Cupping and Dry Needling For Plantar Fasciitis

Plantar fasciitis is a common problem that accounts for more than 1 million patient visits per year (Riddle 2004).  One in 10 people will experience plantar fasciitis in their life time (Trojian  2019).  It can effect both active and sedentary people and it can at times be very challenging to get resolution of symptoms.  Treating people with plantar fasciitis was always a bit frustrating until I added consistent dry needling and cupping.   As I began thinking with a  neuro-inflammatory approach and systemic method of treatment I became much more effective.  

In this article we want to discuss what plantar fasciitis is, risk factors surrounding plantar fasciitis, and the rationale behind our treatment method including cupping and dry needling that leads to more consistent success with our clients.  It is likely at some point you have googled exercises for plantar fasciitis (maybe even did some of them), tried physical therapy, or other treatment option without success.  I hope that after reading this article you will have a better understanding of some of the potential mechanisms behind plantar fasciitis and  different ways to address them. 

What is plantar fasciitis?

Plantar fasciitis is a term for an irritation for the plantar fascia on the bottom of the foot.  The classic presentation is pain that lives on the bottom or inside edge of the heel of the heel. Typically, pain is worse in the mornings or with prolonged walking or standing.  It usually is very tender to touch or direct pressure to that area.  There are other differential diagnosis for pain in this area so it is always best to consult with a healthcare provider to ensure the pain you are experiencing is actually some form of plantar fasciitis. 

Three potential reasons you have plantar fascia pain.  

When you have pain on the bottom inside edge of the heel the only thing we know for sure is that the sensory and pain nerves in that area are hypersensitive.  Pain is your brains way of protecting itself from harm from either a real or perceived threat. We are going to discuss three potential threats that we usually see in the clinic.  This is not an inclusive list and it is always best to consult with a medical provider about your specific problem. 

 Potential Threat #1.

Local tissue damage.  One mechanism, and probably the mechanism we think about most, is damage to the fascia itself.  The fascia is a think connective tissue band that provides structural support to the foot to help maintain the arch of the foot.  When we walk or run the foot rolls slightly to the inside (called pronation) several muscles on the inside and bottom of the foot and the plantar fascia stretch and then recoil to propel the foot into the next step.  This is called the windlass mechanism (Bolga 2004).  You can read an entire article on the biomechanics of the plantar fascia and the windlass mechanism written by Bolga 2004 here if you want to get into the details.  One theory is that excessive pronation, high volume running, or prolonged standing can cause stress to this area that leads to damage of the fascia itself. Inflammation is our way to fix damage in the body.  A mix of chemicals and proteins show up to try and clear out waste products and repair damaged tissue.  With this mix of inflammation there are pain sensitizing chemicals come along for the ride and trigger the nerves to send pain signals to the brain.  These things are important because pain is how our brain knows to protect the damaged area.  The big take away is that we need to halt whatever is causing the damage, create an environment for healing to occur,  and to the best of our ability resolve the inflammation as the inflammatory process stops. 

Potential Threat #2. Irritation of the nerve.   

Nerves are like little power lines they supply motor or muscle control one way and relay sensory information back to the brain the other way. The nerve that supplies motor and sensory to the bottom of the foot and the plantar fascia is the tibial nerve.  The tibial nerve is a branch off of the sciatic nerve which is the big nerve running through your hip and down the back of your leg. The tibial division runs down the middle of your calf and then turns to the inside and runs behind the inside of your heel bone into the bottom of the foot. Tension anywhere along that nerve pathway can create the perception of pain in the foot.  Some would theorize that any alteration of input to that nerve may affect all the structures down stream of it.  We want to make sure that there is no restriction or irritation along that entire nerve pathway.  This means evaluation of the low back, sciatic nerve pathway, and tarsal tunnel.  If you have ay perception of pain or stiffness in the low back, hip, hamstring, calf, or inside ankle. You are going to want to resolve that to reduce input / pain on the tibial nerve.

