Plantar Fasciitis Stretches? Why My Patients Skip Them

Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003 Jul;85-A(7):1270-7. DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF.

Abstract
BACKGROUND:
Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. We hypothesized that patients with chronic plantar fasciitis who are managed with the structure-specific plantar fascia-stretching program for eight weeks have a better functional outcome than do patients managed with a standard Achilles tendon-stretching protocol.

METHODS:
One hundred and one patients who had chronic proximal plantar fasciitis for a duration of at least ten months were randomized into one of two treatment groups. The mean age was forty-six years. All patients received prefabricated soft insoles and a three-week course of celecoxib, and they also viewed an educational video on plantar fasciitis. The patients received instructions for either a plantar fascia tissue-stretching program (Group A) or an Achilles tendon-stretching program (Group B). All patients completed the pain subscale of the Foot Function Index and a subject-relevant outcome survey that incorporated generic and condition-specific outcome measures related to pain, function, and satisfaction with treatment outcome. The patients were reevaluated after eight weeks.

RESULTS:
Eighty-two patients returned for follow-up evaluation. With the exception of the duration of symptoms (p < 0.01), covariates for baseline measures revealed no significant differences between the groups. The pain subscale scores of the Foot Function Index showed significantly better results for the patients managed with the plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and item 2 (first steps in the morning; p = 0.006). Analysis of the response rates to the outcome measures also revealed significant differences with respect to pain, activity limitations, and patient satisfaction, with greater improvement seen in the group managed with the plantar fascia-stretching program.

CONCLUSIONS:
A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. These findings provide an alternative option to the present standard of care in the nonoperative treatment of patients with chronic, disabling plantar heel pain.

My comments:

This paper is relatively famous among physical therapists with relation to the treatment of plantar fasciitis.  They found plantar fascia specific stretches (crossing your leg and bending your toes backwards with your hand 10 times 10 seconds 3 times per day) to be more effective at decreasing pain than equal time on calf stretches. However, I have several problems with the conclusions in spite of the positive outcomes with plantar fascia specific stretches.

First: other research has found that the plantar fascia isn’t particularly tight in patients with plantar fasciitis, while the calf muscles are. So, even if the results of this study are correct with regards to pain reduction you are maybe overstretching a tissue that isn’t tight (plantar fascia), while leaving the one that is tight (calf muscles) abnormally short.

Second: the results of plantar fascia specific stretches, even if better than calf stretches, aren’t particularly impressive. This study only showed a combined pain reduction of 19% after 8 weeks of treatment, compared to 13% for the calf stretches.  So to me it seems like a lot of bother for not a lot of effect with either.  Pain at worst decreased more at 26% with the plantar fascia stretches compared to 14.7% with the calf stretches but that still just bringing an 8/10 pain down to a 6/10 pain after 8 weeks of stretching 3 times per day.

Third: a recent study found relatively simple strengthening exercises were significantly more effective at treating plantar fasciitis when performed once every other day. They were more effective than these plantar fascia specific stretches performed 3 times per day every day.  Even that study did not address strengthening of foot intrinsic muscles, and hip abductors and extensors known to be weaker in those with plantar fasciitis and other similar conditions.

Fourth: I think the researchers, perhaps inadvertently, stacked the deck in favor of the plantar fascia stretch group and against the calf stretch group. They placed particular importance on pain reduction during the first steps getting out of bed. The plantar fascia stretching group did their first stretches before they got out of bed, while the calf stretch group did their first stretches of the day after getting out of bed.  The plantar fascia group was warmed up already for their first steps of the day, which is when plantar fasciitis pain is known to be most painful.  This is why I think they found pain at worst was reduced with plantar fascia stretches.

Last: the plantar fascia is a passive structure that supports the arch of the foot, and if it is stretched out, other structures (muscles, tendons and ligaments) logically must either take up that load or the foot will flatten. This likely leads to other problems, including posterior tibial tendinopathy potentially resulting down the road in acquired flat foot deformity.  So while plantar fascia stretches may be the current conventional wisdom, conventional wisdom is often long on convention and short on wisdom.  When developing my physical therapy protocols, I’ll chose more current research, applied logic and sound reasoning over conventional wisdom 10 times out of 10.

