Heel Pain – Plantar Fasciitis: Revision 2014
Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association
JOSPT, 2014;44(11);A1-A23 (click if you would like to read the entire Clinical Practice Guideline)
I am going to do a review of a review. These are the clinical practice guidelines for the assessment and treatment of plantar fasciitis. The original review was done in 2008 and was revised in 2014. Plantar fasciitis is one of, if not the, most common foot pain that I see clients about. What this document does is review and grade the scientific literature for plantar fasciitis. I will focus more on the treatment side of plantar fasciitis because that is more practical information for the readers. What can they do to get rid of the pain in their … foot?
Examination: I will simply say/ type a few words about the examination. Part of the examination is paperwork. The review states that certain outcome measures should be used to measure the effect of the plantar fasciitis on the client. The Foot and Ankle Ability Measurement (FAAM), Foot Health Status Questionnaire (FHSQ), Foot Function Index (FFI) and or the Lower Extremity Functional Scale (LEFS).
Treatment: I will go through all the different types of treatment for plantar fasciitis that they discuss in the review with a little bit of commentary on my own. We will discuss manual therapy, stretching, taping, foot orthoses, night splints, physical agents (low-level laser, phonophoresis, ultrasound), footwear, education, therapeutic exercise and neuromuscular re-education and dry needling.
The brand of dry needling in which I am certified is intramuscular stimulation or IMS. My designation is CGIMS, stands for Certified Gunn Intramuscular Stimulation. Click on the previous link to visit my Gunn IMS directory page.
Lots of different treatment options to discuss, so let’s get to it!!
Manual Therapy – there is strong evidence that manual therapy should be used to treat plantar fasciitis. Manual therapy = hands on treatment, including joint mobilizations or manipulations (adjustments) and soft tissue mobilization (massage, transverse frictions). Manual therapy will loosen up tight joints in the foot and loosen up the calf and foot musculature.
I am a firm believer in manual therapy. It is one of the ‘tools’ that I use regularly with all my clients. Not only does manual therapy have good evidence with plantar fasciitis but many more areas of the body.
Stretching – strong evidence is present for this modality as well. Not only stretching the calf muscles, gastroc and soleus, but in addition, specific plantar fascia stretching.
Home exercises are so important to help complement the manual therapy and other things your physiotherapy gets you to do/ practice.
Taping – once again strong evidence for the use with plantar fasciitis. Taping is beneficial in initially (the first 3 weeks) decreasing the pain and improving function.
The tape job most often talked about is the low dye tape job or the modified/augmented low dye tape job. This is talking about using athletic tape not K-Tape or any type of elastic therapeutic tape.
Foot Orthoses – strong evidence for orthotics either custom or non-custom, both have equal outcomes. Ideally, the foot orthoses should support the medial long arch and cushion the heel. They should be used to improve function over the short term (2 weeks) to long term (up to one year).
This does not mean that once you have an orthotic you have it for life! Once the pain has decreased wean yourself off the orthotics and continue with the foot strengthening exercises your physiotherapist should have given you by now. I am not against orthotics, I find that once someone gets a pair, they are committed for life. After your foot pain has decreased there is no need for them. Do not stop using them cold turkey! Just like when you started wearing your othotics, you slowly started adding them to your shoes, wearing them for an hour or two the first day. After that you are supposed to add an hour/day until you can wear them all day. The same goes for getting rid of the orthotic. Start to decrease your daily wearing of the orthotic for about an hour/day as well keeping up with the strengthening/ stretching exercises.
Night Splints – strong evidence again!! Using a night splint for 1 – 3 months can help to decrease the morning pain during the first few steps.
There is some evidence that the use of foot orthoses, orthotics, and night splint are synergist modalities when used together. That means if you use a foot orthotic and a night splint, you may get better results than simply using one or the other.
You put the night splint on your foot/leg before going to bed at night. There are various designs of night splints and I do not know if there is one better than another. The first few nights might be a little tough to sleep, it could feel like you have your foot/ankle in a cast.
