  Pain in the very sensitive periosteum of the proximal attachment

o  Bone spurs in the proximal attachment that can lead to collagen degeneration and increased tensile forces on the remaining the proximal plantar fascia fibers

Being overweight, sudden changes in activity levels, and excessive running especially in worn down shoes can predispose people to plantar fasciitis.

Overpronation Combined ankle eversion, abduction, and dorsiflexion.

Neutral Overpronation Underpronation

Pes planus (AKA: flat foot) Longitudinal arch is broken down with the entire sole of the foot touching the ground.

Pes cavus (AKA: high arch) Condition characterized by increased height of the foot’s medial longitudinal arch.

Chronically shortened gastrocnemius and soleus muscles while sleeping at night with ankles in plantarflexion adds tension to the plantar fascia

Orthotics o  Effective: if dysfunctional biomechanics are a cause

Rest from offending activities o  Effective: allows the fascia to heal o  Offending activities include standing, running, and walking

Corticosteroid injections o  Variable effectiveness: may leak into the fat pad causing it to

degenerate and the plantar fascia to rupture

Tension night splint o  Effective: Conditions the plantar fascia to tensile stress o  Reduces the tensile load on the calcaneal attachment o  Looks like a soft cast. Holds the ankle in very slight dorsiflexion

Cryotherapy o  Variable effectiveness: inflammation not always a factor

Extracorporeal shock wave lithotripsy o  Variable effectiveness: may help reduce bone spurs o  Similar treatment is used to break up kidney stones.

o  The goal is to reduce chronic tensile load on the proximal attachment

o  Stretch gastrocnemius, soleus, and toe flexors after soft tissue treatment and several times per day

o  In early stages of treatment when the plantar surface is very tender, focus on the gastrocnemius, soleus, and tibialis posterior

o  Cryotherapy after soft-tissue treatment is helpful to reduce soreness

o  Use caution with any technique that aggravates symptoms

Soft-Tissue Manipulation: Overview Prone

Posterior lower leg Superficial fascia assessment Myofascial release

Foot (plantar surface) Swedish Deep longitudinal stripping Plantar fascia deep transverse friction

Posterior thigh Swedish

Gastrocnemius and soleus Swedish Deep tissue forearm effleurage

Side-Lying (both legs if needed) Tibialis posterior Deep longitudinal stripping Deep longitudinal stripping with active movement

Supine Gastrocnemius and soleus stretch

Posterior lower leg superficial fascia assessment o  Use your palm and fingers to apply light tangential pulling pressure o  Place your hand flatly on the skin surface o  Press in just enough to traction the superficial fascia without sliding o  Slowly traction in all directions taking note of restrictions o  Use before and after treating superficial fascia to gauge progress

Posterior lower leg myofascial release o  Work without lubricant facing either up or down the table o  Place your hand flatly on the skin surface o  Press in just enough to traction the superficial fascia without sliding o  Use your palm and fingers to apply light tangential pulling pressure o  Hold. Wait for a palpable tissue release or indication from the client o  Repeat to address restrictions in the entire calf

Foot (plantar surface) Swedish o  Thumbs circles and wringing

Foot (plantar surface) deep longitudinal stripping o  Strip proximally for client comfort and reduced tensile stress o  Use thumbs to work in 2-4 inch sections o  Pause and repeat in areas of tension o  Progressively work more deeply as tissues soften

Plantar fascia deep transverse friction o  Use fingertips or thumbs o  Focus on the area just distal to the calcaneal attachment o  Use moderate pressure within the comfort of the client o  If painful, reduce pressure. There may be a bone spur o  Work for 1 minute o  Return to this technique several times throughout the session

Posterior thigh Swedish o  Work from general to specific to general o  Effleurage, full, wring, and knead

Gastrocnemius and soleus Swedish o  Effleurage, fulling, wringing, kneading, and longitudinal stripping o  Don’t stop until the muscles are thoroughly warmed and softened

Gastrocnemius and soleus deep tissue forearm effleurage o  Use a forearm working proximally o  Start light and progress to moderate and deep pressure if comfortable o  Be sure to address all of the lateral, medial, and posterior fibers

Positioning and Draping o  Bolster the head using the face cradle cushion o  Top leg is resting on a bolster with the hip and knee slightly flexed o  Bottom femur is pointing toward the foot of the table o  Bottom knee is slightly flexed to prevent joint pain during strokes o  Slide the sheet under the front side of the leg to uncover from the o  patella down

Tibialis posterior deep longitudinal stripping o  Be cautious about your pressure. This may be intense o  Use fingertips or thumbs to work on the bottom leg o  Strip proximally just medial to the tibia o  Work in 2-4 inch sections. Pause and repeat in areas of tension o  Progressively work more deeply as tissues soften

Tibialis posterior deep longitudinal stripping with active movement o  Use fingertips or thumbs on the bottom leg o  Instruct the client:

•  “Slowly alternate between flexing and extending your foot.” o  During dorsiflexion, strip proximally along the medial border of the tibia o  Cover only 2-4 inches per dorsiflexion o  During plantarflexion, pause and hold your position o  Repeat in areas of tension o  Progressively work more deeply as tissues soften