Physical Medicine and Rehabilitation for Plantar Fasciitis

Physical Medicine and Rehabilitation for Plantar Fasciitis

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Plantar fasciitis is typically evaluated and treated without surgery, responding well to physical medicine and rehabilitation approaches such as stretching, splints (or other orthotic devices), modalities, and local injections.

One issue regarding physical medicine and rehabilitation for plantar fasciitis is that chronic plantar pain leads to increased limping; this can produce an antalgic gait pattern that may hinder and possibly decrease mobility to levels that are unacceptable for the performance of activities of daily living (ADLs), including work and recreation.

For further information on this topic, see the Medscape Reference article Plantar Fasciitis.

A retrospective study by Fraser et al, using a large patient record database, determined that between 2007 and 2011, among unique patients with plantar fasciitis who made an ambulatory care visit, only about 7% underwent evaluation by a physical therapist. Of those who were evaluated, the majority were treated with manual therapy and a course of supervised rehabilitation. [1]

The mainstay physical therapy for plantar fasciitis is stretching. [2] Many authors advise against considering surgical referral and intervention until a minimum of 6-9 months of comprehensive nonsurgical treatment has been completed.

There are a number of ways to stretch the plantar fascia and the Achilles tendon. For patients who report that the most severe symptoms occur with the first steps after awakening, stretches should be performed before the patient even gets out of bed.

This can be accomplished by keeping a long towel at the bedside. Upon awakening, the patient can stretch the plantar fascia by using the towel to cause passive dorsiflexion of the ankle, with each hand pulling one end of the towel, using the midportion of the towel to pull on the plantar aspect of the forefoot region. Other techniques for stretching the Achilles tendon include passive stretch while standing and nighttime ankle-foot orthoses to keep the feet in neutral at night (thus stretching the Achilles tendon). [3]

The plantar fascia also can be stretched by having the patient, while seated, roll a soda can between the sole and the floor. Using a cold can of soda may give further symptomatic relief through local cooling.

Passive stretching of the plantar fascia also can be achieved by using one hand at the plantar aspect of the forefoot region, then dorsiflexing the foot.

A study found non–weight-bearing stretching exercises specific to the plantar fascia to be superior to the standard program of weight-bearing, Achilles tendon–stretching exercises in patients with chronic plantar fasciitis. [4] Another study suggests that static progressive stretch bracing may be an effective alternative to static stretching exercises. The study showed no significant difference between static stretching exercises and static progressive stretch braces in terms of pain relief or functional improvement. [5]

According to a recent study investigating plantar fasciitis treatment options, no evidence supports gastrocnemius/soleus stretching as a stand-alone treatment to be as effective as plantar fascia-specific stretching. Gastrocnemius/soleus stretching may be beneficial as supplement to the more isolated plantar fascia-specific stretching. [6]

Orthotics devices are a viable treatment option for patients with plantar fasciitis and are relatively inexpensive compared with other options. Orthotics devices are thought to reduce symptoms by diminishing and absorbing shock that is normally absorbed by the plantar fascia. Another theory proposed is the orthotics attempt to correct postural deviations or muscle deficiencies that may predispose an individual to developing plantar fasciitis. [7]

Commonly prescribed silicone inserts are effective in reducing pain and increasing functions in the short term. Both affordable and readily available, popular recommendation includes first-line treatment with silicone orthotics for patients with plantar fasciitis. [8]

Combined use of foot orthoses and night splits may provide better outcomes than either modality alone. [9]

Dorsiflexing both the ankle and metatarsophalangeal joints can reduce the tension of the posterior calf along with the plantar fascia, thereby reducing pain. These modalities can be applied both during the day, while being active, and at night, increasing the chance of pain reduction. [9]

While evidence has been somewhat inconsistent regarding the effectiveness of night splints and orthoses used separately for reducing pain caused by plantar fasciitis, recent studies suggest that the treatment protocol combining the 2 modalities is more effective than orthotics alone in relieving foot pain in patients with plantar fasciitis. [9] Massage of the plantar fascia, accomplished by running the thumb or fingers lengthwise along the fascia, can be beneficial for patients with plantar fasciitis. The physical therapist may perform this technique during therapy sessions and may instruct the patient or family members on how to continue the massage independently at home.

