Plantar Fasciitis: Orthotics Don’t Help Much

Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 2006 Jun 26;166(12):1305-10. Landorf KB, Keenan AM, Herbert RD.

Abstract
BACKGROUND:
Plantar fasciitis is one of the most common foot complaints. It is often treated with foot orthoses; however, studies of the effects of orthoses are generally of poor quality, and to our knowledge, no trials have investigated long-term effectiveness. The aim of this trial was to evaluate the short- and long-term effectiveness of foot orthoses in the treatment of plantar fasciitis.
METHODS:
A pragmatic, participant-blinded, randomized trial was conducted from April 1999 to July 2001. The duration of follow-up for each participant was 12 months. One hundred and thirty-five participants with plantar fasciitis from the local community were recruited to a university-based clinic and were randomly allocated to receive a sham orthosis (soft, thin foam), a prefabricated orthosis (firm foam), or a customized orthosis (semirigid plastic).
RESULTS:
After 3 months of treatment, estimates of effects on pain and function favored the prefabricated and customized orthoses over the sham orthoses, although only the effects on function were statistically significant. Compared with sham orthoses, the mean pain score (scale, 0-100) was 8.7 points better for the prefabricated orthoses (95% confidence interval, -0.1 to 17.6; P = .05) and 7.4 points better for the customized orthoses (95% confidence interval, -1.4 to 16.2; P = .10). Compared with sham orthoses, the mean function score (scale, 0-100) was 8.4 points better for the prefabricated orthoses (95% confidence interval, 1.0-15.8; P = .03) and 7.5 points better for the customized orthoses (95% confidence interval, 0.3-14.7; P = .04). There were no significant effects on primary outcomes at the 12-month review.
CONCLUSIONS:
Foot orthoses produce small short-term benefits in function and may also produce small reductions in pain for people with plantar fasciitis, but they do not have long-term beneficial effects compared with a sham device. The customized and prefabricated orthoses used in this trial have similar effectiveness in the treatment of plantar fasciitis.

My comments:
I’ve seen a number of studies that compared inexpensive over the counter orthotics to expensive custom made orthotics for plantar fasciitis, and they found there was no difference for the patient. This study was much the same. In fact, the over the counter orthotics came out very slightly ahead of the custom made ones with regards to both pain reduction and improved function (by about 1%), though the difference was not statistically significant.

What was more interesting is that this was the first, and still only, study to compare real orthotics to placebo “sham” orthotics. What they found was that 3 months out, the real orthotics decreased pain only 7-8% better than the sham ones, which was statistically significant but it had the authors question whether orthotics of any kind were worth the effort for plantar fasciitis. I have to admire the honesty coming from the researchers who are Podiatrists with a long history of researching plantar fasciitis and other foot problems.  At 12 months out there was no statistical significance between any of the three groups (custom, over the counter, or sham). The good news is that all three groups did improve over time, but it seems orthotics whether custom made or not only have a minimal beneficial effect. Certainly it seems the custom made orthotics are not worth the expense, with over the counter ones being relatively inexpensive and maybe worth trying on before you buy, or maybe not.

I’m of the opinion that plantar fasciitis should be treated more like tendinopathy, with a greater focus on strengthening muscles of the lower leg and foot with a combination of progressive resistance exercise for the larger muscles and electric muscle stimulation for the foot intrinsics (which most certainly works the foot muscles more intensely than towel bunches do). I notice a pretty good benefit from both clinically, but as of yet, there no research on either strengthening nor EMS for plantar fasciitis. The similarities of the condition with various tendinopathy conditions, along with my outcomes, makes me think it’s worth pursuing.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

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