Research-Based Interventions for Plantar Fasciitis

Modalities
In randomized double-blinded controlled clinical trials, iontophoresis delivered dexamethasone 0.4% or acetic acid 5% (in conjunction with LowDye taping) was used to provide short-term (2-4 weeks) pain relief and improved function.(16)  In this study, patients received 6 treatments of physical therapy over a 2-3 week period.  Patients received either iontophoresis delivered acetic acid 5% (along with LowDye taping) or iontophoresis delivered dexamethasone 0.4% (along with LowDye taping).  The patients in both groups had significant improvement with decreased pain and decreased stiffness.  The patients who received iontophoresis delivered acetic acid 5% had better pain relief than the group that received iontophoresis delivered dexamethasone 0.4%, and both groups had continued pain relief during a 2-week post-treatment follow-up period.(16)

Massage Therapy
Although there is limited evidence to support the efficacy of massage therapy techniques in the treatment of PF (2), one study reported that myofascial trigger point therapy combined with self-stretching did prove efficacious. In this randomized clinical trial, 60 patients with a clinical diagosis of plantar heel pain were randomly divided into 2 groups: a self-stretching (Str) group who received a stretching protocol, and a self-stretching and soft tissue TrP manual therapy (Str-ST) group who received TrP manual interventions (TrP pressure release and neuromuscular approach) in addition to the same self-stretching protocol. The primary outcomes were physical function and bodily pain domains of the quality of life SF-36 questionnaire. Additionally, pressure pain thresholds (PPT) were assessed over the affected gastrocnemius and soleus muscles, and over the calcaneus, by an assessor blinded to the treatment allocation. Outcomes of interest were captured at baseline and at a 1-month follow-up Mixed-model ANOVAs were used to examine the effects of the interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. Results of the 2X2 mixed analasis of variance revealed a significant improvement over time for the physical function, bodily pain domains of SF-36, and pressure pain thresholds over the gastrocnemius, soleus and calcaneus. Patients who received the combination of myofascial trigger point therapy and stretching experienced far greater improvement than those who performed the self-stretching only. The researchers concluded that this study provides evidence that the addition of trigger point massage therapy to self-stretching resulted in superior short-term outcomes as compared to self-stretching alone in the treatment of plantar heel pain.(31)

In Dr. Uridel's experience, deep tissue massage, especially deep longitudinal glides, cross-fiber NMT techniques and myofascial release techniques performed on the plantar fascia are also of benefit to releasing plantar fascial tension and thereby relieving plantar heel pain. Myofascial release of the gastroc-soleus-achilles complex are of benefit to patients with plantar fasciitis due to the continuity of connective tissue between the plantar fascia and achilles tendon. The deep massage and manual myofascial stretching releases some of the tension in the tissues and brings circulation into the area for healing.

Stretching
A number of authors have recommended stretching the calf and/or the plantar fascia and there is moderate evidence to support their recommendations.(2)  As stated above, 80% of patients with PF present with Achilles tendon tightness and limited talocrural dorsiflexion.(1)  The fact that there is continuity between the fibers of the plantar fascia and the Achilles tendon supports justification for gastrocnemius/soleus stretching.(19)  In a randomized, blinded clinical trial, duration and frequency of calf stretching were manipulated as the independent variables to determine the improvement in talocrural dorsiflexion and patient outcomes using outcome measures from the American Academy of Orthopaedic Surgeon’s Lower Limb and Foot and Ankle Modules.(20)  One treatment group of PF patients performed static stretching of the calf (by standing on the edge of a step and allowing their heel to hang off) for a duration of 3 minutes done 3 times per day.  The other treatment group performed the same stretch intermittently for 5 repetitions of 20 second stretching intervals and performed the stretches 2 times per day.  Subjects’ dorsiflexion range of motion and functional outcomes were measured once a month over 4 consecutive months.  Both groups had similar increases in dorsiflexion range of motion and decreases in pain.(20)  In another randomized clinical trial, researchers experimented with a specific stretch for the plantar fascia versus non-specific calf stretching.(17)  Patients in the plantar fascia-specific treatment group were shown a seated stretching technique that required them to place the fingers of one hand across the toes of the involved foot and draw the toes back into extension until a stretch was felt in the arch of the foot.  Patients in the calf-stretching treatment group were shown a standing calf stretch leaning into the wall with the knee bent and the uninvolved foot behind the involved foot (soleus/Achilles stretch).  Each patient was instructed to hold the stretch for 10 seconds, repeat the stretch 10 times and perform the stretching three times a day.  At the end of the eight-week trial, 52% of the treatment group using the plantar fascia-specific stretch versus 22% of the treatment group using the calf stretch reported no pain or significantly reduced pain.(17)  Of importance is the fact that this was not a blinded study and there were a significant drop out of subjects in this study and no “intention to treat” analysis was performed to take this into account.

