By Whitfield Reaves
Plantar fasciitis is the most common cause of heel pain, and occurs in all types of athletic and active individuals. However, simply walking and standing on a hard surface may also cause symptoms. Plantar fasciitis is an inflammation and irritation of the plantar fascia, the connective tissue that supports the arch. Some orthopedic texts suggest the possibility of micro-tears in the fascia at or near its attachment to the calcaneus. Fifty percent of patients may also have a calcaneal heel spur.
Acupuncture treatment uses the extraordinary point Shimian M-LE-5 as the “target” zone for local treatment. This point is located on the centre of the heel in the region of the attachment of the plantar fascia to the calcaneus. Palpation will reliably help determine the precise site for needle insertion. Variations of paired needles at Shimian M-LE-5, possibly with electrical stimulation and/or thread moxa, are often effective as local points. Numerous other secondary points may be considered on the Kidney, Bladder and other related channels. And the inclusion of complementary procedures, such as orthotics for the correction of the biomechanics of the foot, often enhance clinical results.
Plantar fasciitis is the most common cause of heel pain, and occurs in all types of athletic and active individuals. It is commonly seen in runners, and may account for as much as 10 percent of all running injuries . However, simply walking and standing on a hard surface may also cause symptoms. Although acupuncture treatment of plantar fasciitis is sometimes difficult, the practitioner should always approach the condition with the expectation that some success may be achieved. With precise needling and the inclusion of complementary therapies, the percentage success may be quite acceptable.
Plantar fasciitis is an inflammation and irritation of the plantar fascia, the connective tissue that supports the arch. Some orthopedic texts suggest the possibility of micro-tears in the fascia at or near its attachment to the calcaneus. Fifty percent of patients will probably also have a calcaneal heel spur . Being overweight is seen in as many as 40 percent of male and 90 percent of female patients with plantar fasciitis . And while this is usually an overuse (repetitive stress) injury, it may be brought on by acute trauma in strenuous lower extremity activities.
The patient reports pain at the plantar aspect of the heel. Stiffness accompanies this pain, and symptoms may extend along the arch toward the region of Yongquan KID-1 and even as far as the toes. This disorder has a predictable aggravation of pain and stiffness in the morning when taking first steps, or upon standing after prolonged sitting or rest. The symptoms may be alleviated as the patient “warms up” and stretches the fascia with moderate activity. Runners will frequently report that there is no pain during the early stages of a run, only for it to return towards the end of or after a workout. Similarly, it is not uncommon to hear that symptoms are alleviated during the day but worsen at the end of the day.
By far, the most likely diagnosis of heel pain is plantar fasciitis, especially if it follows the predictable patterns of aggravation covered above. However, there are several other possible causes of heel pain that present like plantar fasciitis that the practitioner should not overlook. These include achilles tendonitis, achilles bursitis, and periosteal bruising.
With achilles tendonitis, the tendon will often be thickened and sometimes inflammed when compared to the unaffected side. And it will have a positive “pinch” test – pinching the tendon superior (proximal) to its attachment will produce pain. A positive pinch test directly at the calcaneal attachment may implicate the the achilles bursae. Both of these conditions – achilles tendonitis and bursitis – may refer pain to the heel.
With periosteal bruising, the pain is widespread across the plantar surface of the heel rather than point sensitive at Shimian M-LE-5 in the region of the fascial attachment. Also watch for “fat pad syndrome”, which results in bruising of the heel from repetitive stress due to a thinning fat pad. This is often seen in women and the elderly. And occasionally plantar pain can be referred from the soleus muscle, in what Dr. Janet Travell, in her text on trigger points, describes as “jogger’s heel” . Consider further orthopaedic evaluation to differentiate, if needed.
Some patients do not report the predictable pattern of heel pain that is worse on taking the first steps in the morning or after prolonged sitting. It is possible that periosteal bruising discussed above could present in this fashion. Additionally, the practitioner must always consider entrapment of the medial plantar nerve. The pain is often similar to plantar fasciitis, but the patterns differ; the patient usually reports the most relief in the morning, and pain worsens as the day progresses with use in walking, standing, and other activities. Again, orthopaedic evaluation may be helpful.
