Posts tagged plantar fasciitis
Does Manual Therapy Improve Plantar Fasciitis?

Plantar fasciitis (fasciosis) is a painful diagnosis limiting a patient's ability to stand, walk, or run.  The -itis of the name is a misnomer because very few cases of plantar heel pain involve an inflammatory process.  Instead, a breakdown of soft tissue fibers and cells is noted in the plantar fascia reflecting the sequential stages of healing.  Contributing factors to this diagnosis include a loss of ankle mobility, calf muscle tightness, and foot weakness.  In our Boulder Physical Therapy practice we successfully treat this condition with the combination of exercise and manual therapy treatments designed to rapidly reduce and improve range of motion in the foot and ankle.  

A recent review of the available literature on the utilization of manual therapy for patients with heel pain was conducted (Fraser, J. et al. J Man Manip Ther. 2018).  Authors included 7 previous randomized, controlled trials on the utilization of this treatment in patients with plantar fasciitis.  They reported a significant short (4 weeks) and long term (6 month) improvement in patient function when Physical Therapists included manual therapy into their treatment sessions.  The authors recommended clinicians utilize both joint and soft tissue treatments, in addition to, high level exercise when treating patients with plantar fasciitis.  

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Importance of Manual Therapy in Treatment of Patients with Heel Pain and Plantar Fasciitis
boulder-heel-pain-plantar fasciitis-treatments

Manual therapy or the passive movements of joints and tissues has been shown to be effective at reducing short term pain for a number of conditions including heel pain.  Interventions including joint mobilization and manipulation are commonly provided to patients suffering from heel pain or plantar fasciitis (fasciosis) in order to restore normal mobility to the leg, ankle, and foot.  A recent research review was conducted to determine if these manual therapy interventions were more effective than other Physical Therapy interventions.

Fraser and colleagues in the Journal of Manual and Manipulative Therapy reviewed 7 previous randomized controlled trials to determine the effectiveness of manual therapy in patients with plantar fasciitis (2017).  The authors reported manual therapy demonstrated greater improvements in function at both short and long term follow up compared with stretching, strengthening, or modalities.  Authors recommended clinicians consider both manual therapy and joint manual therapy treatments as part of a individualized Physical Therapy treatment plan.   

Strengthening The Core Of The Foot For Plantar Fasciitis

In our previous posts we have discussed the association between our intrinsic (core) foot strength and foot function during walking and running.  The research has identified a link between weakness and atrophy of these muscles and the development of chronic conditions such as heel pain and plantar fasciitis (fasciosis).  This atrophy is most pronounced in those with long term use of orthotics.  Strengthening of these muscles is a excellent way to alleviate foot and ankle pain, as well as, reduce the risk of recurrence for these chronic conditions.

A recent review of the literature highlighted the impact of strength training on these heel conditions as well as the development of intrinsic foot strength (Huffer et al. PT in Sport. 2016).  The authors reviewed 7 articles on the subject and found strength training was effective for treatment of plantar fasciitis as well as increasing intrinsic foot strength.  The authors reported limited evidence to support the use of minimalist shoes to improve intrinsic foot function.  Interesting, despite improvements in strength, function, and pain the exercises did not show changes in plantar fascia.  This is likely similar to what we see in many tendon conditions where benefits are seen before true tissue changes take place, often requiring up to 1 year for complete healing.   

Weakened Foot Strength and Orthotic Use in Patients with Heel Pain

In our previous posts we have documented the weakness and atrophy of the foot's "core" muscles among patients with heel pain.   Heel pain is one of the most common foot and ankle diagnoses we see in our Boulder Physical Therapy Practice.  This condition is commonly treated with manual therapy and exercises targeting the lower quarter.  A targeted area for exercise involves the foot's core muscles which contribute to stability and function of our arch.  Without adequate strength and control of the arch we are more at risk for conditions such as heel pain and plantar fasciitis.  Recent research highlights the importance of these muscles and the negative impact foot orthoses may have on their function. 