Potential Threat #3. Central Sensitization 

Central sensitization is a term to describe pain hypersensitive as a result of what’s happening at the brain or spinal cord level.  Sensory or pain information is perceived at the brain level.  Amongst other things, pain that has been there for a long time or also includes system wide inflammation can lead to increased hypersensitivity in the brains of interpretation of the signal.  I like to think of this as having the alarm system dial set too sensitive.  Every little thing sets of the alarm.  Same situation here. Every little thing feels like pain.  It is very hard to differentiate between sensitivity that lives at the local tissue level vs sensitivity that lives at the brain / spinal cord level but there are tests that your therapist can do to try and make some differentiation. 

The role of Cupping and Dry Needling for Plantar Fasciitis.  

It is common for people with plantar fasciitis to try the basic stretches and ice bottle rolling techniques for plantar fasciitis.  Often times those things work very well. When the basics haven’t worked and you need more input the nervous and immune systems cupping, dry needling, and other manual therapies are a great choice.  

With any hands on therapy if we can reduce irritation of the nerve, improve blood flow to the area, and reduce inflammation we are most likely going to have a reduction in pain signaling. 

What does cupping do for plantar fasciitis? 

Cupping provides a distraction sensory input and promotes increased blood flow to the tissue different from any other hands on therapy.  All the other massage, foam rolling, massage gun techniques press in. Cupping lifts out.  This is a different input that often times feels comforting to the bottom of the foot who deals with compressive input all the time.  Cupping also allows to address blood vessels, lymphatics, and and sensory nerves that live under the skin.  This more superficial treatment allows me to cover large areas at once and promote fluid exchange.  Getting fluid in and out is crucial to healing and reduced pain signaling. 

What does cupping feel like on the plantar fascia? 

If you have never done cupping before it feels like a weird skin stretch.  If you ever put the vacuum hose on your arm as a kid,  it feels kind of like that.  In areas where you don’t have pain you won’t feel much at all.  In area’s where your pain lives it will feel like a bigger stretch even a little burn like at times.  This is because that tissue is not moving as well, may be inflamed, and the sensory nerves are more sensitive to the same amount of stimulus.  These are actually the areas where you want to treat with cups because something is going to change.  Most people think it feels amazing on the bottom of the foot. That distraction feeling is usually very welcomed.  

What are the marks from cupping? 

There are a few theories behind the marks left after cupping.  Some of the coloration is most likely due to micro rupture of local blood vessels and capillaries in the area.  This is one of the mechanisms behind how we think cupping works.  In areas of restriction of the skin will be less pliable or restrictive around blood vessels.  Less healthy vessels will also tend to break easier.  Your immune system will have to react to this trauma and repair the blood vessels.  The hope is that it builds them back stronger / healthier.  Another component may be the moving or pulling of stagnant fluid to the surface. This is most likely true of the pink to red look you see after cupping.  Fluid or inflammation that is stagnant is not typically idea so if we can help open lymphatic vessels and pull stagnant fluid to the surface where it can be moved out by the lymphatic system it should help in the healing process.  

For plantar fasciitis common cupping areas include the fascia itself, the tarsal tunnel above the inside ankle bone, and then along the muscles of the hip, thigh, calf, and low back. 

What does dry needling do for plantar fasciitis? 

Similar to cupping we are going to get an increase a different nerve input and promote increased blood flow to the area.  The difference with needling is it breaks the skin, it gets deeper, and results in a different immune system response.  There are many proposed mechanisms behind why dry needling works but to simplify it in general it helps increase blood flow, reduce inflammation, and alter nerve input thereby reducing muscle guarding.  When I put the needle in it creates a teeny tiny lesion. Your body has to react to that by generating an immune response and sending blood and healing chemicals to that area.  The hope is if I am near the area where your pain lives I will get a healing response there as well.  If I can increase blood flow, and reduce inflammation the nerve input should decrease and should result in a relaxation of the local muscle tightness /knot. 

In the foot we are trying to reducing inflammation and increase blood flow around the local structures of the plantar fascia and then up and down the muscles of the tibial nerve distribution. 

What does dry needling of the plantar fascia feel like? 