As for examination, start with palpation at the centre of the plantar surface of the heel. This is the extraordinary point Shimian M-LE-5 . Also palpate over the medial tubercle of the calcaneous, as the pain is often found on this medial surface of the heel. Pain with modest pressure from the finger or thumb strongly suggests plantar fasciitis, but you should compare sensitivity with the unaffected side. Pay attention, as you may be able to palpate a heel spur.
Plantar fasciitis is frequently associated with a change in training, such as increased mileage, hills or speed. A change in running shoe or running surface may also contribute to the condition. As with most lower-extremity injuries, consider having the patient evaluated for biomechanical imbalances of the foot. Some texts suggest that up to 80 percent of these injuries are due to excessive foot pronation . Anatomical problems, like decreased fat pad thickness, leg length discrepancy, or high or low arches may also increase the chance of developing plantar fasciitis.
Overview of acupuncture treatment
Plantar fasciitis is most commonly diagnosed under the category of accident/trauma. It is usually a repetitive stress disorder due to the accumulation of micro-trauma. However, occasionally it may occur as an acute strain. Inflammation is at the level of the tendons, ligaments and bone. There is qi and blood stagnation in the channels and collaterals. Internal organ imbalances may possibly contribute (see below).
It is recommended to treat twice a week for three weeks, and then re-evaluate. Most uncomplicated cases will show improvement within six treatments. In chronic cases, continue treatment at least once weekly after the first three-week period.
The four steps
The following are points and techniques to consider in the treatment of the plantar fasciitis. This protocol is organized into four steps, an approach that is useful in sports medicine acupuncture. It makes point selection and needle technique simple, logical and systematic. And it is both easy-to-understand and inclusive for acupuncturists from differing traditions and backgrounds.
Uses points and techniques that may have an immediate effect on the patient, such as a decrease in pain or an increase in range of motion.
Opposite Extremity (upper/lower) method
Needle Shaofu HE-8, the shaoyin corresponding point. This is an example of treating the yin surface of the palm for symptoms on the yin surface of the foot. This point is sometimes effective in plantar fasciitis, and may be the first technique used in the treatment protocol. After needle insertion, have the patient walk (weight bear) for up to five minutes. If there is improvement, retain the needle, and continue with the next steps.
Channel and microsystem points that are not located at the site of injury.
- Fuliu KID-7 plus Jiaoxin KID-8 or
- Dazhong KID-4 plus Shuiquan KID-5
Either of these two paired-point combinations may be helpful to activate the Kidney channel and treat heel pain symptoms. Needle on the affected side, using palpation to assist in point selection.
- Taichong LIV-3 plus Yongquan KID-1
Taichong LIV-3 benefits the tendons and ligaments. Yongquan KID-1 is an adjacent point located directly in the plantar fascia where it separates into bands attaching toward the digits. Use electrical stimulation between Taichong LIV-3 and Yongquan KID-1, a technique that frequently benefits.
- The region of Chengjin BL-56 and Chengshan BL-57
The calf muscles (the gastrocnemius and soleus group) should be palpated from the popliteal fossa at Weizhong BL-40 inferiorly to Chengshan BL-57. This area of the muscle may present with ashi points that are often incorporated into the treatment protocol. These may be considered secondary points.
Other points that may be used, include Sanyinjiao SP-6, the crossing point of three leg yin, and Yanglingquan GB-34, the hui-meeting point of sinews.
Points that benefit the qi, blood and the zangfu organs.
Plantar fasciitis is a repetitive stress injury and internal organ imbalances are therefore usually not causative factors. However, there are several zangfu patterns that may contribute to the condition:
- Liver qi stagnation, Liver yin deficiency and Liver blood deficiency
Liver imbalances may be observed in the patient with plantar fasciitis. These imbalances result in susceptibility of the tendons to inflammation and repetitive stress injury.
- Kidney deficiency
Deficiency in the Kidney and Bladder channels may increase the susceptibility of the plantar fascia to repetitive stress injury.
