plantar fasciitis guidelines

7/28/2019 Plantar Fasciitis Guidelines

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journal of orthopaedic & sports physical therapy | volume 37 | number 1 | january 2007 | a1

C l i n i c a l G u i d e l i n e s

THOMAS G. MCPOIL, PT, PhD HE8HEOB$C7HJ?D"PT, PhDC7HAM$9EHDM7BB" PT, PhD

:7D;A$MKA?9>"MD@7C;I@$?HH=7D=PT, PhD@EI;F>@$=E:=;I"DPT

Heel PainPlantar Fasciitis:

Clinical Practice GuidelinesLinked to the International Classification

of Function, Disability, and Health fromthe Orthopaedic Section of the

American Physical Therapy Association

H;L?;M;HI0Anthony Delitto, PT, PhDJohn Dewitt":FJAmanda Ferland":FJHelene Fearon, PT

Joy MacDermid, PT, PhDPhilip McClure, PT, PhDPaul Shekelle, MD, PhDA. Russell Smith, Jr., PT, EdDLeslie Torburn, PT

For author, coordinator, and reviewer afliations see end o text. 2008 Orthopaedic Section, American Physical Therapy Association (APTA), Inc, and the Journal of

Orthopaedic & Sports Physical Therapy. The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to the photocopying o

this guideline or educational purposes. Address correspondence to Joseph J. Godges, DPT, ICF Practice Guidelines Coordinator, Orthopaedic Section APTA, Inc,

2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: [email protected]

RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2

INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3

METHODS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A3

CLINICAL GUIDELINES:Impairment Function-Based Diagnosis . . . . . . . . . . . . . . . . . . . A4

CLINICAL GUIDELINES:Examinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A8

CLINICAL GUIDELINES:Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A11

SUMMARY OF RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A16

AUTHOR/REVIEWER AFFILIATIONS & CONTACTS . . . . . . . . . . A17

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A17

J Orthop Sports Phys Ther. 2008:38(4):A1-A18. doi:10.2519/jospt.2008.0302


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a2 | april 2008 | number 4 | volume 38 | journal of orthopaedic & sports physical therapy

Recommendations*

H e e l P a i n P l a n t a r F a s c i i t i s : A C l i n i c a l P r a c t i c e G u i d e l i n e

F7J>E7D7JEC?97B


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H e e l P a i n P l a n t a r F a s c i i t i s : C l i n i c a l P r a c t i c e G u i d e l i n e s

journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | a3

7?CE;=K?:;B?D;

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lh\bZmbhg!:IM:"aZlZghg`hbg`^hkmmh\k^Zm^^ob]^g\^&[Zl^]practice guidelines or orthopaedic physical therapy manage-ment o patients with musculoskeletal impairments describedbgma^Phke]A^ZemaHk`ZgbsZmbhglBgm kgZmbhgZe


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INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH

PRIMARY ICF CODES

Body functions b28015 Pain in lower limb

b2804 Radiating pain in a segment or region

Body structure s75023 Ligaments and ascia o ankle and oot

s75028 Structures o ankle and oot, neural

Activities andparticipation d4500 Walking short distancesd4501 Walking long distances

d4154 Maintaining a standing position

SECONDARY ICF CODES

Body functions b7100 Mobility o a single joint (increase or decrease in mobility)

b7101 Mobility o several joints (increase or decrease in mobility)

b7203 Mobility o tarsal bones (increase or decrease in mobility)

b7300 Power o isolated muscles and muscle groups (weakness o intrinsics)

b7401 Endurance o muscle groups

b770 Gait pattern unctions (antalgic gait)

Body structure s75020 Bones o ankle and oot (calcaneus/heel spur)

s75022 Muscles o ankle and eet (extensor digitorum brevis, abductor hallucis, abductor digiti quinti,gastrocnemius/soleus)

s75028 Structure o ankle and oot, specified as tarsal tunnel/flexor retinaculum

s198 Structure o the nervous system, specified as tibial nerve and branches

Activities and

participationd4101 Squatting

d4104 Standing

d4106 Shiting the bodys centre o gravity

d4302 Carrying in arms (object)

d4303 Carrying on shoulders, hip, and back

d4350 Pushing with lower extremities

d4351 Kicking

d4502 Walking on dierent slopes

d4503 Walking around obstacles

d4551 Climbing

d4552 Running

d4553 Jumping

d4600 Moving around within the home

d4601 Moving around within buildings other than home

d4602 Moving around outside the home or other buildings

INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS

Primary ICD-10 M72.2 Plantar ascial fibromatosisPlantar asciitis

Secondary ICD-10 G57.5G57.6

Tarsal tunnel syndromeLesion o plantar nerve

B


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FH;L7B;D9;Plantar fasciitis is the most common foot condition

treated by healthcare providers. It has been estimated that

ieZgmZk_Zl\bbmblh\\nkl bgZiikhqbfZm er+fbeebhg:f^kb-

cans each year and afects as much as 10% o the population

over the course o a lietime.48Bg+)))ma^?hhmZg]:gde^

Li^\bZeBgm^k^lm@khnih_ma^HkmahiZ^]b\L^\mbhg%:IM:%

surveyed over 500 members and received responses rom

117 therapists.47H_mahl^k^lihg]bg`%*))bg]b\Zm^]maZm

plantar asciitis was the most common oot condition seen in

their clinic.47 Rome et al49 reported that plantar asciitis ac-

counts or 15% o all adult oot complaints requiring proes-

sional care and is prevalent in both nonathletic and athletic

ihineZmbhgl'MZngmhg^mZe54 conducted a retrospective case-

control analysis o 2002 individuals with running-related in-

cnkb^lpahp^k^k^_^kk^]mhma^lZf^lihkmlf^]b\bg^\^gm^k'

Ma^rk^ihkm^]maZmieZgmZk_Zl\bbmblpZlma^fhlm\hffhg

condition diagnosed in the oot and represented 8% o all

bgcnkb^l'

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that increased the risk o developing plantar asciitis in this

lmn]rihineZmbhgp^k^li^g]bg`ma^fZchkbmrh_ma^phkd]Zr

on the eet and a body-mass index o greater than 30 kg/m 2.