The beauty of our neurologic dry needling of the plantar fascia we have options.  If you have never had dry needling it typically gives you this strange, deep, dull ache sensation.  Not totally unlike regular trigger point massage just deeper and more focused.  It’s kind of weird, but you grow to like it because you know when you get that deep ache,  it works. There are ways to avoid the deep ache which also have been shown to be effective.  Needling in the plantar fascia is much the same except the bottom of the foot can be a little more sensitive.  The bottom of the foot has a lot of sensory fibers and the brain devotes a significant amount of attention to them so everything is a little heightened.  Normally dry needling is not sharp or pinchy at all because the needle is so small but admittedly it can be a little bit on the actual bottom of your foot because of the increased feedback.  It’s not awful and most people are okay with it, but if you don’t like it we have options to treat the muscles near the innervation along the tibial nerve up higher where the needles won’t feel sharp at all.  It’s always good to have options. 

Both cupping and dry needling are introducing a targeted stress to the system and then allowing your body to fix the problem.  The beauty of this is it is a natural immune and homeostatic response with no medications.  There are usually two parts to a cupping and dry needling treatment session. The initial nerve input part and the overall healing response.  The immediate reaction after a session is usually one of relief as muscle tone is decreased and nerve input is reduced. I call this a nerve reset.  The second phase is your bodies response to the micro trauma we created with the cups and needles.  This immune repair response is vital for the long term healing of the tissues and micro vessels in the area. 

Strength exercises for plantar fasciitis.  

Strength for me is typically something that is emphasized once the pain is more managed.  It is also a time to work on things that might increase stress at the foot.  For example, if you are not getting stable control of the knee and hip through gait it may cause the foot to overpronate and that might be placing increased stress on the fascia. In the early stages strength should focus on strengthening the muscles above the foot to try and reduce overall force and stress to the fascia.  Then once the pain is resolved if you want to get into strengthening the intrinsic muscles off the foot with your towel curls and marble pick up go for it! 

Stretching exercises for plantar fasciitis. 

The plantar fascia is a pretty dense connective tissue.  Think of the amount of force it must transmit with running and jumping etc.  I’m pretty sure you’re not going to lengthen it with a 30 second calf stretch.  In my opinion, if you want to stretch it for sensory input great, it might feel nice, but not with the intension of lengthening the fascia. Our goal with stretching is to explore ranges of motion we don’t normally get to so our body starts to feel comfortable there.  Things like great toe extension, ankle range of motion, and hip range of motion are important to explore because if you have access to them, you will get to use big muscles for movement patterns, which should take pressure of the plantar fascia and smaller muscles in the foot and inside ankle. 

Other System Wide Things You Must Consider.  

It is common for people with plantar fasciitis to just throw some YouTube stretches and rolling out it without having an understanding or why the pain lives there.  This will work some of the time but if you have a better idea of why the nerve is sensitive you can adjust and modify your rehab program to those causes and not just go through some arbitrary motions. 

1. Promote an Environment For healing. 
1. Relative rest.  Avoid further irritation of the tissue by removing the threat.  This could mean improving standing posture, reducing running volume, or making other changes that may have caused the damage in the first place. 
2. Promote a system for healing.  You want to make sure you have all the necessary components to repair tissue.  You can go down a rabbit hole with this but at a minimum I would suggest a few things. 
1. Eat Clean:  Remove foods that generate inflammation for you. This is a personalized thing but if high sugar, gluten, diary bothers you then I would not recommend having a pizza party. If your body has to deal with inflammation from something else it will have devote resources to deal with that inflammation instead of fixing the injury. 
2. Stay Hydrated:  A large amount of the healing process is about fluid exchange.  We need to make sure the body is able to flush waste products out and get healing products to the area. Don’t be dehydrated. 
3. Supplements.  There are a million things out there but I would at least recommend having sufficient levels of vitamin C and bone collagen to support connective tissue repair. 
4. Move often.  We need fluid exchange. Muscle contraction helps move fluid along in the body so stay active.  You want to move as much as you can without pissing off the foot.

If you or someone you know has been dealing with Plantar fasciitis check out our 6 week program. 

https://www.phytforfunction.com/punt%20plantar%20fasciitis

or email us at [email protected] for recommendations.  

To learn more about the neuroinflammatory model of treatment take our online course at

https://integrativedryneedling.com/courses/neuro-release-treatment-courses-home-study/

References. 

Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. J Athl Train. 2004 Jan;39(1):77-82. PMID: 16558682; PMCID: PMC385265.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC385265/

Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25(5):303-310.

Trojian T, Tucker AK. Plantar Fasciitis. Am Fam Physician. 2019 Jun 15;99(12):744-750. PMID: 31194492.