Plantar Fasciopathy

     It has been estimated that Plantar Fasciitis occurs in approximately 2 million people and can account for between 8% and 15% of all foot pain complaints. While the term "-itis" is often associated with inflammation, there is growing evidence that there might not be an inflammatory state, but rather a degenerative process occurring in the plantar fascia. Because of this growing belief, authors are saying a more appropriate term would be "plantar fasciopathy" or "plantar heel pain."  
    
    Plantar heel pain is best described as a sharp pain in the patient's rear foot that is worse in the morning (usually the first step out of bed) and at the beginning of a weight bearing activities. The pain typically lessens with continued activity, but often increases toward the end of the day. Individuals most susceptible to developing heel pain are middle-aged women, obese individuals, athletes, and runners. Clinically, you will see excessive pronation and a depressed longitudinal arch in many of these clients. Some extrinsic factors contributing to the pathology include training surfaces, shoe wear, and poor training methods. Understanding the anatomy makes it clear why this population is at an increased risk. The plantar fascia runs from the medial tuberosity of the calcaneus and inserts into the metatarsophalangeal joints, the proximal phalanges, and the flexor tendon sheaths. The fascia is responsible for supporting the longitudinal arch of the foot and assisting in dynamic shock absorption. The attachment of the plantar fascia to the medial calcaneal tuberosity explains why patients often experience pain upon palpation of that area.
   
    Diagnosis of plantar fasciopathy is often made on a clinical basis. Due to degenerative changes and tendon thickening, the diagnosis may be made with an ultrasound as well.  Current treatment methods include rest, modalities, stretching, strengthening, manual therapy, splinting, orthotics, surgery, and more. New research is constantly being published due to the high incidence of the injury.  This review will take an in depth look at several of the available treatment techniques for plantar fasciopathy. Many of the studies we looked at included strengthening and stretching in the treatment plans along with some other intervention. Improvement was often shown in both groups, but we were unable to find any studies that specifically looked at one type of strengthening exercise compared to another. Some of the most common barefoot exercises seen in the clinic include towel scrunching and picking up marbles. Due to the biomechanical theory of the plantar fascia aiding in the support of the medial arch, it would seem logical to include strengthening of the posterior tibialis in rehabilitation. The posterior tibialis is the prime muscle for raising the medial longitudinal arch and can take stress off the plantar fascia. As noted in our previous posts, the exercise to most effectively activate the posterior tibialis is resisted forefoot adduction.

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      A 2011 randomized control trial we looked at compared the effectiveness of a self-directed stretching program to a stretching program plus trigger point release therapy. The stretching only group was instructed to perform a gastroc stretch, soleus stretch, and seated plantar fascia-specific stretch. The trigger point group performed the same stretching, but also received trigger point release to the gastroc and soleus muscles. While both groups improved, the trigger point therapy group reported higher physical function, less bodily pain, and increased pressure pain thresholds for short term outcomes.   

     Another study we reviewed compared a new calcaneal taping technique versus a sham taping group, a stretching group, and a no treatment group. The calcaneal taping technique inverted the heel to raise the medial longitudinal arch. A first piece of tape pulled the calcaneus medially. Pieces 2 and 3 followed the same pattern, overlapping 1/3 of each prior piece of tape. Piece 4 wrapped around the heel lateral to medial, supporting the arch and anchoring pieces 1-3. This 4 piece technique was considered quick and cost effective. This calcaneal taping intervention resulted in significantly greater reductions in pain compared to the sham taping, stretching, and no treatment groups.  Additionally, a study comparing Medial Arch Support to Low-Dye Taping found that both groups had improvements in pain, but the Medial Arch Support had significantly greater improvements. These interventions should be considered for short-term relief, so that the patient can be pain-free for more intense therapy or activities.
    
    A third intervention we reviewed assessed the effects of low level laser therapy in the treatment of plantar fasciitis. Laser treatments were given 3 times per week for 4 weeks with a 30mW . 83 um continuous-wave IR diode laser. The goal of the laser therapy was to alter cellular metabolism, protein synthesis, and create an immune response. The conclusions of randomized controlled evaluation found that low level laser therapy was not beneficial in the treatment of plantar heel pain. A study we looked at compared the effects of stretching and orthotics vs. e-stim, stretching, and orthotics. Both groups improved, but there was not difference between the two groups, so e-stim appears to have no additional benefit.
    
    With the recent boom in barefoot running, there has been a movement to begin incorporating barefoot or minimalist exercises/training into rehabilitation of plantar fasciitis. The theory involves placing increased forces on the intrinsic muscles of the foot, so that they can be retrained to support the arch and take stress off the plantar fascia. A study we looked at how the addition of Nike Free 5.0 shoes could affect the patients' complaints. The Nike Free 5.0 shoes offer a flexible midsole that somewhat mimics barefoot training. In the study, two groups were assigned an exercise protocol that involved balance training, stretching and strengthening exercises. One group wore conventional shoes, while the other wore the Nike Free 5.0 shoes. At the end of the study, both groups had a significant decrease in pain, the Nike Free 5.0 shoes more so. Due to the poor design, the results of this study must be looked at closely. At 24 participants, it was a small sample size and there may have been a psychological effect, since the Nike group received new shoes, while the conventional group used old shoes. Along with other factors, it is not clear if minimalist shoes can enhance rehabilitation for individuals with plantar fasciitis. It would be interesting to see the effect of more minimalist-type shoes (New Balance Minimus, Vibram Five Finger, etc.) could have on therapy in a properly done study.

