Journal of Bodywork & Movement Therapies 21 (2017) 212e215

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

PREVENTION & REHABILITATION: PRACTICAL PAPER

Calf stretching in correct alignment. An important consideration in

plantar fasciopathies
Mark Silvester, Dip. Phty., Adv Dip Phty., Dip. Manip.Ther. (NZ) Physiotherapist
366G Huia Road, Titirangi, Auckland, 0604, New Zealand

a b s t r a c t

Stretching of the calf muscles is important in the treatment of plantar fasciopathy. In order to correctly
stretch the calf muscles without strain on the plantar fascia the correct alignment of the lower limb
should be maintained. A clinical method of achieving this is presented along with a practical guide to
assisting the patient to become familiar with correct lower limb alignment.
2016 Elsevier Ltd. All rights reserved.
PREVENTION & REHABILITATION: PRACTICAL PAPER

1. Introduction further pronation.

There is general agreement in the literature that there are two
key biomechanical factors that relate to plantar fasciopathies. These
are over-pronation at the foot and a lack of dorsiexion at the talo-
crural joint (Hossain and Makwana, 2011; Beeson, 2014; Martin
et al., 2014). From a clinical perspective it appears likely that
these two factors are linked, in that a lack of dorsiexion, for
example, following an ankle sprain, will cause an individual to roll
the foot into pronation to compensate for lack of talo-crural
movement into dorsiexion during gait.
A key clinical intervention in plantar fasciosis is the recom-
mendation to engage in a stretching program for the gastrocnemius
and soleus (Martin et al., 2014). This is most commonly performed
in the wall lean position (Fig. 1.) with the knee extended for
gastrocnemius and exed for soleus.
2. Assessment of alignment
Surface marking the middle of the foot is a simple procedure
of drawing a line between the second and third metatarsal bones.
Deciding where to surface mark the middle of the upper leg for
alignment purposes is more difcult. If the tibial tubercle is used
as the upper mark then any rotation that may occur above it at
the knee (tibio-femoral joint) is not observable. If the middle of
the patella is marked instead, a sesamoid bone which is itself
subject to signicant mal-alignment problems is used as the
reference point (McConnell, 1996; Barton et al., 2014).
In clinical practice the author marks a point in the middle of
the femur as the upper mark. Although this surface marking is
subject to the vagaries of any attempt to mark a deep anatomical
point on the skin it may be the best point for the reasons
mentioned above. This procedure is done by palpating the
femoral condyles to gauge orientation of the femur and then
moving up to the femur approximately 5 cm above the knee
(Fig. 2).

In order to assess whether a patient is stretching in the correct

orientation and that compensatory over-pronation is not causing
the arch to atten it is helpful to apply some surface marks to help
guide the patients awareness of their lower limb alignment. If the
patient is stretching incorrectly this can cause two clinical prob-
lems. Firstly it may give an incorrect reading of the true calf length,
and secondly, if the arch is attening as they stretch, instead of
contributing to correct alignment they risk straining the arch into
E-mail address: mark@backforthefuture.co.nz.
3. Stretching
The patient can now use the vertical alignment of the two
marks to perform the stretch on both gastrocnemius and soleus
correctly (Fig. 3A and B). This produces a stretch targeted to the
intended muscle and preserves the alignment of the foot. For any
patient who has a tendency to over-pronate this alignment
will feel abnormal and it will also create a stronger feeling of
stretch.

http://dx.doi.org/10.1016/j.jbmt.2016.11.002
1360-8592/ 2016 Elsevier Ltd. All rights reserved.
 M. Silvester / Journal of Bodywork & Movement Therapies 21 (2017) 212e215 213

Fig. 1. A. Gastrocnemius stretch. B. Soleus stretch in a wall lean position.

PREVENTION & REHABILITATION: PRACTICAL PAPER

Fig. 2. Surface marking the middle of the femur.

4. Alignment correction
In order for corrected alignment to feel more normal it can be
helpful for the patient to correct their alignment in the mirror
rst. This can be done via a small knee bend referred to by
Sahrmann, in her classic (2002) text (as a standing movement
test, Bilateral hip/knee exion (partial squat). The patient stands
facing a mirror and initially brings their feet into the sagittal
plane (or less than 10 lateral to it). Most patients who over-
pronate will then need to laterally rotate the hip to bring the
 214 M. Silvester / Journal of Bodywork & Movement Therapies 21 (2017) 212e215

Fig. 3. Wall lean stretch of gastrocnemius (Fig. 3A) and soleus (Fig. 3B) in alignment looking from the front at the rear leg.
PREVENTION & REHABILITATION: PRACTICAL PAPER

Fig. 4. Small knee bend position with surface marks in the middle of the foot and the thigh with the knees in a slight valgus Fig. 4A., and the knees corrected using the surface mark
alignment Fig. 4B.

mark on the femur into vertical alignment with the mark on the
foot. This is best done with the knees slightly exed. (Fig. 4). They
then extend their knees maintain the new alignment with
external rotation at the hip. Try to get the patient to relax
their feet and toes, we want the main effort of re-alignment to
come from the external rotators of the hip not by actively exing
the toes or inverting the foot. If they are unable to get into
proper alignment without supinating the foot excessively it
may indicate a structural problem such as femoral ante-version
and a Craig's test (Magee, 2014) would be appropriate to check
for this.
The patient is instructed to practice the small bend of the knees
to help them feel familiar with the newly aligned position. The
patient is further instructed to take care not to bend the knees too
far forward as a knee position which is forward of the ankle causes
strain on the knee joint. Instead encourage the patient to shift the
hips back which produces hip exion and more of a squatting
motion.
It can also be practiced in a single leg stepping position i.e.
walking on the spot. This helps a patient to integrate better
 M. Silvester / Journal of Bodywork & Movement Therapies 21 (2017) 212e215 215

alignment into gait (Fig. 5).

The relationship between calf muscle shortness, plantar fasci-
opathy and lower limb alignment is an important one for therapists
to understand if they are to a give the best advice and therefore gain
the best results for their patients.

References

Beeson, P., 2014. Plantar fasciopathy: revisiting the risk factors. Foot Ankle Surg. 20
(2014), 160e165.
Barton, C., Balachandar, V., Lack, S., Morrissey, D., 2014. Patellar taping for patel-
lofemoral pain: a systematic review and meta-analysis to evaluate clinical
outcomes and biomechanical mechanisms. Br. J. Sports Med. 48 (6), 417e424.
Hossain, M., Makwana, N., 2011. Not Plantar Fasciitis; the differential diagnosis
and management of heel pain syndrome. Orthop. Trauma 25 (3), 198e206.
Martin, R.L., Davenport, T.E., Reischl, S.R., McPoil, T.G., Matheson, J.W., Wukich, D.K.,
McDonough, C.M., 2014. Heel pain - plantar fasciitis: revision 2014. J. Orthop.
Sports Phys. Ther. 44 (11), A1eA33.
McConnell, J., 1996. Management of patellofemoral problems. Man. Ther. 1 (2),
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Magee, D.J., 2014. Orthopaedic Physical Assesment 6 th Edition. WB Saunders. ISBN
9781455709779.
Sahrmann, S., 2002. Diagnosis and Treatment of Movement Impairment Syn-
dromes. Mosby.

Fig. 5. Stepping forward in correct alignment.

PREVENTION & REHABILITATION: PRACTICAL PAPER