Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis - A prospective clinical trial with two-year follow-up

Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 665, Rochester, NY 14620, USA.
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 09/2006; 88(8):1775-81. DOI: 10.2106/JBJS.E.01281
Source: PubMed


In a previous investigation, eighty-two patients with chronic proximal plantar fasciitis for a duration of more than ten months completed a randomized, prospective clinical trial. The patients received instructions for either a plantar fascia-stretching protocol or an Achilles tendon-stretching protocol and were evaluated after eight weeks. Substantial differences were noted in favor of the group managed with the plantar fascia-stretching program. The goal of this two-year follow-up study was to evaluate the long-term outcomes of the plantar fascia-stretching protocol in patients with chronic plantar fasciitis.
Phase one of the clinical trial concluded at eight weeks. At the eight-week follow-up evaluation, all patients were instructed in the plantar fascia-stretching protocol. At the two-year follow-up evaluation, a questionnaire consisting of the pain subscale of the Foot Function Index and an outcome survey related to pain, function, and satisfaction with treatment was mailed to the eighty-two subjects who had completed the initial clinical trial. Data were analyzed with use of a mixed-model analysis of covariance for each outcome of interest.
Complete data sets were obtained from sixty-six patients. The two-year follow-up results showed marked improvement for all patients after implementation of the plantar fascia-stretching exercises, with an especially high rate of improvement for those in the original group treated with the Achilles tendon-stretching program. In contrast to the eight-week results, the two-year results showed no significant differences between the groups with regard to the worst pain or pain with first steps in the morning. Descriptive analysis of the data showed that 92% (sixty-one) of the sixty-six patients reported total satisfaction or satisfaction with minor reservations. Fifty-one patients (77%) reported no limitation in recreational activities, and sixty-two (94%) reported a decrease in pain. Only sixteen of the sixty-six patients reported the need to seek treatment by a clinician.
This study supports the use of the tissue-specific plantar fascia-stretching protocol as the key component of treatment for chronic plantar fasciitis. Long-term benefits of the stretch include a marked decrease in pain and functional limitations and a high rate of satisfaction. This approach can provide the health-care practitioner with an effective, inexpensive, and straightforward treatment protocol.