    A meta-analysis we looked at studied the effects that a shoe orthotic could have on plantar fasciitis. The study found that the addition of orthotics could decrease pain and improve function within 6-12 weeks. The control utilized night splinting, which had an improvement of pain as well, but not function. There were several issues with these findings. There was a definite lack of blinding throughout the included studies, which could have introduced some bias to the results. Also, it is unknown whether or not the patients' symptoms and function improved based off of natural healing processes or not due to the fact that there was no true control. While the theory of stress relief of the plantar fascia seems logical, there is no evidence that decreasing the mechanical forces on the plantar fascia can decrease symptoms. Also, another study found that the addition of a night splint can help improve patients' symptoms, but does not have an effect on the recurrence of the pathology.

    One of the more common interventions that is performed is stretching. A study we looked at compared the results of the standard achilles tendon stretch to a sitting plantar fascia stretch. For the plantar fascia stretch, the patient would cross his/her legs and place the affected foot on the opposite knee. The patient then grasps the toes (especially the big toe) and maximally dorsiflexes them until a stretch is felt in the foot. In the study, the patients would perform their stretch first thing in the morning and before getting up after sitting for awhile. The study found both interventions to be successful, but the plantar fascia specific stretch more so. It should be noted that the study had no true control to rule out the patients' improvements due to natural healing processes.
   
    Dry needling is still a limited treatment technique for physical therapists; however, patients can have access to acupuncture on a wider basis. One article compared two groups to see the effect of acupuncture on plantar fasciitis. Both groups received standard treatments, such as icing, stretching, intrinsic foot strengthening, and NSAIDs. One group received acupuncture, additionally. Both groups found improvements in pain. There was no difference between the two groups after 4 weeks, but the acupuncture group was slightly better after 8 weeks.
   

    A treatment technique that is gaining popularity involves Instrument Assisted Soft Tissue Mobilization (IASTM). There are many products out there that fall under the category of IASTM: Graston Technique, ASTYM, Edge Tool, etc. The theory is generally the same behind them in that, through use of the tools, a healing inflammatory phase can be initiated by stimulating blood flow, nutrients, and fibroblasts to the area. Through proliferation of the fibroblasts, healing and formation of collagen can begin. The soft tissue mobilization can additionally aide in reorganization of the collagen fibers to proper orientation. This study in particular was a preliminary look at Graston Technique, discussing the theory, protocol, initial evidence, and some case studies. As plantar fasciitis is a soft tissue pathology, IASTM could have useful implications for patients with this disorder. When further research is performed on the subject, it may be found that IASTM has a very important place in treating these patients.

References:
Abd El Salam MS, Abd Elhafz YN. "Low-dye taping versus medial arch support in managing pain and pain-related disability in patients with plantar fasciitis." Foot Ankle Spec. 2011 Apr;4(2):86-91. Web. 10/13/12.

Bassford, Jeffrey. "A Randomized Controlled Evaluation of Low Level Laser Therapy: Plantar Fasciitis." Arch Phys Med Rehabil. 79. (1998): n. page. Web. 8 Oct. 2012.

Beyzadeoğlu T, Gökçe A, Bekler H. "[The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis]." Acta Orthop Traumatol Turc. 2007;41(3):220-4. Web. 10/13/12.
Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. "Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up." J Bone Joint Surg Am. 2006 Aug;88(8):1775-81. Web. 10/12/12.

Hammer, WI. "The effect of mechanical load on degenerated soft tissue." J body Mov Ther. 12.3 (2008): 246-256. Web. 8 Oct. 2012.

Hyland, Matthew. "Randomized Control Trial of Calcaneal Taping, Sham Taping, and Plantar Fascia Stretching for the Short-term Management of Plantar Heel Pain." Journal of Orthopaedic and Sports Physical Therapy. 36.6 (2006): n. page. Web. 8 Oct. 2012.

Karagounis P, Tsironi M, Prionas G, Tsiganos G, Baltopoulos P. "Treatment of plantar fasciitis in recreational athletes: two different therapeutic protocols." Foot Ankle Spec. 2011 Aug;4(4):226-34. Web. 10/13/12.

Lee SY, McKeon P, Hertel J. "Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis." Phys Ther Sport. 2009 Feb;10(1):12-8. Web. 10/10/2012.

Renan-Ording, Romulo. "Effectiveness of Myofascial Trigger Point Manual Therapy Combined with a Self-stretching Protocol for the Management of Plantar Heel Pain: A Randomized Control Trial." Journal of Orthopedic and Sports Physical Therapy. 41.2 (2011): 43-51. Web. 8 Oct. 2012.

Ryan, M, S Fraser, K McDonald, and J Taunton. "Examining the degree of pain reduction using a multielement exercise model with a conventional training shoe versus an ultraflexible training shoe for treating plantar fasciitis." Phys Sportsmed. 37.4 (2009): 67-84. Web. 10 Oct. 2012.

Stratton M, McPoil TG, Cornwall MW, Patrick K. "Use of low-frequency electrical stimulation for the treatment of plantar fasciitis." J Am Podiatr Med Assoc. 2009 Nov-Dec;99(6):481-8. Web. 10/13/12.