Research Review by Dr. Shawn Thistle©

Date:

July 2008

Study Title:

Heel Pain – Plantar Fasciitis: Clinical Practice Guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association

Reviewers:

DeLitto S, Dewitt J, Ferland A, Fearon H, MacDermaid J, McClure P, Shekelle P, Smith AR, & Torburn L

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2008; 38(4): A1-A18.

Summary:

Plantar Fasciitis (PF) is one of the most common foot conditions seen in manual medicine practice. The most current epidemiological data on PF suggests that it afflicts up to 10% of the adult population over the course of a lifetime, and accounts for 15% of all foot complaints requiring professional care. This review will summarize the Clinical Practice Guidelines on PF published by the American Physical Therapy Association.

Plantar Fascia Anatomical Features
  • the PF consists of 3 general bands: medial, central, and lateral; the central band originates from the medial tubercle on the plantar surface of the calcaneous
  • the following muscles share the origin of the central band of the PF: flexor digitorum brevis, abductor hallucis, and the medial band of the quadratus plantae
  • the most common area of involvement is near this attachment (enthesis) of the central band
Risk Factors for Developing Plantar Fasciitis

The specific cause of PF is poorly understood, and thought to be multifactorial. That being said, the following factors have been established in multiple studies as being associated with the development of PF:
  • reduced ankle dorsiflexion range of motion (thought to be the most important, although information about specific degrees of limitation is lacking)
  • body mass index (BMI) > 30 kg/m2 in a non-athletic population
  • work-related weight bearing (evidence not as strong for this)
  • repetitive micro-trauma (evidence not as strong for this)
Clinical Presentation and Differential Diagnosis
  • the diagnosis can be made with relative certainty on clinical assessment alone
  • patients normally report an insidious onset of pain under the plantar surface of the heel upon weight-bearing, particularly after a period of non-weight-bearing
  • the pain is most noticeable in the morning during the first steps upon rising
  • pain may be severe enough to cause antalgic gait
  • pain normally lessens with activity, but may worsen near the end of the day
  • the history may reveal a recent increase in activity level
  • pain may be described as sharp and localized, achy, “tight”
  • associated paresthesias are uncommon
  • Differential Diagnoses: calcaneal stress fracture, bone bruise, fat pad atrophy, tarsal tunnel syndrome, Paget’s disease, Sever’s disease, S1 radiculopathy, soft tissue/primary/metastatic tumours
Clinical Assessment

The following tests can be used to assess for PF (It is important to note that imaging is normally not necessary in the assessment of this condition):
  • palpation of the proximal PF attachment and associated musculature
  • active and passive ankle dorsiflexion ROM
  • Tarsal Tunnel Syndrome Test (should be negative for PF) – dorsi-flex and evert the foot, extend the toes, and tap over the tarsal tunnel area to determine if a positive Tinnel’s sign is present (test should be done for 5-10 seconds)
  • Windlass Test – with the ankle in neutral, the first metatarsal-phalangeal joint is passively extended which tensions the PF – a positive test is reproduction of the primary complaint
  • Longitudinal Arch Angle - with the patient standing, the medial malleolus (MM), navicular tuberosity (NT), and first metatarsal head (MTH) are marked with a pen – then a goniometer is used to measure the angle between lines joining the MM-NT, and MTH-NT (curiously, no data provided on optimal or pathological measurement values, despite the recommendation to use this test)
INTERVENTIONS FOR PLANTAR FASCIITIS:

The following interventions were included in these clinical guidelines, and rated based on their levels of supporting evidence in the typical A, B, C, and D manner:
  • Modalities: Dexamethasone (0.4%) or acetic acid (5%) delivered via iontophoresis may provide short-term pain relief (2-4 weeks) and improved function (Evidence Grade “B”: moderate – a single high-quality RCT, or a preponderance of Level II studies [lower quality RCTs, prospective studies, or diagnostic studies])
  • Manual Therapy: there is minimal evidence to support the use of manual therapy including nerve mobilization techniques. Suggested manual techniques include: talocrural joint posterior glide, subtalar joint lateral glide, anterior and posterior glides of the first tarsometatarsal joint, subtalar joint distraction manipulation, soft tissue mobilization near potential nerve entrapment sites, and passive neuromobilization techniques (Evidence Grade “E”: theoretical/foundational – a preponderance of animal or cadaver studies, from conceptual models/principles, or from basic sciences research)
  • Stretching: gastrocnemius and soleus stretching may provide short-term (2-4 months) pain relief and improved calf flexibility. Dosage of stretching can be either sustained (3 minutes) or intermittent (20 seconds) performed twice per day – neither has been shown to be superior to the other (Evidence Grade “B”: moderate – a single high-quality RCT, or a preponderance of Level II studies [lower quality RCTs, prospective studies, or diagnostic studies])
  • Taping: calcaneal or low-Dye taping may provide short-term pain relief (7-10 days), and improvement in function (Evidence Grade “C”: weak – a single low quality RCT or a preponderance of lower level studies including statements of consensus by content experts)
  • Orthotic Devices: prefabricated or custom orthotics may provide short-term relief of pain (3 months) and improve function. There seems to be no difference between prefabricated or custom orthotics, and there is no evidence for either type of orthotic for longer-term pain relief (1 year) (Evidence Grade “A”: strong – a preponderance of high/medium-quality RCTs including at least one high-quality study )
  • Night Splints: can be considered for patients with symptoms longer than 6 months, and should be worn for 1-3 months. The type of splint (posterior, anterior, or sock-type) does not appear to affect outcome (Evidence Grade “B”: moderate – a single high-quality RCT, or a preponderance of Level II studies [lower quality RCTs, prospective studies, or diagnostic studies])

Conclusions & Practical Application:

Plantar fasciitis can be a difficult condition to manage in some cases, while others respond quickly to conservative treatment. These clinical guidelines synthesized the existing literature on this condition, and combined with expert opinion of those on the review panel, providing clinicians with a simple set of instructions for assessment and diagnosis of this condition. As most already know, it is normally not difficult to diagnose.

These guidelines also highlight the need for further quality research to determine which treatments are most effective for this condition. Many who practice specific soft tissue techniques such as Active Release Techniques (ART®) report high success rates with this condition, but need to mobilize and publish these results before their treatment is included in guidelines such as these.