By Zhenya Kurashova Wine
Originally published in Massage & Bodywork magazine, June/July 2000.
In the next several issues I will cover some of the most frequently occurring injuries in runners. We will start with the foot and progress up the body. As always, I welcome your questions and comments. Please remember that if incorporating the treatments I outline here, the work will only be effective if the protocols are followed exactly, especially when it comes to the duration and frequency of treatment.
Feet are more important to us than we realize, and especially so to the runner. When I worked with the University of North Carolina-Chapel Hill runners in the late 1980s, the program had a $10,000 a year shoe budget (sad to say they did not have a massage therapist budget, so runners had to pay for my services out of their own pocket). Good shoes are very important in running, but few runners go beyond a “good shoe” in taking care of their feet.
One of the more common injuries in older runners is a heel spur. Heel spurs occur due to repetitive overuse of the feet, and especially if most of the running occurs over a prolonged period of time on a hard surface (such as road running).
Heel spur is an accumulation of calcified deposit that attaches itself onto the calcaneus. This calcified deposit is a product of inflammation produced through constant trauma to the calcaneus. The tissue surrounding the calcaneus is not very vascular, and the exudate — a by-product of inflammation — has very few ways to be carried away from the area. After a period of time, this exudate will calcify (or harden) and, after repeated trauma, greater amounts of this calcified deposit will create what we call heel spur.
The simplest solution for this problem is preventing it from happening. Make sure there is an additional heel padding in the shoe. These can be purchased in any drug store, with better varieties available at a shoe repair shop. Another way to prevent this injury is to replace running shoes at least twice a year (even more often for long-distance runners). Most often I see older runners suffering from this problem (those over 50) who are running every day or every other day.
There are surgical treatments available in order to remove heel spurs, but very few runners opt to go this route. The main reason is the length of rehabilitation after the surgery — from six to eight weeks. Weight bearing is not allowed for the first week or more, and the physical therapy after surgery is extensive. Effective non-surgical methods include rest and ultrasound. Regular massage for this condition is not very effective due to the location of the trauma. The calcaneus is covered by a lot of tough tissue, and in order to dissolve the calcified deposit we need to work very deep.
Goals, Objectives and Treatment
The main goal of Russian Neuromuscular Re-Education treatment is to produce enough direct heat in the area of calcified deposit to dissolve it. Other goals include increasing tissue elasticity in the heel and foot area, and increasing arterial flow to the area so the tissue can heal.
These goals are accomplished through 10–15 minute pressure stretching of the area. You should begin by placing the patient prone, with his feet resting on a support at least 6 inches high. This will allow you to work deep. Use only a small amount of lubricant — too much oil won’t allow you to go deep. Begin to work in the arch area using the heel of your hand. Press down and move your heel in a rubbing motion, back and forth and in circles. This will activate arterial circulation and increase tissue elasticity.
Form your hand in a fist, and by using the medial phalanges, perform the same motion as before. This change in hand position will allow you to go deeper. As the tissue heats up, you may use the knuckles of your fist to penetrate even deeper. Once the arch area is sufficiently pliable, move on to the heel itself. Begin the treatment by palpating on the calcaneus in order to establish the size of the calcification, as well as its location. I have to warn you, the area of calcification is usually very tender to the touch so you may have to take some time when increasing the depth of your touch.
After establishing the location of the spur, begin the same procedure as described for the arch area. This is necessary in order to increase the circulation and the elasticity of the soft tissue. By increasing circulation and tissue elasticity, you accomplish two things: your touch will penetrate deeper with the soft tissue being more pliable; and increased pliability and circulation will allow the calcified deposit to be carried away as it starts dissolving.
After preparing the tissue, proceed to deeper pressure on the area of the spur. You will have to use your fingers to go deeper. I find it most effective when index and middle fingers are used together. After several minutes of deep, direct pressure (with a slight motion back and forth) you may have to rest your fingers. Continue with the circular pressure stretching, using the knuckles of your closed fist. Remember that the area you are working is very small; you will cover only an inch or so of tissue. I do not recommend using your thumbs due to the great strain you may cause yourself.