Physical Agents – there is conflicting evidence for the physical agents. Conflicting evidence means that there are some studies that stay certain modalities work and some studies that have found no difference between groups of people that used the same modalities. These may or may not help.
Low-level Laser – may help to reduce pain and activity limitations in people with plantar fasciitis.
When you read at some clinics that use ‘Laser Therapy’, low-level laser is what they are advertising. It may be helpful for plantar fasciitis.
Phonophoresis – what the heck is phonophoresis?
Phonophoresis is the use of ultrasound to enhance the delivery of topically applied drugs. Phonophoresis has been used in an effort to enhance the absorption of topically applied analgesics and anti-inflammatory agents through the therapeutic application of ultrasound.
The above definition was taken from: https://en.wikipedia.org/wiki/Phonophoresis
Phonophoresis with ketoprofen gel may help to reduce pain in people with plantar fasciitis.
Ultrasound – this physical agent cannot be recommended for people with plantar fasciitis. There are no high-quality evidence to support the use of therapeutic ultrasound for treatment.
Footwear – there is weak evidence to say that some footwear choices may help to decrease the pain. There are two suggestions: rocker bottom shoe with foot orthoses and rotate your shoes, have more than one pair, for people that stand for long periods of time.
Note that neither of these suggestions say anything about running shoes! Standing in one spot is not natural, well maybe in the past 50 years (I am thinking of cashiers). I would think that if you have to stand, in one spot, for long periods of time, having cushioned shoes, more than one pair and possibly standing on a rubber mat may be helpful.
Education – weight loss, there is theoretical/foundational evidence. The therapist could provide education/ counselling on exercise strategies to maintain optimal lean body mass.
The more a client knows about their condition, it is beneficial. In Lance Armstrong’s first book, “It’s Not About The Bike”, he talked about how cancer patient survivor rates increased with simply increasing their knowledge and being actively involved in their treatment. I believe that is true not just with cancer but the vast majority of conditions. If you become actively engaged in your rehabilitation, i.e. doing the exercises, following the advice of your physiotherapist or other health care professional, I believe you have a better chance to succeed at whatever you want to do.
Therapeutic Exercise and Neuromuscular Re-Education – there is only expert opinion (the lowest level of scientific evidence). There is really no evidence to support strengthening except that physiotherapists say that it is good to strengthen.
My thought is strengthening is very rarely harmful to anybody. Doing exercises not only to the foot musculature but in addition, the entire lower extremity. This would start at the hip and work its way down to the foot. I very recently read an article that supports strength training and you will read about it in blog post soon. The new article was not about plantar fasciitis, specifically but sports injuries in general.
Dry Needling (aka IMS) – there is only expert opinion again. Therefore dry needling cannot be recommended for individuals with plantar fasciitis. There is very limited evidence to support dry needling, there was only one study. In the study, the compared people with plantar heel pain, getting dry needling vs. physical agents and exercise. The dry needling group was, on average, finished in 3.2 weeks while the physical agents/exercise group was, on average, 21.1 weeks of treatment. However, when they looked at pain intensity at discharge, there was minimal differences as well as at 6 months and 2 years.
The big thing in which I would like to point out is the 3.2 weeks of treatment for dry needling vs the 21.1 weeks of treatment when dry needling was not used. Even though, it was only one study, dry needling looks to be advantageous to decrease the number of treatments needed to decrease the pain in the foot.
As you can see there are many ways to stop that pain in the foot! Unfortunately, you might have to stop running for a while… I swear it is only a while! I know that runners hate cycling and water running, just as cyclists hate running. I try to get people to take a break from the sport only for a week or two, if needed. Within those couple of weeks, hopefully the client has been doing their exercises, strengthening and stretching. In addition, during those weeks off, there are many things that runners could do to help the plantar fasciitis not to return, for example work on their hip mobility, core strength/ endurance, upper body strength, lower body strength, go to yoga with a friend…