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    • "Patients (n = 47) randomized to the usual care group will receive an information booklet with general information on plantar fasciopathy. This information booklet will contain information on the use of pain medication and possible stretching and strength exercises (plantar specific stretching identical to the protocol used by DiGiovanni et al.[25]and unilateral heel raises adapted from exercises as described by Rathleff et al.[26]) that are considered to be helpful for all patients with plantar fasciopathy . The patients in this group will not be referred to a podiatrist. "
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    ABSTRACT: Background: Plantar fasciopathy is a common cause of foot pain, accounting for 11 to 15 % of all foot symptoms requiring professional care in adults. Although many patients have complete resolution of symptoms within 12 months, many patients wish to reduce this period as much as possible. Orthotic devices are a frequently applied option of treatment in daily practice, despite a lack of evidence on the effectiveness. Therefore, the objective is to study the (cost)-effectiveness of custom made insoles by a podiatrist, compared to placebo insoles and usual care in patients with plantar fasciopathy in general practice and sports medicine clinics. Method/design: This study is a multi-center three-armed participant and assessor-blinded randomized controlled trial with 6-months follow-up. Patients with plantar fasciopathy, with a minimum duration of complaints of 2 weeks and aged between 18 and 65, who visit their general practitioner or sport physician are eligible for inclusion. A total of 185 patients will be randomized into three parallel groups. One group will receive usual care by the general practitioner or sports physician alone, one group will be referred to a podiatrist and will receive a custom made insole, and one group will be referred to a podiatrist and will receive a placebo insole. The primary outcome will be the change from baseline to 12 weeks follow-up in pain severity at rest and during activity on a 0-10 numerical rating scale (NRS). Secondary outcomes include foot function (according to the Foot Function Index) at 6, 12 and 26 weeks, recovery (7-point Likert) at 6, 12 and 26 weeks, pain at rest and during activity (NRS) at 6 and 26 weeks and cost-effectiveness of the intervention at 26-weeks. Measurements will take place at baseline and at, 2, 4, 6, 12 and 26 weeks of follow-up. Discussion: The treatment of plantar fasciopathy is a challenge for health care professionals. Orthotic devices are frequently applied, despite a lack of evidence of the effectiveness on patient reported outcome. The results of this randomized controlled trial will improve the evidence base for treating this troublesome condition in daily practice. Trial registration: Dutch Trial Registration: NTR5346 . Date of registration: August 5(th) 2015.
    Full-text · Article · Dec 2016 · BMC Musculoskeletal Disorders
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    • "Plantar fasciitis is a common condition and can occur as a single occurrence or repeatedly throughout life (Digiovanni et al. 2006; Hyland et al. 2006). It is most common in people who exercise frequently or especially in people with a high body mass index (BMI) (Digiovanni et al. 2006; Weiner 2006; Moraes do Carmo et al. 2008). The plantar fascia is a thick fibrous connective tissue which originates at the medial tuberosity of the calcaneus and inserts into the proximal phalanges (Kumar et al. 2013). "
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    ABSTRACT: One of the sexual hormones, estrogen, increases elasticity of human connective tissue such as the anterior cruciate ligament during the menstrual cycle in women. In the present investigation, the plantar fascia was investigated to see if there is a difference in elasticity with the menstrual cycle. Fifteen young healthy females in the age range of 18-35 years old with a regular menstrual cycle were tested twice throughout one full menstrual cycle; once during the early follicular phases and once at ovulation. Foot length, while standing on both feet and one foot were used to assess plantar fascia elasticity, ultrasound measured plantar fascia thickness while lying and standing, and posture sway and tremor using a balance platform during 8 different balance tests were assessed to see the impact of elasticity changes. Foot length increased significantly at ovulation compared to menstruation when standing on two feet (p = 0.03) and standing on one foot (p < 0.001). There was also a significant increase in plantar fascia in thinning per kilogram weight applied to the foot at ovulation compared to menstruation (p = 0.014). Associated with this increase in elasticity at ovulation, there was a reduction in balance in the most difficult balance tasks and an increase in tremor during ovulation (p < 0.05). Plantar fascia elasticity change during the menstrual cycle might have effects on posture sway and tremor, which could have a potential risk of falling. Therefore, healthy professionals working with young female adults should recognize these physiological effects.
    Preview · Article · Nov 2015 · The Tohoku Journal of Experimental Medicine
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    • "Randomized controlled studies have shown that stretching exercises improve recalcitrant plantar fasciopathy symptoms within a reasonable time frame [14] [15] [25]. The therapeutic mechanism involved in any stretching exercise is speculative, and there has been no clear explanation of why such treatment works. "
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    ABSTRACT: Whether shock wave therapy or shock wave therapy combined with plantar fascia-specific stretching is more efficient in treating chronic plantar heel pain remains unclear. The aim of the study was to test the null hypothesis of no difference of these two forms of management for patients who had unilateral plantar fasciopathy for a minimum duration of twelve months and which had failed at least three other forms of treatment. One hundred and fifty-two patients with chronic plantar fasciopathy were assigned to receive repetitive low-energy radial shock-wave therapy without local anesthesia, administered weekly for three weeks (Group 1, n=73) or to receive the identical shock wave treatment and to perform an eight-week plantar fascia-specific stretching program (Group 2, n=79). All patients completed the nine-item pain subscale of the validated Foot Function Index and a subject-relevant outcome questionnaire. Patients were evaluated at baseline, and at two, four, and twenty-four months after baseline. The primary outcome measures were a mean change in the Foot Function Index sum score at two months after baseline, a mean change in item 2 (pain during the first steps of walking in the morning) on this Index, and satisfaction with treatment. No difference in mean age, sex, weight or duration of symptoms was found between the groups at baseline. At two months after baseline, the Foot Function Index sum score showed significantly greater changes for the patients managed with shock-wave therapy plus plantar fascia-specific stretching than those managed with shock-wave therapy alone (p < 0.001), as well as individually for item 2 (p< 0.001). Twenty-four patients in Group 1 (32%) versus forty-seven patients in Group 2 (59%) were satisfied with the treatment (p< 0.001). Significant differences persisted at four months, but not at twenty-four months. A program of manual stretching exercises specific to the plantar fascia in combination with repetitive low-energy radial shock-wave therapy is more efficient than repetitive low-energy radial shock-wave therapy alone for the treatment of chronic symptoms of proximal plantar fasciopathy. Copyright © 2015. Published by Elsevier Ltd.
    Full-text · Article · May 2015 · International Journal of Surgery (London, England)
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