Adopting a multidimensional individualized approach to plantar fasciitis treatment
| September 12, 2013
Plantar fasciitis is thought to affect around 10 percent of people at some point in their lifetime. For such a prevalent condition, we really should have its treatment down to a fine art by now, shouldn't we? But this really isn't the case. There are many forms of treatment out there that have all been used in attempts to cure the condition, but so far there is no one treatment that has demonstrated consistently good results. And therein lies the problem. Using a single dimensional treatment program will never be effective in treating such a complex condition. In addition, every case is different and should be treated based on the findings of a thorough assessment, not with a "one size fits all" approach. I am writing this article after hearing — in disbelief — a new client tell me how he was immediately offered a steroid injection by his doctor to treat his classic PF symptoms, which had been persistent for eight weeks. No other treatment method or advice on self-management was offered. No referral for physical therapy. Just straight down the injection path. This got me searching for stats on the success rate of injections versus conservative therapies. While this particular doctor's approach does not appear to be the norm, he could be forgiven if he had skimmed over the many articles I discovered, all claiming that physical therapy is ineffective when compared with injections of PRP, steroids or extracorporeal shock wave therapy (ESWT). If these more invasive forms of treatment fail, the only option left is to go under the surgeon's knife. While there are some positive results coming through for research into the use of PRP and ESWT in treating this condition, these are as yet out of reach for most patients due to a combination of cost and availability. This is not, however, the case for steroid injections. In some cases, I believe they are being administered too early and without the patient fully understanding the reasons, risks (mainly fascia ruptures) and low success rates involved (estimated at 35 percent). Treat the Causes It is now fairly conclusive that plantar fasciitis is a degenerative ailment, as opposed to the inflammatory condition that its moniker suggests. To reflect this, we really should be calling it plantar fasciosis. So, if it has been established that there are no inflammatory cells present, why are we still treating the condition with anti-inflammatory injections? And if the cause is degenerative, what is causing the degeneration of this tissue? Degeneration is caused by an increased load on a tissue over a period of time. What's loading the fascia? Well, there is no one answer here as the cause will be different for each individual. And here we start to come back around to my first point — a single dimensional treatment protocol will not work. Many of my following suggestions have previously been shown to be ineffective, but when you look at the methodology behind such research it is clear that wearing insoles alone, or just stretching the calf muscles is not going to be sufficient to correct the movement dysfunctions that have developed over months, years or even decades. On the subject of stretching the calf muscles, a recent paper looked into the muscle lengths of both the calf muscles and hamstring group in those with PF symptoms, compared to healthy volunteers with no foot pain. The results demonstrated with clarity that those with PF consistently demonstrated shortened calf and hamstring muscles. This indicates that stretching should certainly play a part in our treatment protocols. The Multidimensional Individualized Approach Stretches shouldn't however be the only form of treatment. We should be addressing the causes of the muscle shortening too — such as hip extensor weakness and hip flexor shortening leading to plantarflexor overuse to aid propulsion; running on the forefoot (especially if attempting to transition to this style) and the wearing of inappropriate footwear such as very flat or very high-heeled shoes. Excessive and prolonged pronation during the gait cycle has also been shown to be a cause of PF due to repeated overstretching of the fascia at the medial calcaneal tubercle. Correcting this movement pattern requires strengthening of the muscles that control this excess motion — tibialis posterior and anterior, peroneus longus, the ankle plantarflexors, the hip abductors, etc. Stretching the calf complex and using soft tissue techniques to gain more dorsiflexion at terminal stance phase has also been shown to reduce "compensatory" pronation where the available range is less than 15 degrees. In cases where the structure of the foot has resulted in a low longitudinal arch, or excessive subtalar or forefoot varus, orthotics may be helpful. Night splints have also been shown to be effective in increasing dorsiflexion ROM and subsequently decreasing heel pain when used in conjunction with orthotics. The use of appropriate footwear and other self-management techniques should also be discussed with the patient. However, just as excess pronation can contribute to development of the condition, so can underpronation — as often seen in those with a "high arch." This equates to a rigid foot that is poorly suited to shock absorption. This reduced shock absorption capacity results in higher tension forces being applied to the plantar fascia insertion. In this case, the recommendation is more focused on increasing the mobility of the first metatarsophalangeal, subtalar, talonavicular and talocrural joints, as well as the extensibility of the fascia itself. Graded mobilizations, soft tissue techniques and fascial stretching have been shown to be effective in these cases. There are also some factors that should always be discussed with the patient, regardless of the biomechanical causes of the condition and that are never taken into account when it comes to research into conservative treatment methods. These include training techniques, sporting and day-to-day footwear and the patient's weight, if necessary. Conclusion Further research that uses a multidimensional approach is needed to realistically measure the success of physical therapy for treating plantar fasciitis. Each patient in the test group should be assessed and prescribed suitable exercises, physical therapy and orthotics where necessary, as opposed to one treatment protocol for all patients. Control groups should include patients using one type of treatment alone to compare any positive results gained through the more comprehensive treatment approach.
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