So what do we do instead?  If the calf muscles are tight we do stretch them, but more importantly we strengthen the all the muscles (intrinsic and extrinsic, including the hips) that support the foot arch with a combination of exercise and EMS. Thus, improving overall fitness while we take the stress off the plantar fascia.  Besides strengthening, EMS has the great side effect of immediately reducing pain.

Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember Spinal Flow Yoga for you or someone you know in the future.


Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

3 thoughts on “Plantar Fasciitis Stretches? Why My Patients Skip Them”

  1. I can attest to the following statement you have made:

    “So, even if the results of this study are correct with regards to pain reduction you are maybe overstretching a tissue that isn’t tight (plantar fascia), while leaving the one that is tight (calf muscles) abnormally short.”

    With minor plantar fasciitis and tendonitis in my foot, I’ve recently noticed that my calves play a direct correlation to my foot pain. The better my legs feel, that better my feet feel.

  2. Hi Chad, I was just researching exercises for plantar fasciitis and came across some of your notes which were super interesting about strengthening the fascia on the foot rather than (or more than) lengthening (and still lengthening calves), I just wondered if you have any updated research or strengthening/lengthening advice. Obviously it depends on the individual as well.. Also, I just saw after that you studied at Sampoorna India – I just graduated from there yesterday that is SUCH a weird coincidence!

    • Hi Georgia!

      That’s amazing you went so Sampoorna! I have such good memories from there.

      About plantar fasciitis, I have been focusing on spine rehabilitation and integrating my rehab principles with Yoga for Spinal Flow, so I don’t have a lot to add on top of my prior blogs on plantar fasciitis. However, I do have a few things to say. At the time I was doing those blogs I was rehabbing primarily with free weights and machines, which did work very well. But since trying to make my programs more home exercise friendly, I do think the calf raises of Spinal Flow will help. The Levels-2 and 3 being single legged, and balancing, should integrate the ankle invertor and evertor muscles better than with a weight machine. However, the downside is you wouldn’t be stretching them as much, so I think for home exercise you would want to do some or all of your calf raises off of a block, working up to three sets of 15, or as many as you can, reps. I think my “inner squeeze” and “side-hip out” exercises will hit the ankle inverter and evertor muscles even more. The side hip outs would also increase hip abductor strength helping prevent the foot from rolling in, thus over-stretching the plantar fascia from the top down.

      From the bottom up, I did a blog on the short foot exercise for foot intrinsics, but having worked with that exercise a bit, I don’t think it’s intense enough to build any real strength. Thus the best way to strengthen the foot intrinsic muscles is still with EMS. I’ve changed how I do that a bit. I used to use one channel with two electrodes under each foot, where you stood on the electrodes to prevent foot cramping as sprint coach Charlie Francis taught. However, now I prefer to use one channel, with one electrode under the center of right foot, and the other under the left and to do it seated. That way you can read a book, or do something while the EMS is going on, and the electrodes being so far apart allowed for deeper stimulation. The feet do cramp that way but I have found you get used to it. Both ways work however. EMS doesn’t necessarily cost that much for plantar fasciitis either because needing only 1-2 channels a Rosco Medical TwinStim 4 (the 3 and lower sucks) works great, is powerful and can be programmed to do any of my favorite programs, and you can find them on ebay for something like $70. You would still want large rubber carbon electrodes, otherwise the stim will hurt before your can turn it up high enough to do any good.

      Worst comes to worse, ignore the pain and it should eventually go away. If you get even a single cortisone shot the fascia is much more likely to tear. You do yoga, so probably this isn’t an issue, but I’ll mention it for others; excess bodyweight increases the incidence of plantar fasciitis almost four fold, so being at ideal weight would almost certainly help if that’s an issue. Since you do yoga, hypermobility is more likely an issue, so increasing strength over what is very likely already greater than normal flexibility through weight training, or strength focused Spinal Flow Yoga, could help restore balance.

      I hope something in there helps.

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