Application of ice is an important part of the treatment process to reduce pain and inflammation. Ice should be applied after exercise and may be performed either as an ice massage for 5 minutes or by applying an ice pack for 15-20 minutes. The physical therapist also may recommend other modalities, such as ultrasonography, phonophoresis, or iontophoresis, to assist further with pain relief and reduction of inflammation.

In some cases, taping of the plantar fascia by an athletic trainer or physical therapist can help decrease stress on the fascia, enabling the patient to better tolerate activity. Taping techniques are used to distribute force away from the stressed and irritated fascia and to provide some relief from discomfort caused by weight-bearing activities.

If the patient needs to decrease activity level because of this condition, remember to suggest alternative means of maintaining strength and cardiovascular fitness (eg, swimming, water aerobics, other aquatic exercises). Generally, in patients with plantar fasciitis due to work-related causes, the physical therapist can perform work-hardening activities with physician supervision.

Local corticoid steroid injections (CSIs) are a popular choice in treatment of plantar fasciitis, but evidence supports their use for a short-term benefit only. [10]  This conclusion was supported by a literature review by Li et al. Using a meta-analysis of four studies (289 patients total), the investigators found that although patients with plantar fasciitis who underwent corticosteroid injections experienced better pain relief after one month than did patients receiving placebo injections, no such difference was found between the two groups after two months. [11]

The patient should be instructed to contact the physician before the scheduled follow-up appointment if there is significant progression of the symptoms or if there are any local signs of infection at the injection site.

Extracorporeal shock wave therapy (ESWT) is an effective treatment for reducing pain associated with plantar fasciitis. Shock waves are sound-wave vibrations that are generated and are transported through tissue by fluid and solid-particle interaction. This creates local tissue injury, causing new vessel growth, as well as increasing the amount of tissue growth factors within the localized area. Therefore, one of the proposed theories is that ESWT stimulates healing by creating a wound environment at the site of treatment.

Adverse effects include calcaneal pain, erythema on the calcaneal area, local edema, local paresthesia, and local bruising, all of which have generally been reported as short term and tolerable.

At moderate and high intensity, ESWT may reduce pain and improve function in patients with chronic plantar fasciitis and potentially reduce the need for invasive procedures (ie, surgery). The effectiveness of focused ESWT was demonstrated in a study by Gollwitzer et al on patients with chronic plantar fasciitis. The prospective, multicenter, double-blind, randomized, placebo-controlled study, which included 246 patients and a 12-week follow-up period, found that focused ESWT was successful in reducing heel pain in 50-65% of patients. [12]

Benefits to ESWT versus surgery include the risks associated with surgery such as swelling of heel fad, calcaneal fracture, injury to posterior tibial nerve or its branches, flattening of the longitudinal arch, and delayed recovery. ESWT can be administered in an outpatient setting, and patients are not required to avoid weight bearing to delay return to work.

ESWT is a cost-effective modality and one of the few treatments tested and supported with evidence-based medicine standards for approaching plantar fasciitis treatment. [13]

Endoscopic plantar fasciotomy (EPF) and ESWT are both effective for treating chronic plantar fasciitis, with EPF favored for outcome. However, ESWT treatment could be preferred since the athlete can remain active while undergoing treatment. Therefore, ESWT may be a viable first-line treatment with little disadvantages, especially when an athlete wishes to continue to be active. [13]

Fraser JJ, Glaviano NR, Hertel J. Utilization of Physical Therapy Intervention Among Patients With Plantar Fasciitis in the United States. J Orthop Sports Phys Ther. 2017 Feb. 47 (2):49-55. [Medline].

