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.
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.
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.
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.
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.
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.
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.