While ankle dorsiflexion, obesity, and work-related weight

bearing were reported to be independent risk actors, reduced

ankle dorsiflexion appeared to be the most important.

48

IIIn a recent systematic review examining risk actors

associated with chronic plantar heel pain, Irving et

al24 reported a strong association between a body-

mass index o 25 to 30 kg/m2 and a calcaneal spur in a non-

Zmae^mb\ihineZmbhg'Ma^rk^ihkm^]Zp^ZdZllh\bZmbhg_hkma^

development o plantar asciitis with increased body-mass

index in an athletic population, increased age, decreased an-

de^]hklb^qbhg% ]^\k^Zl^]klmf^mZmZklhiaZeZg`^Ze chbgm

extension, and prolonged standing. Irving and colleagues24

noted that the relationship between static oot posture as well

as dynamic oot motion and the development o plantar as-

ciitis was inconclusive.

IIMa^g]bg`lh_Bkobg`^mZe24 with regard to static

oot posture and dynamic oot motion are o inter-

est because the high incidence o plantar asciitis in

runners has been anecdotally attributed to repetitive micro-

mkZnfZZllh\bZm^]pbma^q\^llbo^ikhgZmbhg'F^llb^kZg]Ibm-

tala37 as well as Wearing et al58 have assessed dynamic oot

motion retrospectively in both runners and walkers with

plantar asciitis. Both studies reported no diferences be-

tween case and control groups, but the sample size evaluated

in these studies were small.

BClinicians should consider limited ankle dorsiflex-

ion range o motion and a high body-mass index in

nonathletic populations as actors predisposing

patients to the development o heel pain/plantar asciitis.

9B?D?97B9EKHI;Based on long-term follow-up data in case series

comprised primarily o patients seen in an orthopaedic out-

patient setting, the clinical course or most patients was posi-

tive, with 80% reporting resolution o symptoms within a

12-month period.34,60

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Clinicians should consider diagnostic classifications

other than heel pain/plantar asciitis when the pa-

tients reported activity limitations or impairments

o body unction and structure are not consistent with those

presented in the diagnosis/classification section o this guide-

line, or, when the patients symptoms are not resolving withinterventions aimed at normalization o the patients impair-

ments o body unction.

?C7=?D=IJK:?;IImaging studies are typically not necessary or the diagnosis

o plantar asciitis.8,39 Imaging would appear to be most use-

ul to rule out other possible causes o heel pain or to establish

a diagnosis o plantar asciitis i the healthcare provider is

in doubt.8BgZk^\^gmlmn]r%Hl[hkg^^mZe 41 utilized lateral

radiographs to assess radiographic changes in 27 patients di-

agnosed with plantar asciitis in comparison to 79 controls.

:lbgè^[ebg]^]^qZfbg^kôZenZm^] maîeZbgghgp^bàm&

bearing films. Calcaneal spurs were observed in 85% o the

individuals with plantar asciitis and in 46% o those in thecontrol group. Plantar ascia thickness and at pad abnor-

malities were the 2 best actors or group diferentiation o

plantar asciitis, with a sensitivity o 85% and a specificity o

2.'Ma^l^Znmahkl\hg\en]^]maZm\Ze\Zg^Zelinklp^k^ghm

a key radiographic eature to distinguish diferences between

ma^+`khnilZg]maZmZeZm^kZeghgp^bàm&[^Zkbg`kZ]bh -

graph to assess sot tissue changes should be the first choice

i imaging is desired.41

CLINICAL GUIDELINES

Examination

EKJ9EC;C;7IKH;I

IWhile the majority of the studies reviewed

or this guideline have utilized the Foot Function

Index (FFI), Foot Health Status Questionnaire

!?ALJ"%hkma^?hhmZg]:gde^:[bebmrF^Zlnk^!?::F"Zl

_ng\mbhgZehnm\hf^jn^lmbhggZbk^l%hgerma^?::FaZl[^^g

validated in a physical therapy practice setting.33Ma^?::F

\hglblmlh_Z+*&bm^fZ\mbobmb^lh_]Zberebobg`!:=E"Zg]Zg

1&bm^flihkmlln[l\Ze^'FZkmbg^mZe33oZeb]Zm^]ma^?::F_hk

test content, internal structure, score stability, as well as re-

lihglbo^g^llnlbg`*.*iZmb^gml_hkma^:=Eln[l\Ze^Zg]*,)

patients or the sports subscale over a 4-week treatment pe-

kbh]'Ma^m^lm&k^m^lmkêbZ[bebmrpZl)'12Zg])'10_hkma^:=E

Zg]lihkmlln[l\Ze^l%k^li^\mboêr'FZkmbg^mZe 33 reported that

ma^fbgbfZeer\ebgb\ZeerbfihkmZgm]b^k^g\^l_hkma^?::F

p^k^1ihbgml_hkma^:=Eln[l\Ze Zg]2ihbgml_hkma^lihkml

subscale.

A

Clinicians should use validated sel-report ques-

mbhggZbk^l%ln\aZlma^??B%?ALJ%hk?::F%[^-ore and ater interventions intended to alleviate

the impairments o body unction and structure, activity limi-

tations, and participation restrictions associated with heel

pain/plantar asciitis. Physical therapists should consider

f^Zlnkbg`\aZg`^ho^kmbf^nlbg`ma^?::FZlbmaZl[^^g

validated in a physical therapy practice setting.

79J?L?JOB?C?J7J?EDC;7IKH;I

VThere are no activity limitation measures

specifically reported in the literature associated with

heel pain/plantar asciitisother than those that

are part o the sel-report questionnaires noted in this guide-

ebg l Hnm\hf^F^Zlnk l l^\mbhg' Ahpô^k% ma^ _heehpbg`

measures are options that a clinician may use to assess chang-

es in a patients level o unction over an episode o care.

