Thursday, December 2, 2010

Stretching to Tame the Pain of Plantar Fasciitis

Plantar fasciitis can be an annoying, possibly debilitating, cause of foot pain. According to a new study, patients with acute plantar fasciitis who regularly perform simple stretching exercises can experience superior pain relief and greater satisfaction than are afforded by treatment with shockwave therapy.

Plantar fasciitis is a common cause of pain on the bottom of the heel and roughly two million patients are treated for the disorder each year. Whether plantar fascia-specific stretching or shock-wave therapy is most effective as an initial treatment for this condition has been unclear. Writing in the Journal of Bone and Joint Surgery (JBJS), an international team of investigators report on the relative effectiveness of these two forms of treatment in patients with acute plantar fasciitis [Rompe et al. 2010]. All participants had heel pain that had persisted for a maximum of 6 weeks and had not been previously treated.

A total of 102 patients were randomly assigned to either (a) an 8-week stretching program [n=54], or (b) 3 sessions of low-energy radial shock-wave therapy, without local anesthesia, during each of 3 weeks [n=48]. Followup evaluations were at 2, 4, and 15 months. At the 2-month followup, patients in the fascia-stretching group experienced significantly greater pain relief. At both the 2- and 4-month evaluations, 65% of patients in the stretching program reported satisfaction with treatment; however, only 29% did so after shockwave therapy. However, by 15 months both groups were comparable on all measures of treatment efficacy.

COMMENTARY: As we have previously discussed [here], research has shown shockwave therapy to be a generally effective treatment for patients with chronic or recalcitrant plantar fasciitis (heel pain of more than 8 weeks duration). Outcomes of this current study suggest that, if treatment is started early, a simple, noninvasive, and inexpensive measure such as stretching exercise can be effective. In a news report [here], John Furia, MD, one of the study authors stated, “The earlier you understand how stretching fits in, and the earlier you learn how frequently to perform the simple plantar stretch, the less likely you will require a more invasive treatment method.”

Fascia StretchHere is the plantar fascia-stretching protocol, adapted from recommendations by the American Academy of Orthopaedic Surgeons (see photo):
  • In a seated position, cross the affected foot (shoeless but stockings can remain on) over the knee of the other leg.

  • Grasp the toes of the painful foot and gently pull the toes toward the shin.

  • Place a thumb along the plantar fascia and rub along the entire bottom of the foot to massage and stretch it. The fascia should feel like a tight band along the bottom of the foot when properly stretched.

  • Hold the stretch for 10 seconds. Repeat it 10 to 20 times for each affected foot, and repeat the exercise several times each day.
Furia recommends that this exercise should be performed in the morning before getting out of bed, and after any long periods of sitting. If there is sharp heel pain when getting up, a stretch should have been done before standing or walking. We also have previously described research using this exercise for chronic plantar fasciitis, in which the plantar fascia-stretching exercises were performed each day for 8 weeks and as required for any recurrences of heel pain thereafter [DiGiovanni et al. 2006].

> DiGiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006(Aug);88-A(8):1775-1781 [
discussion here].
> Rompe JD, Cacchio A, Weil L, et al. Plantar Fascia-Specific Stretching Versus Radial Shock-Wave Therapy as Initial Treatment of Plantar Fasciopathy. J Bone Joint Surg Am. 2010;92:2514-2522 [
abstract here].
# For additional information see: Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain. J Foot Ankle Surg. 2010 (May-Jun);49(3 Suppl):S1-S19 [
access to full article here].