THE THERAPY CORNER

Plantar Fasciitis – What’s the latest?

This topic was first addressed early on in this series, with an update some years later [Therapy Corner #13 and 59; both can be found online via a link to The Therapy Corner on the Chargers’ website].  I think enough time has passed to take another look, to see if anything has changed in the approach to managing this very common running ailment.

In 2008, the Orthopedic Section of the American Physical Therapy Association published Clinical Practice Guidelines for management of plantar fasciitis [JOSPT, April 2008].  The expert panel’s recommendations pertaining to the diagnosis, prognosis, interventions, and outcomes measures for this condition were based on the best evidence available in the scientific literature through May 2007.

Deciphering the technical and scientific jargon in the panel’s recommendations and interpreting the different “levels” of evidence and corresponding “grades” of recommendation can be difficult.  I will try to summarize the most relevant points, hopefully to provide some useful guidelines for you when seeking treatment, should you unfortunately experience this condition.

First, let’s look at what the panel had to say about the two interventions I wrote about previously.  The first time, I recommended stretching exercises for the calf muscles, since shortening of those muscles often causes compensatory overpronation of the foot, which has for years been thought to be a major cause of plantar fasciitis.  So, are either of these assertions true?

According to the panel, decreased ankle dorsiflexion (upward movement of the foot, which stretches the calf muscles) is indeed a risk factor for the development of plantar fasciitis.  And concurrently, there is good evidence to support interventions (stretching, manual therapy) that increase that range of motion to successfully treat the condition, with the caveat that the improvements found to date are short-term. 

Interestingly, while the evidence fails to validate the long-held belief that overpronation is a prime risk factor, the highest level studies support the use of orthotic inserts, which are designed for the most part to control pronatory movement, for at least short-term management of plantar fasciitis.  Complicating this issue even further is the data that indicate no difference in effectiveness between pre-fabricated and custom orthotics.

Clinical observation and experience led me to assert, in my second article on this topic, that shoes – both running and daily-wear – often seem to be a factor in the development of plantar fasciitis, due to either poor fit or faulty construction.  Yet the panel never mentions this even in passing. (So much for personal theories...)

Other management approaches reviewed by the panel include:

• Night splints – there is moderate evidence to support the use of these devices, which maintain the ankle in a dorsiflexed position, for cases that have lasted more than 6 months.  Duration of use should be 1-3 months.
• Taping – there is weak evidence supporting the use of taping for short-term (7-10 days) relief of symptoms.
• Modalities – there is moderate evidence indicating that iontophoresis – the delivery of chemicals, such as corticosteroids – may provide short-term (2-4 weeks) pain relief and improved function.

 Overall, it would appear there have been no significant revelations that would warrant a complete revision of management strategies when treating plantar fasciitis.  Twenty years ago it was a challenging problem to address; today, it remains one that requires respect for the scientific evidence supporting various interventions while demanding a holistic stance in approaching each case as an individual one.

Gabe Yankowitz, PT, DPT, OCS

Gabe is a long-time runner and physical therapist in the outpatient physical therapy clinic at St. Camillus Health and Rehabilitation Center in Syracuse.  While he treats all orthopedic conditions, running injuries are his special interest.