As you can see, this treatment consists of two parts — the preparatory part (work in the arch area) and the actual heel work. In the first few treatments you may spend more time in preparatory work than you do in working on the heel itself. Clients need to be told that the treatment will change in days to come. As the arch area will retain its pliability with continuous treatment, subsequent treatments will require less time on the client’s arch, and more time working on the heel. In fact, by about the fourth or fifth treatment you may altogether stop working on the arch area and concentrate your efforts solely on the heel itself.
I find this treatment is one of the hardest on my hands, and although it is very effective, I do not schedule more than two clients with this particular problem in one work day. I also space them far apart, so that my hands have a chance to rest between treatments.
This treatment is best for the client when it’s done every other day. You should ultimately see the client 9–12 times. During the duration of the treatment program, I ask my clients to stop running altogether so there is no more cumulative trauma while the tissue tries to heal. Clients who have to be on their feet at work are encouraged to have at least 10–15 minutes of sitting activity every hour.
By the end of the treatment you should see a great decrease of pain in the area. The client may resume activity, but I do not recommend these clients resume running. This is a difficult request to fulfill, as many heel spur clients are avid runners. I suggest deep water running, instead of road running. For clients unable to comply with that request, I suggest running on padded track (available at most health spas).
Another foot condition I often see in my practice is fallen arches. Like heel spur, this can also be caused by bad foot gear, as well as continuous overuse. Arches fall with age, and they also can fall if the client has increased their weight without increasing their arch support during running. The only solution for a fallen arch is to correct it with an arch support. This is not quite as simple as it sounds.
Arch supports available at drugstores are not as effective as one would hope to see. Yet, there are a few routes to explore when looking for a good support. A podiatrist (foot doctor) is very specialized in this area, and I often refer my clients to them. A problem arises in the type of support each podiatrist uses. Most podiatrists use plastic molded supports. I find most clients have a problem with a hard, plastic support.
I prefer the cork-and-leather supports built by several companies throughout the country. I find that these custom-built arch supports are not only effective, but also comfortable enough for the clients to wear regularly.
I send clients to be measured for the support after one week of treatments. It takes 2–3 weeks for the supports to be built, so when my treatment is finished, the client can maintain the arch we re-created in treatment.
Goals, Objectives and Treatments
The main goal here is to increase tissue elasticity in the arch area, and to increase arterial flow to the area so the tissue can heal. These goals are accomplished through 10–15 minute pressure stretching of the arch area.
Once again the client should be prone with the feet resting on a support at least 6 inches high. This will allow good access to the feet and you will be able to work as deep as needed. Use only a small amount of oil so your pressure is not compromised.
Begin to work at the toes and move into the arch area using the heel of your hand. Press down and move the heel in a rubbing motion (back and forth) as you progress forward from the toes toward the heel. This will increase the tissue elasticity. As circulation and elasticity increase, you can allow your pressure to become greater.
Form your hand in a fist, and by using the medial phalanges, perform the same motion as before while moving from the toes toward the heel. Do not move too fast through the tissue — progress about a 1/2 inch with each motion.
You may also move in spiral motion from the toes toward the heel. As the tissue heats up, use the knuckles of your fist to penetrate even deeper. After 10–12 minutes you should see a significant change in the tissue — it should become more supple, and you should see an increase in the arch.
This treatment can be done every day or every other day for 12 treatments. By the end of the treatment set you should see a normalized arch. Make sure the client is fitted for an arch support, as the arch you create for the client will not stay on its own.
This treatment can also be used for plantar fasciitis, or inflammation of the plantar fascia. The same goals, as described above, will apply. Clients suffering with plantar fasciitis will see decrease of pain after 3–5 treatments, and see complete recovery by the end of the treatment set.
In the next issue we will cover achilles tendinitis, shin splints and strain of the calf muscles.