I^k\^gmh_mbf^^qi^kb^g\bg`Zgde^%_hhm%hka^êiZbgho^k

the previous 24 hours

IZbgeôêpbmabgbmbZelmîlZ_m^klbmmbg`hkerbg`

IZbgeôêpbmalbgè^&e^`lmZg\^

IZbge oêpbmalmZg]bg`_hkZli^\b^]i^kbh]h_mbf^%ln\a

as 30 minutes

IZbg eôê Z_m^k pZedbg` Z li \b^] ]blmZg\^% ln\a Zl

1000 m

In addition, the Patient-Specific Functional Scale is a ques-

tionnaire that can be used to quantiy changes in activity

limitations and level o participation or patients with heelpain.53Mabll\Ze ^gZ[e^lma^\ebgb\bZg mh\hee^\mf^Zlnk^l

related to unction that may be diferent than the measures

that are components o the sel-report questionnaires noted

bgma^Hnm\hf^F^Zlnk^ll^\mbhgh_mabl`nb]êbg^'

FClinicians should utilize easily reproducible activity

limitation and participation restriction measures

associated with their patients heel pain/plantar as-

ciitis to assess the changes in the patients level o unction

over the episode o care.

F


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F>OI?97B?CF7?HC;DJC;7IKH;I

Active and Passive Ankle Dorsiflexion

ICF category Measurement o impairment o body unction: mobility o a single joint

Description The amount o active ankle dorsiflexion range o motion measured with the knee extended

Measurement method The patient is positioned in prone with eet over the edge o the treatment table. The examiner asks the patient to dorsiflex the ankle

or an active measurement, or the examiner passively dorsiflexes the ankle, while ensuring that the oot does not evert or invert

during the dorsiflexion maneuver. At the end o the active or passive dorsiflexion range o motion, the examiner aligns the stationary

arm o the goniometer along the shat o the fibula and aligns the moving arm o the goniometer along the shat o the

5th metatarsal.

Nature of variable Continuous

Units of measurement Degrees

Measurement properties There is ample evidence to support the intrarater reliability o dorsiflexion range o motion measurements (reported intraclass

correlation coefcient (ICC) or active assessment varies rom 0.64 to 0.92; ICC or passive assessment varies rom 0.74 to 0.98). There

is some evidence to support interrater reliability with reported ICC varying rom 0.29 to 0.81.35

The Dorsiflexion-Eversion Testfor Diagno sis of Tarsal Tunnel Syndrome

ICF category Measurement o impairment o structure o the nervous system, other specified

Description In non-weight bearing, dorsiflexion o the ankle, eversion o the oot, and extension o all o the toes is maintained or 5 to 10 seconds

to determine i the patients symptoms are elicited

Measurement method With the patient sitting, the examiner maximally dorsiflexes the ankle, everts the oot, and extends the toes maintaining the position

or 5 to 10 seconds, while tapping over the region o the tarsal tunnel to determine i a positive Tinel sign is present or i the patient

complains o local nerve tenderness.

Nature of variable Nominal

Units of measurement None

Measurement properties Kinoshita et al25 perormed this test on 50 normal and on 37 patients (44 eet) treated operatively or tarsal tunnel syndrome. In the

normal group no signs or symptoms were produced by the test. In the 44 symptomatic eet, the test increased numbness or pain in 36

eet and the Tinel sign became more pronounced in 41 eet.

Diagnostic accuracy indices for

increased numbness, based on

the study by Kinoshita et al*

95% Confidence Interval

Sensitivity

Specificity

Positive likelihood ratio

Negative likelihood ratio

0.81

0.99

82.73

0.19

0.67 - 0.90

0.91 - 1.00

5.22 - 1309.51

0.10 - 0.35


more pronounced Tinel sign,based on the study by Kinoshita

et al*


Sensitivity

Specificity



0.92

0.99

84.07

0.08

0.81 - 0.97

0.91 - 0.99

5.96 - 485.48

0.03 - 0.22

Cadaver model In 6 cadavers, Alshami et al2 reported that dorsiflexion-eversion o the ankle combined with extension o the metatarsophalangeal

joints significantly increased strain in the tibial nerve, lateral plantar nerve, and medial plantar nerve. However, this maneuver

also significantly increased strain in the plantar ascia. During this investigation, both components (dorsiflexion-eversion and

metatarsophalangeal joint extension) resulted in significant strain increases. This maneuver also resulted in significant excursion o

the tibial (6.9 mm, P= .016) and lateral plantar (2.2 mm, P= .032) nerves in the distal direction.

*Using Altmans convention for diagnostic studies with a zero count in the 2-by-2 contingency table (adding 0.5 to all 4 cel ls) 4


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Wi ndlass Test

ICF category Measurement o impairment o body structure: ascia and ligaments o the oot

Description Extension o the first metatarsophalangeal joint in both weight bearing and non-weight bearing to cause the windlass eect o the

plantar ascia and determine i the patients heel pain is reproduced

Measurement method The test is perormed in 2 positions: non-weight bearing and weight bearing.

NON-WEIGHT BEARING: With the patient sitting, the examiner stabilizes the ankle joint in neutral with 1 hand placed just behind the

first metatarsal head. The examiner then extends the first metatarsophalangeal joint, while allowing the interphalangeal joint to flex.

Passive extension (ie, dorsiflexion) o the first metatarsophalangeal joint is continued to its end o range or until the patients pain is

reproduced.

WEIGHT BEARING: The patient stands on a step stool and positions the metatarsal heads o the oot to be tested just over the edge o the

step. The subject is instructed to place equal weight on both eet. The examiner then passively extends the first metatarsophalangeal

joint while allowing the interphalangeal joint to flex. Passive extension (ie, dorsiflexion) o the first metatarsophalangeal joint is

continued to its end o range or until the patients pain is reproduced.