Local and adjacent points at the site of injury.
- The extraordinary point Shimian M-LE-5
The extraordinary point Shimian M-LE-5 is the “target” zone of the plantar fascia and its attachment to the calcaneus. This point is located in the centre of the plantar surface of the heel . All local needling is in relationship to Shimian M-LE-5. Palpation will help determine the precise site of needle insertion.
The following is a summary of several variations on this local point. The practitioner may consider from one ahshi point to as many as four needle insertions. This naturally will be determined by the signs and symptoms of the patient, and the size of the “zone of pain” on the calcaneus and the attachment of the plantar fascia.
1. Two points at Shimian M-LE-5
Two needles are inserted perpendicularly into the two most sensitive ashi points in the region of Shimian M-LE-5. The depth is about 0.5 inches, varying with each patient. Some patients have a very thin “fat pad” on the heel, making insertion depth less than 0.5 inch. Consider electrical stimulation.
2. “Medial” Shimian
Palpation often reveals point tenderness near the medial tubercle of the calcaneous. This is about one-third of the distance between Shimian M-LE-5 and the point Zhaohai KID-6. Consider this zone to be “medial” Shimian. Insert the needle at “medial” Shimian, directed toward the centre of the heel. The depth reached should be about 1 inch. Two needles may be used at this zone, determined by palpation. Electrical stimulation may benefit.
3. Shimian M-LE-5 + “medial” Shimian
“Medial” Shimian may be paired with Shimian M-LE-5 in the centre of the heel. The needle inserted in the region of “medial” Shimian will be roughly a 90 degree angle to a perpendicular insertion at the text location of Shimian M-LE-5 in the centre of the heel. In some cases, you could add a second set of needles, making four needles in total in this treatment protocol, in other word, two needles are perpendicular, in the centre of the heel and the other two are inserted from the medial side, directed towards the centre of the heel. Again, consider electrical stimulation on these four needles.
Comments on treatment technique
With each of these variations above, needling is directly into the plantar fascia at or near its attachment to the calcaneus – the site of qi stagnation and blood stasis. In theory, we are increasing micro-circulation through these tissues. However, with all direct needling comes the possibility of aggravation. Explain this to your patients so they can be prepared. The flaring up these tissues is often clinically beneficial.
Three depths of insertion
This technique may be more comfortable to the patient and reduce the possibility of aggravation. Use three depths of needle insertion during a 30-minute treatment session. For the first 10 minutes, the needles are inserted to a superficial depth. For the second 10 minutes, the needles are inserted deeper, to an intermediate depth. For the final 10 minutes, the needles are inserted to the deepest position. With this final depth, the needle approaches the plantar surface of the periosteum and the bone. If the needle hits the calcaneus, retract it slightly. Electrical stimulation may be used between paired points in each of the three depths.
Warm needling may also be considered in this treatment. Some practitioners avoid needling directly into the heel, and therefore use only thread moxa. While they report good results with this technique, the inclusion of the needle is recommended. Alternatively, you may follow the needle treatment with thread moxa at the site of insertion. Consider five small, rice grain-size threads on each point needled.
Illustrations by Deborah Kelley, LAc
Many thanks to Whitfield Reaves for permission to reprint this article. Whitfield teaches courses in the U.S., Canada and Europe on the acupuncture treatment of sport’s injuries and he maintains a private practice in Boulder, Colorado. He is the author of “The Acupuncture Handbook of Sport’s Injuries and Pain”.
Whitfield Reaves OMD, LAc holds a Doctorate of Oriental Medicine degree (SAMRA University of Health Sciences, 1983) and is a Professor at Southwest Acupuncture College. His training includes an internship in Beijing, China and his thesis, titled “Acupuncture and the Treatment of Common Running Injuries”, was one of the first English language works integrating traditional Chinese acupuncture with Western orthopedic and sports medicine. His clinical experience includes medical care for athletes at the 1984 Olympic Games in Los Angeles, as well as for numerous national track and field, triathlon, skiing, and cycling events over the past 25 years.