Radford JA, Landorf KB, Buchbinder R, Cook C. Effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskelet Disord. 2007 Apr 19. 8:36. [Medline]. [Full Text].

Baldassin V, Gomes CR, Beraldo PS. Effectiveness of prefabricated and customized foot orthoses made from low-cost foam for noncomplicated plantar fasciitis: a randomized controlled trial. Arch Phys Med Rehabil. 2009 Apr. 90(4):701-6. [Medline].

Flanigan RM, Nawoczenski DA, Chen L, Wu H, DiGiovanni BF. The influence of foot position on stretching of the plantar fascia. Foot Ankle Int. 2007 Jul. 28(7):815-22. [Medline].

Sharma NK, Loudon JK. Static progressive stretch brace as a treatment of pain and functional limitations associated with plantar fasciitis: a pilot study. Foot Ankle Spec. 2010 Jun. 3(3):117-24. [Medline].

Anderson J, Stanek J. Effect of foot orthoses as treatment for plantar fasciitis or heel pain. J Sport Rehabil. 2013 May. 22(2):130-6. [Medline].

Lee WC, Wong WY, Kung E, Leung AK. Effectiveness of adjustable dorsiflexion night splint in combination with accommodative foot orthosis on plantar fasciitis. J Rehabil Res Dev. 2012. 49(10):1557-64. [Medline].

Garrett T, Neibert PJ. The Effectiveness of a Gastrocnemius/Soleus Stretching Program as a Therapeutic Treatment of Plantar Fasciitis. J Sport Rehabil. 2013 May 22. [Medline].

Saxena A, Fournier M, Gerdesmeyer L, Gollwitzer H. Comparison between extracorporeal shockwave therapy, placebo ESWT and endoscopic plantar fasciotomy for the treatment of chronic plantar heel pain in the athlete. Muscles Ligaments Tendons J. 2012 Oct. 2(4):312-6. [Medline]. [Full Text].

Yucel U, Kucuksen S, Cingoz HT, et al. Full-length silicone insoles versus ultrasound-guided corticosteroid injection in the management of plantar fasciitis: A randomized clinical trial. Prosthet Orthot Int. 2013 Mar 7. [Medline].

Li Z, Yu A, Qi B, et al. Corticosteroid versus placebo injection for plantar fasciitis: A meta-analysis of randomized controlled trials. Exp Ther Med. 2015 Jun. 9 (6):2263-2268. [Medline].

Gollwitzer H, Saxena A, DiDomenico LA, et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study. J Bone Joint Surg Am. 2015 May 6. 97 (9):701-8. [Medline].

Dizon JN, Gonzalez-Suarez C, Zamora MT, Gambito ED. Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: a meta-analysis. Am J Phys Med Rehabil. 2013 Jul. 92(7):606-20. [Medline].

Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Todd P Stitik, MD Professor, Department of Physical Medicine and Rehabilitation, Director, Outpatient Occupational/Musculoskeletal Medicine, Rutgers New Jersey Medical School

Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Ossur, Fidia.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, Association of Academic Physiatrists

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Allergan<br/>Received honoraria from Allergan for speaking and teaching. for: Allergan.

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Everett C Hills, MD, MS Assistant Professor of Physical Medicine and Rehabilitation, Assistant Professor of Orthopaedics and Rehabilitation, Penn State Milton S Hershey Medical Center and Pennsylvania State University College of Medicine

Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, Association of Academic Physiatrists, American Academy of Physical Medicine and Rehabilitation, American Association for Physician Leadership, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Debra Ibrahim New York College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Evish Kamrava St George’s University School of Medicine

Disclosure: Nothing to disclose.

Cyrus Kao St George’s University School of Medicine

Disclosure: Nothing to disclose.

Jason Lee St George’s University School of Medicine

Disclosure: Nothing to disclose.

Leia Rispoli Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Dev Sinha, MD American University of Antigua School of Medicine and Health Sciences

Disclosure: Nothing to disclose.

Physical Medicine and Rehabilitation for Plantar Fasciitis

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