Nature of variable Nominal

Units of measurement None

Measurement properties De Garceau et al13 perormed the test on 22 patients with plantar asciitis and 43 other patients who served as a control group. None

o the patients in the other oot pain or control groups reported pain or symptoms in either weight bearing or non-weight bearing.Seven (31.8%) o the 22 patients with plantar asciitis had pain during the weight-bearing test, while only 3 had pain during the

nonweight-bearing test. While the Windlass test had a high specificity (100%), the sensitivity o the test was poor (< 32%) or both

the weight-bearing and nonweight-bearing tests


the weight-bearing test, based on

the study by DeGarceau et al*


Sensitivity

Specificity



0.33

0.99

28.70

0.68

0.17 - 0.53

0.91 - 1.00

1.71 - 480.43

0.51 - 0.91

Diagnostic accuracy indices

for the nonweight-bearing

test, based on the study by

De Garceau et al*


Sensitivity

Specificity

Positive likelihood ratioNegative likelihood ratio

0.18

0.99

16.210.83

0.07 - 0.40

0.91 - 1.00

0.88 - 298.750.67 - 1.02

Cadaver model In 6 cadavers, Alshami et al2 reported that extension o all metatarsophalangeal joints significantly increased strain in the plantar

ascia (+0.4%, P= .016). However, this maneuver also significantly increased strain in the tibial nerve (+0.4%,P= .016).

*Using Altmans convention for diagnostic studies with a zero count in the 2-by-2 contingency table (adding 0.5 to all 4 cel ls) 4

Longitudinal Arch Angle

ICF category Measurement o impairment o body unction: mobility o a multiple joints

Description The angle ormed by 1 line projected rom the midpoint o the medial malleolus to the navicular tuberosity in relation to a second line

projected rom the most medial prominence o the first metatarsal head to the navicular tuberosity

Measurement method With the patient standing with equal weight on both eet, the midpoint o the medial malleolus, the navicular tuberosity, and the most

medial prominence o the first metatarsal head are identified using palpation and marked with a pen. A goniometer is then used to

measure the angle ormed by the 3 points with the navicular tuberosity acting as the axis point.

Nature of variable Continuous

Units of measurement Degrees

Measurement properties McPoil and Cornwall36 reported that the longitudinal arch angle (LAA), a static measure o oot posture, was highly predictive o

dynamic oot posture during walking. In their study, digital photographs o the medial aspect o both eet or 50 subjects were recorded

and used to calculate the LAA. These authors also reported that the LAA demonstrated acceptable intra and interrater reliability. To

date, the LAA has only been shown to serve as an accurate threshold or determining the level o risk or developing medial tibial stress

syndrome.52 The LAA provides a measure o oot structure and unction that could be related to the development o plantar asciitis.


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Numerous interventions have been described or the treat-

ment o plantar asciitis, but ew high-quality randomized,

controlled trials have been conducted to support these

therapies.12

7DJ?#?D


12/19



ness were independently assessed using a visual analogue

scale prior to starting treatment, at the conclusion o 2 weeks

o treatment, and 2 weeks ollowing the conclusion o the

mk^Zmf^gm'Ma^k^lnemlbg]b\Zm^]maZm[hmaZ\^mb\Z\b]Zg]

dexamethasone, when delivered via iontophoresis in combi-

nation with low-Dye taping, provided good short-term relieh_iZbgZg]_ng\mbhg':\^mb\Z\b]ikh]n\^]`k^Zm^kbfikho^-

ments in morning pain than dexamethasone, but continued

relie o pain during the 2-week posttreatment period was

only observed in the dexamethasone group.40

BDexamethasone 0.4% or acetic acid 5% delivered

via iontophoresis can be used to provide short-term

(2 to 4 weeks) pain relie and improved unction.

C7DK7BJ>;H7FO

IVThere is limited evidence to support the use

o manual therapy as an intervention or plantar

asciitis. Young et al61 reported on 4 patients re-

erred to physical therapy or plantar asciitis or unilateral

ieZgmZka^êiZbg'Ma^]nkZmbhgh_lrfimhfl_hkma^-iZ-

mb^gmlkZg`^]_khf/mh.+p^^dl'Ma^Znmahklnl^]ZiZbg

rating scale and a sel-reported unction scale to assess out-

\hf^ho kZi^kbh]h_*mh,fhgmal':ee-iZmb gmlk^\^bo^]

fZgnZema^kZirZg]lmk^m\abg`'MphiZmb^gmlp^k^Zelhik^ -

scribed oot orthoses and another patient received additional

lmk^g`ma^gbg`^q^k\bl^l'Ma^fZgnZema^kZirm^\agbjn^lnmb-

ebs^]bg mabl\Zl^l^kb^l bg\en]^]mZeh\knkZechbgm ihlm kbhk

èb]^l%ln[mZeZkchbgmeZm^kZeèb]^l%Zgm^kbhk(ihlm^kbhkèb]^l

h_ma^klmmZklhf mZmZklZechbgm%Zg]ln[mZeZkchbgm]blmkZ\-

mbhgfZgbineZmbhgl':ee-iZmb^gmlbgmabl\Zl^l^kb^lkîhkm^]

a rapid improvement in pain and unction as a result o the

bgm^ko^gmbhglnmbebs^]'F^r^k^mZe38 reported on 1 patient re-

erred to physical therapy or plantar asciitis with an 8-

month history o subcalcaneal heel pain that limited standing

Zg]pZedbg`'MabliZmb^gmla^êiZbgpZlkîkh]n\^]pbma

the straight-leg raising (SLR) test in combination with ankle

dorsiflexion and eversion to sensitize the tibial nerve, sug-

gesting that there was a neurogenic component to this pa-

mb^gmla^ê iZbg'Ma^^qZfbgZmbhgg]bg`l h_mabliZmb gm

appear consistent with the findings o Coppieters and associ-

ates11 who reported significant strain and excursion o thetibial nerve in 8 embalmed cadavers when ankle dorsiflexion

bl\hf[bg^]pbmama^LEKm^lm'MabliZmb^gmpbmaa^êiZbg

]^l\kb[^][rF^r^k^mZe38 received passive and active mobi-

lization aimed at restoring pain-ree sot tissue mobility along

ma^\hnkl^h_ma^f^]bZgg^ko^'MaîZllbo^g^nkZefh[bebsZ-

tion procedures were perormed with the patient in the slump

sitting position. Because restricted ankle dorsiflexion, exces-

sive pronation, and posterior tibialis weakness were also

ound, low-Dye taping and therapeutic exercises were uti-

lized to control excessive pronation and reduce stress on the

plantar ascia. Following 10 treatment sessions over a period

o 1 month, this patients heel pain resolved and his standing

Zg]pZedbg`mhe^kZg\^p^k^_neerk^lmhk^]':emahnà\Zl^l^-

ries provide a low level o evidence, the findings o Young et

al61Zg]F^r^k^mZe 38 provide the oundation or uture ran-

domized, controlled clinical trials to assess the efectivenesso manual therapy as an intervention or plantar asciitis.