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Taping
There is some evidence to support the use of adhesive athletic taping techniques to support the medial longitudinal arch to relieve tension in the plantar fascia and provide short-term (1-10 days) pain relief.  In a patient-blinded randomized clinical trial, researchers tested the effectiveness of the low-Dye taping technique in relieving pain and improving function in patients with PF.(22)  Patients received Low-Dye taping for 3 to 9 days (median 7 days) and reported significant improvement with decreased pain and increased function at a one-week follow-up.(22)  In a single-group repeated measures study, researchers tested the windlass taping technique (a modified low-Dye taping technique)with a small group of patients with PF.(11)  Immediately upon taping and after wearing the tape for a 24 hour period, the subjects reported a significant decrease in pain.(11) Because taping techniques provide short-term relief of pain from PF, they can be used to relieve symptoms while the patient awaits orthotics.

Orthotic Devices
Although current evidence to support the connection between foot biomechanics and PF is inconclusive, cadaver studies have confirmed the effect of orthotic devices in relieving the strain on the plantar fascia.(23,24)  Also, a number of randomized controlled clinical trials have been conducted to determine the effectiveness of pre-fabricated and custom orthotics in the reduction of pain and improvement of function related to PF.(2)  Based on the five strongest studies, it is concluded that there is no significant difference in outcomes between patients who wore pre-fabricated orthotics or custom orthotics and both types of orthotic devices provide significant short-term (3 months) decreased pain and increased function in patients with PF.(2)

Night Splints
In a systematic review of 27 research articles, reviewers gave night splints an effectiveness rating equal to that of stretching in the treatment of PF.(25)  In a randomized clinical trial of 40 patients with chronic PF, researchers found a 91% success rate when patients wore the tension night splint for 8 to 12 weeks.(26)  Another study reported an 88% improvement in patients with chronic PF when patients wore a night splint for 4 weeks.  Based on somewhat limited research, it is concluded that night splints should be used as an intervention on patients with symptoms of greater than 6 months duration and to be effective, the night splints should be worn every night for 1 to 3 months.(22)

Acupuncture and Acupressure

It has been suggested that some acupoints have a specific effect on heel pain. The aim of one study was to determine the efficacy and specificity of acupuncture treatments for plantar fasciitis. Subjects were randomly assigned to the treatment group (n = 28) or control group (n = 25). The treatment group received needling at the acupoint PC 7, which is purported to have a specific effect for heel pain. The control group received needling at the acupoint Hegu (LI 4), which has general analgesic properties. Subjects received treatment five times a week for 2 weeks, with an identical method of manual needling applied to the two acupoints. The primary outcome measure was morning pain on a 100-point visual analog scale (VAS) at one month post-treatment. Secondary outcome measures included a VAS for activity pain, overall pain rating as well as pressure pain threshold using algometry. Results revealed significant differences in reduction in pain scores, favoring the treatment group, at one month for morning pain (22.6 ± 4.0 versus 12.0 ± 3.0, mean ± SEM), overall pain (20.3 ± 3.7 versus 9.5 ± 3.6) and pressure pain threshold (145.5 ± 32.9 versus -15.5 ± 39.4). Researchers concluded that acupuncture can provide relief for people suffering with plantar fasciitis heel pain and that the acupoint PC7 is a relatively specific point for the reduction of heel pain. It would follow that acupressure massage on the PC7 acupoint would provide benefit.

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Extracorporeal Shock Wave Therapy

Developed in the 1980’s for the treatment of kidney stones, Extracorporeal Shock Wave Therapy (ESWT) machines have been re-designed to treat a variety of musculoskeletal conditions with high-intensity acoustic radiation.  This is an outpatient procedure that takes 18 minutes and is performed one time.  Presently it is approved in the US by the Food and Drug Administration (FDA) for treatment of PF, lateral epicondylitis, supraspinatus tendonitis, patellar tendonitis and Achilles tendonitis.  For the treatment of PF, the FDA criteria are quite specific.  The patient has to have experienced heel pain for at least 6 months and had at least three other types of treatments (oral anti-inflammatory medication, physical therapy, orthotics, cortisone injections, etc.) without relief.  The most accepted theory of how ESWT works is that the high-intensity sound waves cause cavitation, which leads to fibroblast and tenocyte production that heal the injury.  Another theory is that the micro-trauma caused by ESWT stimulates neo-vascularization and tissue healing.  The final theory has to do with its counter-irritant and pain gating effect.   It could be a combination of these three effects that lead to a decrease in pain.  Contra-indications for ESWT are neurological or vascular diseases of the foot, history of plantar aponeurosis rupture, open growth plates, pregnancy, implanted metal in the area (ie. screws, plates) and patients on medication for blood clotting.  In recent research, ESWT has been shown to be very effective in treating chronic recalcitrant plantar fasciitis.(27)  In a recent systematic review of randomized clinical trials, ESWT received the highest grade in effectiveness as an intervention for treating chronic PF.(25)  In another systematic review with meta-analysis, researchers recommend ESWT as a “safe and effective nonsurgical method for treating chronic, recalcitrant heel pain” and “should be considered before any surgical intervention.”(28)

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