Dry Needling for Plantar Fasciitis: The Importance of Needling the Multifidus & Manipulating the Spine to Achieve Maximum Patient Potential & Outcomes
Jason Schuster
Doctor of Physical Therapy, Owner & Founder of Intricate Art Spine & Body Solutions, a Continuing Education Company Teaching Other Doctors How To Do a Few Things.
Plantar fasciitis (PF) is a common impairment that can be seriously challenging to treat to full resolution, without recurrence. One of the reasons for this is there are a lot of issues all over the body that can cause plantar fasciitis, most of them not being in the foot. Another reason that PF oftentimes is a recurring, chronic problem, is that many of the muscles that cause PF are impossible to properly treat without dry needling. The multifidus is one such muscle.
If I had to pick one muscle in the body to needle, it would for sure be the multifidus. Aside from having an awesome name and being the tastiest piece of elk meat, the multifidus is the deepest and most important spinal stabilizer. In humans, that is. Very possibly in elk as well, but I would have to brush up on my elk anatomy before making any definitive statements… How do you think trying to needle a wild elk would go?... I’m pretty sure I could ride one and needle at the same time… Anyway, the multifidus travels from the occiput or C2 (depends on what book you read), all the way to the sacrum, S2 or so. The multifidus is the closest muscle to the majority of nerve roots exiting our spinal cord and intervertebral foramina that we can safely needle. The psoas is another, but the multifidus crosses way more spinal levels. The multifidus is also the most direct, longest spinal compressor we have. For this reason, I include multifidus needling, to the laminar periosteum, in all of my treatments, regardless of whether or not they have an issue with their multifidus, which almost all PT patients do.
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Some type of increased neuroplastic effect occurs when you connect the spinal level to the distal innervation of the impairment. This effect is further amplified if you needle bilateral and add low frequency microcurrent, I like 2 Hz. There are solid data from numerous research studies indicating that acupuncture and dry needling work, on some level, via improving central and peripheral neuroplasticity, secondary to improved ANS homeostasis and other factors, some known, many unknown. Regardless of the specific neurophysiologic mechanisms, a primary component of needling efficacy is the amount of ANS homeostasis induced. One way this is achieved is through increased and regulating blood flow. Needling the multifidus at the nerve root level of the distal impairment, along with whatever else you are treating, bilateral, significantly improves treatment efficacy. I never used to do this or use electricity very much when I first started needling. Over the years, treating lots of people and reading lots of research (dry needling, acupuncture, gene therapy, neurophysiology, quantum biology, chemistry & physics, etc.), has opened my eyes to how incredibly awesome and powerful this method is for improving patient outcomes for all impairments, not just PF.
Let’s think about the multifidus on a mechanical level. Being the deepest, most direct spinal compressor, side bender, and opposite side rotator, along with the fact it crosses almost the entire spinal column, allows multifidus pathology to directly affect spinal joint orientation. Abnormal segmental positioning of the spine can lead to all sorts of crazy primary, secondary and tertiary stuff, including PF.
Let’s assume we are dealing with a shortened, hypertonic, hypoxic, right multifidus, especially in the lumbosacral region, L4-S2, or so. A tight, contracted, right multifidus causes left lumbar rotation, right lumbar extension, and right lumbar side bending. Think about the right superior aspect of the PSIS and the posterior superior sacroiliac ligament, and how the multifidus crosses the lumbosacral junction. With a tight right multifidus, the right L5 transverse process is inferior and anterior of where it should be, pulling or pushing (depends how you think about it) the right PSIS anteriorly. This leads to anterior rotation of the right ilium, creating a “leg length discrepancy,” with a longer right leg.
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A deviated lumbar spine and pelvis, secondary to multifidus pathology, generates a “longer” right leg, creates compensatory gait patterns typically leading to right foot eversion, and increased stress traveling through the plantar fascia. There are many other possible deviations and compensatory strategies other than the deviations mentioned above. Everyone is different. Although, you can be sure, a dysfunctional multifidus and a deviated pelvis is going to indirectly cause deviation in one or both feet. All our body weight is traveling through small joints and structures in the foot, exponentially increasing the forces placed through the foot. In the knee joint, for example, 4x our body weight goes through each knee joint, each step we take. Any pelvic deviation is going to place abnormal stresses in the foot and lead to impairment, like PF.
The most effective way to treat the multifidus, by far, is needling followed by manipulation. There is no way to directly treat the multifidus without needles, just like almost all muscles. However, the deeper the muscle is, and the multifidus is in there, the harder it is to treat. Without needles. With needles, it is super easy. Another thing that happens to the multifidus when pathologic, is it becomes infiltrated with fat, adipose tissue. This causes dysfunction and forces the other, bigger, fast twitch (remember, multifidus is primarily slow twitch) muscles, like the paraspinals and latissimus, to attempt a job they are not made for; all-day, dynamic stabilization of the spine. Then these muscles, along with the multifidus, get grumpy, tight, painful, hypoxic, and further compress the spine, compounding distal impairments, like PF. Without needling first, manipulating the pelvis and lumbar spine is way more difficult for the practitioner and uncomfortable for the patient, not to mention less effective.
To reach the lumbosacral multifidus, you must needle through one, two or all of the paraspinals, and the latissimus, depending on your approach. This is nice for us, because if any one of those muscles is pathologic, all the others around it will be as well, especially in chronic situations. Regulating multifidus length with needling, followed by reduction of the spine, pelvis and extremities to neutral with manipulation (which also regulates muscle length), results in reduced gait pattern compensation, normalized kinetic chain joint / soft tissue mobility, and reduces pain and inflammation in the foot.
Remember, S2-S4 is a parasympathetic-dominant portion of the autonomic nervous system (ANS). Just about any patient coming in with PF is going to present with pain and hyperactive sympathetics, which can cause or be caused by pain, leading to allodynia, hyperalgesia, hypersensitivity, etc. So, not only are you normalizing muscles and joints by needling and manipulating this area, you are also targeting the parasympathetic portion of the ANS. This has a wonderful homeostatic effect on the ANS, which helps all medical impairments I know of. Remember, the majority of PT patients present with sympathetic hyperactivity.
The most direct location to target the PANS is the concha of the ears. Second best, S2-S4. Third best, base of C2 spinous or the suboccipital periosteum. Try adding all these needles into all your other treatments. You will see amazing results simply by regulating the ANS towards homeostasis. Also remember, the multifidus goes from the sacral plexus to C2 for sure, maybe higher. So, by needling the multifidus at C2 and the sacral plexus, you are needling both ends of the muscle and targeting two parasympathetic-dominant sections of the spine. By adding microcurrent traveling along the spine, through the multifidus and other muscles, you achieve a super comfortable and effective full spine and ANS treatment. This has beneficial effects on the entire body and mind.
Let me know if anyone has any questions about anything. Talk to you soon.
Jason