EMa^k^blfbgbfZeôb]^g\^mhlniihkmma^nl^h_

manual therapy and nerve mobilization procedures

to provide short-term (1 to 3 months) pain relie

and improved unction. Suggested manual therapy proce-

]nk^lbg\en]^3mZeh\knkZechbgmihlm^kbhkèb]^%ln[mZeZkchbgm

lateral glide, anterior and posterior glides o the first tarso-

f^mZmZklZechbgm%ln[mZeZkchbgm]blmkZ\mbhgfZgbineZmbhg%lh_m

tissue mobilization near potential nerve entrapment sites,

and passive neural mobilization procedures.

IJH;J9>?D=Numerous authors have recommended that calf

stretching should be one o the interventions incorporated

into the management program or patients with plantar as-

ciitis.18,39,40,42,45 Ma^\hgmbgnbmrh_\hgg^\mbo^mblln^[^mp^^g

ma^:\abee^lm^g]hgZg]maîeZgmZk_Zl\bZ%ZlpêeZlma^_Z\mmaZm

decreased ankle dorsiflexion is a risk actor in the development

h_ieZgmZk_Zl\bbmbl%ikhob]^llhf^cnlmb\Zmbhg_hk\Ze_lmk^m\abg`'

IIPorter et al43 conducted a prospective, randomized,

blinded study to assess the duration and requency

o cal stretching on improvement in ankle dorsi-

flexion range o motion and patient outcome as determined

nlbg`ma^:f^kb\Zg:\Z]^frh_HkmahiZ^]b\Lnk`^hglEhp -

^kEbf[Zg]?hhmZg]:gde^Fh]ne^l'IZkmb\biZgmlbg\en]^]

54 patients with plantar asciitis who perormed a sustained

stretch, 40 patients with plantar asciitis who perormed an

intermittent stretch, and 41 healthy individuals who served

as controls. Participants were instructed to stretch their cal

muscles standing at the edge o a step with the heel hanging

of the edge while keeping the knee straight and the oot in a

g^nmkZeihlbmbhg!ghZ[]n\mbhghkZ]]n\mbhg"'Ma^bg]bob]n -

als in the sustained stretch group stretched or 3 minutes at

Zmbf^%,mbf^lZ]Zr'Mahl^bgma^bgm^kfbmm^gmlmk^m\a`khnistretched or five 20-second intervals, twice daily. Partici-

pants in both the sustained and intermittent stretch groups

had ankle dorsiflexion range o motion and unctional out-

comes assessed prior to starting treatment and once a month

or 4 consecutive months. Participants in the study were pro-

ob]^]pbmaghhma^kmk^Zmf^gmbgm^ko^gmbhgl':mma^^g]h_-

months, 40 patients remained in the sustained-stretch group

and 26 patients remained in the intermittent-stretch group.

Ma^k^lnemlbg]b\Zm^]maZmpabe^ma^k^p^k^gh]b^k^g\^lbg

outcome between the 2 stretching groups, both groups had


13/19



similar increases in ankle dorsiflexion. Furthermore, the in-

crease in ankle dorsiflexion correlated with a decrease in pain

or both groups.43

III

DiGiovanni14 et al conducted a prospective,

randomized study to determine i a plantar ascia-specific stretch would be more efective than cal

lmk^m\abg`'Ma^l^Znmahklarihma^lbs^]maZmZieZgmZk_Zl\bZ&

specific stretch might have a greater amount o patient com-

pliance as well as a greater improvement in unctional

hnm\hf^l' Hg ang]k^] hg iZkmb\biZgml p^k^ bgbmbZeer

Zllb g^] mh+ `khnil3 \Ze_ lmk m\abg`!g6.)"Zg]ieZgmZk

ascia-specific stretching (n = 51). Both groups received over-

ma^&\hngm^klh_mbglhe l%Z ,&p^^d\hnkl h_GL:B=L%Zg]

iZmb^gm^]n\Zmbhgk^`Zk]bgìeZgmZk_Zl\bbmbl'MaîeZgmZk_Zl-

cia tissue-specific stretch was perormed in sitting, with the

patient placing the fingers o one hand across the toes o the

involved oot, then pulling the toes back (extension) toward

ma^labgngmbelmk^m\abg`pZl_êmbgma^Zk\ah_ma^_hhm'Mh

confirm that they were stretching the ascia, patients were

instructed to use the opposite hand to palpate the tension o

ma^_Zl\bZhgma^[hmmhfh_ma^_hhm'Ma^\Ze_&lmk^m\abg``khni

was instructed to perorm the stretch in standing while lean-

ing into the wall with the nonafected oot behind the leg be-

ing stretched. Patients in the cal-stretching group were

asked to stand on their orthotics while stretching, in a slightly

toe-in stance. Both groups were instructed to hold each

stretch or a count o 10, repeat the stretch 10 times, and

i^k_hkfma^lmk^m\a, mbf li^k]Zr'H_ ma^bgbmbZe*)*iZ-

tients, heel pain was either eliminated or much improved at

8 weeks in 24 (52%) o the 46 patients who perormed the

plantar ascia specific stretch, as compared to 8 (22%) out o

36 patients who perormed cal stretching. It is important to

note, however, that this study was not blinded, a large per-

centage o patients dropped out o the study (28% cal

stretching, 10% plantar ascia stretch), and only the data or

those patients who completed the 8-week trial were

analyzed.14

BCal muscle and/or plantar ascia-specific stretch-

ing can be used to provide short-term (2 to 4

months) pain relie and improvement in cal muscle

^qb[bebmr'Ma^]hlZ`^_hk\Ze_lmk^m\abg`\Zg[^^bma^k,mbf^la day or 2 times a day utilizing either a sustained (3 minutes)

or intermittent (20 seconds) stretching time, as neither dos-

age produced a better efect.

