This subject came up in a conversation with a client so I wanted to do some research and this is what I found. BTW, I’m a big supinator!  

Supination and pronation in the foot are terms used to describe the mechanics of how you stand, walk, and run. Ideally, your weight should be balanced on your feet as you move. Your feet shouldn’t lean in (pronation) or out (supination). In a proper stride, your foot should roll forward from heel to toe.

As you walk or run, your feet “roll” from side to side a bit with each stride. This movement is called pronation, and there is an optimal degree of it. If you overpronate or underpronate (also called supination), these mechanical problems can, over time, cause injuries. And, because the feet are the foundation that supports your body when you are upright, overpronation and supination can have a ripple effect, causing issues in your knees, hips, and back.

Pronation vs Supination

WHAT IS OVERPRONATION OF THE FOOT?

Overpronation is when the arch of the foot collapses excessively downward. This causes the foot to roll too far toward your centerline. Overpronation can result in a number of injuries including:

• Iliotibial (IT) band syndrome (inflammation of a ligament on the outside of the knee)
• Stress fractures in the foot or lower leg
• Shin splints
• Heel pain
• Achilles tendonitis
• Bunions
• Plantar fasciitis
• Chronic lower back pain
• Patellofemoral pain syndrome

Pronation causes include flat, flexible feet with little or no arch. Pregnancy, obesity and regularly running long distances can also cause or intensify overpronation. Signs that you overpronate include:

• No clear space between your foot and the floor where your arch should be
• For runners, more tread wear on the inner part of your shoes
• Footprints that show a connection between your heel and toes that is the full width of your foot (this should be about half the width of your foot)

Treatment for overpronation may include wearing more supportive shoes, wearing orthotics, and doing exercises to strengthen your arches and the surrounding muscles.

WHAT IS THE SUPINATION OF THE FOOT?

Supination (or under pronation) is when your weight rolls onto the outer edges of your feet rather than slightly inward as it should. This results in you pushing off with your smaller toes at the end of your stride rather than with the ball of your foot and big toe.  Excessive supination can cause:

• Ankle injuries
• Knee stress and pain
• Back and hip pain
• Plantar fasciitis

Supination causes include having an inherited problem with your foot structure. It can also be caused by weak muscles in your foot, ankle, or leg that result from wearing tight, rigid shoes, or prior damage to the tendons or muscles of the foot. Indicators that you supinate include:

• Shoe wear that is focused on the outer edges
• Little or no arch visible when you make a footprint
• Frequent ankle sprains

People don’t realize the importance of correct biomechanical function and the many effects that improper biomechanics can have on the entire body. Some people are able to compensate for these issues and remain completely asymptomatic, however many patients have foot, knee, hip, and back issues which are actually perpetuated by poor foot function and they never know it. The importance of a thorough foot and ankle biomechanical evaluation can make a profound impact on a patient’s life.

 LEARN MORE ABOUT SUPINATION CAUSES AND TREATMENT OPTIONS

Treatment for supination includes wearing lightweight everyday shoes with plenty of room for your toes, wearing running shoes designed for supinators, and using orthotic insoles to correct under pronation. Analyzing and improving your foot strike can have a positive impact on your body.

 

 

Massage for Foot Pronation and Supination

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.

Adding Clarity

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, a 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.”

At A Glance

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.

Technique Matters

Both conditions are manageable, but with a caveat, emphasizes Doug Nelson, a 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 the problem,” Nelson says. “That’s key since plantar fasciitis often involves stretching the plantar fascia, 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 has been used to treat plantar fasciitis and relax painfully tight muscles back into a normal posture, explains Erin Revels, a licensed massage therapist in Clayton, North Carolina. Revels, who works beside a physical therapist and chiropractor at 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.

Toeing the (Fine) Line

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.

BONUS

       

 

*Disclaimer: This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. The information provided is for educational purposes only and is not intended as a diagnosis, treatment, or prescription. The decision to use, or not to use, any information is the sole responsibility of the reader. These statements are not expressions of legal opinion relative to the scope of practice, medical diagnosis, or medical advice, nor do they represent an endorsement of any product, company, or specific massage therapy technique, modality, or approach. All trademarks, registered trademarks, brand names, registered brand names, logos, and company logos referenced in this post are the property of their owners.