J7F?D=Adhesive strapping appears to provide short-term

relie o pain in patients with a clinical diagnosis o plan-

mZk _Zl\bbmbl' :l ikôbhnler ghm^] bg ma ]bl\nllbhg hg

fh]Zebmb^l% Hl[hkg^ Zg] :eeblhg40 reported that ionto-

phoresis combined with low-Dye taping provided relie o

pain and stifness when assessed 4 weeks posttreatment.

Hyland et al21 conducted a prospective, randomized,

controlled trial to determine the efect o calcaneal

taping in comparison to sham taping and stretching. Forty-one patients with a clinical diagnosis o plantar asciitis were

Zllb`g^]mh-`khnil3\Ze\Zg^ZemZibg`!g6**"%laZfmZibg`

!g6*)"%lmk^m\abg`hger!g6*)"%Zg]Z\hgmkhe!g6*)"'Ma^

stretching group was given both cal stretching and plantar

_Zl\bZ&li^\b\lmk^m\abg`^q^k\bl^l'Ma^\Ze\Zg^ZemZibgìkh-

cedure was designed to invert the calcaneus, thus to improve

biomechanical position. Patient outcome was assessed using a

visual analogue scale or pain and a patient-specific unction

scale (PSFS) prior to treatment and ater 1 week o treatment.

While stretching and sham taping decreased pain, calcaneal

taping demonstrated a significantly greater decrease in pain

than either stretching or sham taping. No diferences with

regard to unction were ound among the 4 groups, although

calcaneal taping did have the greatest pretest versus posttest

]b^k^g\^'Ng_hkmngZmêr%mabllmn]rpZlghm[ebg]^]%aZ]Z

lfZeegnf[^kh_ln[c^\mlZllb`g^]mh^Z\a`khni%Zg]hger

provided a 1-week ollow-up.21

IIIRadord et al46 perormed a participant-blinded,

randomized trial to determine the efectiveness o

low-Dye taping or pain and improvement o unc-

mbhgbgiZmb^gmlpbmaieZgmZk_Zl\bbmbl':lZfie^lbs^h_2+iZ-

mb^gmlpZl]bob]^]bgmh+^jnZe`khnilh_-/3*`khnik^\^bobg`

low-Dye taping with sham ultrasound and the other group

k^\^bobg`laZfnemkZlhng]hger'Hnm\hf^f^Zlnk^lbg\en]^]

first-step pain, assessed using a visual analogue scale, as well

as the change in oot pain, oot unction, and general oot

health as determined using the Foot Health Status Question-

gZbk^!?ALJ"'Hnm\hf^pZlZll^ll^]ikbhkmhma^bgbmbZmbhg

o treatment and ater 1-week. Participants in the taping

group had their oot taped or a median o 7 days (range 3 to

9 days). Similar to the findings reported by Hyland et al,21 the

low-Dye tape group reported a small but significant difer-

ence in first-step pain in comparison to the sham group. No

significant diferences in FHSQ scores were ound between

the 2 groups; however, limitations o this study include no

control group and short-term ollow-up o outcomemeasures.46

CCalcaneal or low-Dye taping can be used to provide

short-term (7 to 10 days) pain relie. Studies indicate

that taping does cause improvements in unction.

EHJ>EJ?9:;L?9;IFoot orthoses are frequently utilized as a component

h_ma^\hgl^koZmbo^fZgZ`^f^gmieZg_hkieZgmZk_Zl\bbmbl'Ma^

III


14/19



cnlmb\Zmbhg`bo^g _hkma^nl^h_ _hhmhkmahl^l blmh]^\k^Zl^

abnormal oot pronation that is thought to cause increased

lmk^llhgma^f^]bZe[Zg]h_maîeZgmZk_Zl\bZ'Mh]Zm^%ôb -

dence that establishes an association between plantar asciitis

and oot motion is inconclusive.24 Studies conducted using

cadaver specimens suggest that oot orthoses can reduce thestrain in the plantar ascia during static loading, reduce the

collapse o the medial longitudinal arch, and reduce elonga-

tion o the oot associated with pronation.26,27,28

Seven randomized, controlled clinical trials have been con-

ducted to determine the efectiveness o oot orthoses or the

mk^Zmf^gmh_ieZgmZk_Zl\bbmbl'Mphh_ma^l^lmn]b^lôZenZm^]

the efect o magnetic insoles on plantar heel pain.9,59 Both

studies concluded that magnets do not provide an additional

benefit compared to nonmagnetic insoles or the treatment

o plantar heel pain.

IIMa k^fZbgbg . lmn]b l _h\nl^] hg \hfiZkbg

various types o oot orthoses including customized,

preabricated, elt arch pads, and heel cups or pads.

Lynch et al31 compared the efectiveness o 3 types o conser-

oZmbo^ma^kZir_hkma^fZgZ ^f^gmh_ieZgmZk_Zl\bbmbl':mhmZe

h_*),ln[c^\mlp^k^Zllb`g^]mh*h_,mk^Zmf^gm`khnil3Zgmb&

bgZffZmhkrma^kZir\hglblmbg`h_Z\hkmb\hlm^khb]bgc^\mbhg

Zg]GL:B=l!g6,."%ZgZ\\hffh]Zmboôbl\hêZlmb\a^ê

cup (n = 33), and a mechanical treatment which consisted o

an initial low-Dye taping ollowed by custom orthoses (n =

,."'MaîkbfZkrhnm\hf^f^Zlnk^pZliZbgkZmbg`[Zl^]hg

a visual analogue scale and patients were ollowed or 3

fhgmal'Ma^Znmahklkîhkm^]maZmma^f^\aZgb\Zemk^Zmf^gm

group had a greater reduction in pain and had ewer drop-

outs than the other 2 groups. In addition to the act that pain

was the only outcome measure assessed, the oot orthoses

group had the conounding short-term efect o taping. 31

IIMnkebd^mZe57 ocused on the efect o oot orthoses

alone by evaluating 60 patients with plantar asci-

itis, assigned to either a custom, unctional oot or-

thosis group (n = 26), or a generic gel heel pad group (n = 34).

While the actual duration o the intervention was unclear,

most patients were ollowed or at least 3 months, with 5 sub-

c^\ml]khiibg`hnmh_maâ^êiZ]`khni'MhZll^lliZmb^gmoutcomes, a 5-item outcome survey was developed by the au-

mahkl'Ma^Znmahklkîhkm^]maZmma^\nlmhf%_ng\mbhgZe_hhm

orthoses group had better outcomes than the heel pad group.

Ng_hkmngZmêr%ma^Znmahk&]ôêhi^]hnm\hf^l\Ze^pZlghm

evaluated or reliability or validity and the group assignment

was not blinded.57

Pefer et al42 conducted a randomized multicenter

trial involving 236 patients diagnosed with plan-

tar asciitis recruited rom 15 orthopaedic oot and

Zgde^\ebgb\l'MaîZmb^gmlbgma^lmn]rp^k^nl^]mhôZenZm^

.]b^k^gmmk^Zmf^gml3!*"\Ze_lmk^m\abg`hger%!+"Zlbeb\hg^

heel pad and cal stretching, (3) a elt arch insert and calstretching, (4) a rubber heel cup and cal stretching, and (5)

Z\nlmhf%_ng\mbhgZe_hhmhkmahlblZg]\Ze_lmk^m\abg`'Ma^

patients were ollowed or an 8-week period and they used

the pain subscale o the Foot Function Index (FFI) as their

hnm\hf^f^Zlnk ' Ma^r kîhkm^] maZmma^ `khnil mk^Zm^]

with the preabricated inserts (silicone pad, elt arch insert,

rubber heel cup) had significantly better outcomes than the

group treated with custom orthotics and the group treated

pbmalmk^m\abg`hger':emahnàma^1&p^^d bgm^ko^gmbhgi^-

riod or this study was extremely short, the results indicate

that preabricated orthoses are efective and that stretching

and preabricated orthoses are more efective than stretch-

ing alone.42

IIFZkmbg^mZe32 evaluated custom oot orthoses in

comparison to preabricated arch supports and

night splints in 255 patients with plantar asciitis.

Patients were randomly assigned to 1 o 3 treatment groups

and the primary outcome measures were sel-reported first

step pain as well as pain during work, leisure, and exercise

Z\mbobmb^lnlbg`ZoblnZeZgZeh`n^l\Ze^'H_ma^+..iZmb^gml

initially enrolled in the study, only 193 were seen at the final

12-week ollow-up visit. Patients in the preabricated ortho-

ses group and the night splint group had the poorest compli-

ance rates and the highest number o patients withdrawn,

pbma+*Zg]+/% k^li^\mboêr':m ma^ *+&p^^d _heehp&ni

visit, there was no significant diference in pain reduction

[^mp^^gma^,`khnil'Ma^Znmahkl]b]bg]b\Zm^maZmiZmb^gm

compliance was greatest with the use o custom oot

orthoses.32

IMh ]Zm^% ma fhlm ehg`&m^kf% \hfikâ^glbo^

clinical study o the eectiveness o oot ortho-

ses in the management o plantar asciitis was

conducted by Landor et al.29Ma^r\hg]n\m^]ZiZkmb\b-

pant-blinded, randomized trial utilizing 136 patients

with a clinical diagnosis o plant ar asciitis. Patientsp^k^kZg]hfer Zeeh\Zm^]mh *h_ , mk^Zmf^gm`khnil3 !*"

a sham orthosis constructed o sot, thin oam (n = 46), (2) a

preabricated firm oam orthosis (n = 44); and (3) a custom,

l^fbkb`b]ma^kfhieZlmb\hkmahlbl!g6-/"'Ma^hnm\hf^f^Z-

sure used was the pain and unction domains o the Foot

A^ZemaLmZmnlJn^lmbhggZbk^!?ALJ"'Hnm\hf^lp^k^ Zl-

sessed prior to initiation o treatment, at 3 months, and at 12

fhgmal':mma^,&Zg]*+&fhgma_heehp&nioblbml%^Z\a`khni

lost only 1 to 2 members to ollow-up, so that the total num-

[^kh_iZmb^gmlkôb^p^]Zm*+fhgmalpZl*,*':_m k,fhgmal%

I


15/19



FHSQ pain and unction scores avored the use o preabri-

cated and custom orthoses over the sham orthoses, although

hgerma^^ \mlhg_ng\mbhgp k^lb`gb\Zgm'Ma^k^p k^gh

significant diferences or pain and unction scores among

Zgrh_ma^,mk^Zmf^gm`khnilZmma^*+&fhgmakôb^p'Manl%

while the preabricated and custom orthoses did produce ashort-term efect in pain and unction, ater 1 year o wear all

3 types o oot orthoses produced a similar patient

outcomes.29

APreabricated or custom oot orthoses can be used

to provide short-term (3 months) reduction in pain

Zg]bfikho^f^gmbg_ng\mbhg'Ma^k^Zii^Zklmh[^

no diferences in the amount o pain reduction or improved

unction created by custom oot orthoses in comparison to

ik^_Z[kb\Zm^]hkmahl^l'Ma^k^bl\nkk^gmerghôb]^g\^mhlni -

port the use o preabricated or custom oot orthoses or long-

term (1 year) pain management or unction improvement.

D?=>JIFB?DJI

IICrawford and Thomson12 in their Cochrane

review reported limited evidence to support the use

o night splints as an intervention or patients with

ieZgmZk_Zl\bbmbleZlmbg`fhk^maZg/fhgmal':d^r\ebgb\Ze

issue is the duration o use once night splint therapy has been

initiated. Batt et al7 reported that between 9 and 12 weeks o

night splint wear time was required to achieve a good outcome

in 40 patients with chronic plantar asciitis. Powell et al44

ound that only 1 month o wearing the night splint was su-

cient to create an 88% improvement in 37 patients with

\akhgb\ieZgmZk_Zl\bbmbl'Ma^k^_hk^%[Zl^]hgebfbm^]ôb]^g\^%

it would appear that a night splint should be worn between 1

and 3 months to achieve adequate symptom improvement.

IIIn a recent study, Roos et al50 investigated the e-

ects o oot orthoses and night splints, either indi-

vidually or combined, in a prospective, randomized

trial with a 1-year ollow-up. Forty-three patients with a mean

duration o symptoms o 4.2 months were assigned to 1 o 3

`khnil3_hhmhkmahl^lhger!g6*,"%_hhmhkmahl^lZg]gbàm

splint (n = 15), or night splint only (n = 15). Follow-up data

were available on 38 patients ater 1 year. While previousstudies had used a posterior night splint, Roos et al50 utilized

an anterior night splint. In addition to daily logs to monitor

\hfiebZg\^%ma^?hhmZg]:gde^Hnm\hf^L\hk^!?:HL"pZl

nl^]ZlZghnm\hf^f^Zlnk^'Ma^k^lnemlbg]b\Zm^]maZm\hf -

pliance to either the oot orthoses or night splint was good (at

least 75%) and all 3 groups had a reduction in pain as early

as 6 weeks and at the 1-year ollow-up. Improvements in

_ng\mbhgZl]^m^kfbg^]nlbg`ma^?:HLlniihkm^]ma^nl^h_

oot orthoses over night splints.

Fhlmgbàmliebgml%pa^ma^kZgm^kbhkhkihlm^kbhkbg

design, are abricated using a rigid thermoplastic

material that can be uncomortable or the patient

Zg]e^Z]mhghg\hfiebZg\^'Fhk^k^\^gmer%Zlh_m%lh\d&mri^

night splint has been made commercially available that uti-

lizes a Velcro strap to position the ankle in neutral and thetoes in slight extension. Barry et al6 retrospectively analyzed

the use o this type o night splint in comparison to stand-

ing cal stretching in 160 patients with a clinical diagnosis o

ieZgmZk_Zl\bbmbl'Ma^f^Zg]nkZmbhgh_lrfimhfl_hkZee*/)

patients prior to the start o treatment was approximately 2

fhgmal':emahnàma^k^Zk^gnf^khnlblln^lpbmamabllmn]r

bg\en]bgìhhk\hgmkheh_bgmkh]n\mbhgh_Z]cng\mbo^mk^Zm -

ments, a 13% dropout o the patients receiving cal stretch-

ing, and the use o pain as the only outcome measure, the use

o the sock-type night splint did result in a shorter recovery

time and ewer additional interventions.6:ikhli^\mbo^%kZg-

domized controlled trial is required to validate this specific

type o night splint.

BNight splints should be considered as an interven-

tion or patients with symptoms greater than 6

fhgmalbg]nkZmbhg'Ma^]^lbk^]e^g`mah_mbf^_hk

p^Zkbg`ma^gbàmliebgmbl *mh,fhgmal'Ma^mri^h_gbàm

splint used (ie, posterior, anterior, sock-type) does not appear

to afect the outcome.

III


16/19



F F7J>E7D7JEC?97B


17/19



7KJ>EHI

J^ecWi=$CYFe_b"PT, PhD

Regents Proessor

Department o Physical Therapy

Northern Arizona University

Flagsta, Arizona

[email protected]

HeXHeoB$CWhj_d"PT, PhD

Assistant Proessor

Rangos School o Health Sciences

Duquesne University

Pittsburgh, Pennsylvania

[email protected]

CWhaM$9ehdmWbb" PT, PhD

Proessor

Department o Physical Therapy

Northern Arizona University

Flagsta, [email protected]

:Wd[A$Mka_Y^"MD

Chie, Division o Foot

and Ankle Surgery

Assistant Proessor o

Orthopaedic Surgery

University o Pittsburgh

Medical Center


[email protected]

@Wc[i@$?hh]Wd]"PT, PhD

Director o Clinical Research

Department o Orthopaedic SurgeryUniversity o Pittsburgh

Medical Center


[email protected]

@ei[f^@$=eZ][i"DPT

ICF Practice Guidelines Coordinator

Orthopaedic Section, APTA, Inc

La Crosse, Wisconsin

[email protected]

H;L?;M;HI

7dj^edo:[b_jje"PT, PhD

Proessor and Chair

School o Health and

Rehabilitation Sciences

University o Pittsburgh


[email protected]

@e^d:[m_jj"DPT

Director o Physical Therapy Sports

Medicine Residency

The Ohio State University

Columbus, Ohio

[email protected]

7cWdZW


18/19


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@CEH;?D


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INSTRUCTIONS TO AUTHORS

CORRECTIONS

I

n the April 2008 clinical guide-

lines Heel PainPlantar Fasciitis by

McPoil et al, the table under Levels oEvidence, on page A4, row 2, the greater-

than sign () should be a less-than sign

(), to read 80% ollow-up.

In the September 2008 issue, on page

551, or the article titled Diferential Di-

agnosis o a Patient Reerred to Physical

Therapy With Low Back Pain: Abdomi-nal Aortic Aneurysm, the second au-

thors name was misspelled. The correct

spelling is Zachary Preboski. This cor-

rection also applies to the Table o Con-

tents o that issue.

Please accept our apology or these

errors. Corrected reprints o the articlesare available to members and subscrib-

ers or download on theJOSPTweb site

(www.jospt.org). T

ERRATA

plantar fasciitis guidelines

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