McClinton and colleagues studies 27 patients with heel pain compared to matched peers who ddi not have any heel pain (JOSPT 2016).  Participants' foot strength was tested using two clinical tests for foot "core" strength.  Not surprisingly, the patients with heel pain had significantly less foot strength than their asymptomatic peers.  Interestingly, longer use of foot orthoses was associated with lower performance on these strength measurements.   Stabilization of the arch with foot orthotics may weaken the foot's core muscles because they prevent these muscles from performing their natural function.  

Patient's are encouraged to contact their local PT on the most appropriate treatments for their heel and foot pain.  

Intrinsic Foot Muscle Atrophy and Heel Pain

Plantar Fasciitis is a common overuse condition affecting many runners in Boulder.  Authors report it is the 3rd most common running related injury and total costs involving plantar fasciitis cost over 375 million dollars per year (Taunton et al. 2002).  Much of these costs can be attributed to the chronic nature of the condition reaching up to 12 months in some individuals.  Treatment by a Physical Therapist involving manual therapy to the lower quarter joints and strengthening exercises have been shown to accelerate recovery and shorten this duration of symptoms.

The plantar fascia is a passive restraint to forces across the foot and ankle when we stand or weight bear on one foot.  In addition to the plantar fascia we are able to use hip and leg muscles, muscles crossing the ankle, and intrinsic foot muscles, deep in the foot, to absorb these running forces.  Commonly in patients with plantar fasciitis we find reduced strength and balance throughout the leg.  A key element to successful treatment of plantar fasciitis involves restoring both global strength in the leg and local strength in the foot to reduce abnormal loading patterns across the heel and arch of the foot. 

A recent article examined the size of the intrinsic foot muscles in experienced runners with and without plantar fasciitis (Cheung et al. J Sci Med Sport. 2015).  10 of the 20 runners were diagnosed with chronic heel pain (>2 years) while the others served as a control group.  The authors noted atrophy of the intrinsic foot musculature in the runners with plantar fasciitis.  We are not able to determine cause and effect in this study design but this indicates the importance of intrinsic foot strengthening in patients’ with heel pain.   The stronger these muscles become the better their tolerance to control forces across the foot in running.  In turn, less forces will be applied to the passive elements of the foot like the plantar fascia.

 To learn more on how Physical Therapy can help your heel pain contact your local Boulder Physical Therapist.


Heel Pain (plantar fasciitis) and Physical Therapy Treatments
Heel pain, plantar fasciitis, boulder physical therapy

Heel Pain (Plantar Fasciitis) Background

Plantar fasciitis/fasciosis is the most common cause of heel pain. Patient often complain of pain upon their first steps in the morning, sharp pain under the heel which may spread into the arch of the foot. These symp- toms are often worse on a return to standing or walking after a period of rest (sitting).

Previously thought to be an inflammatory condition, current research suggests the condition is a non inflammatory degenerative process more consistent with fasciosis. Further, authors noted 0 cases of inflammation in the tissues of 50 individuals with heel pain(3).

2 million individuals will experience heel pain each year and about 10% of people will experience heel pain at some point in their lifetime(6). 

plantar fascia, anatomy, physical therapy treatments

Heel Pain and Physical Therapy Treatments 

Corticosteroid injections into the plantar fascia have been found to be ineffective, and may result in serious side effects including rupture(4,5). Systematic reviews report the risks of injections do not out weigh the benefits for these interventions(8).

A systematic review found extracorporeal shockwave therapy does not appear more effective than stretch- ing in reducing pain in patients with heel pain(9).

Clinical Practice Guidelines for the treatment of heel pain and plantar fasciosis recommend a multimodal program of Physical Therapy including manual therapy, stretching, taping, foot orthotics, and night splints(8).

Foot orthotics have been shown to reduce pain, decreasing loading, and improve short and long term function patients with heel pain(8). 

heel pain, plantar fasciitis, physical therapy, manual therapy, boulder

Physical Therapy Evidence and Heel Pain

Anti pronation taping to the arch and heel for up to 3 weeks is supported by practice guidelines for pain reduction(8).

Grade A evidence is available for manual therapy interventions, including joint mobilization and manipulation and soft tissue mobilizations, of the lower quarter in patients with heel pain(8).

A systematic review by Brantingham et al. reported the effectiveness of these manual therapy interventions in a review of the medical literature(10).

Renan-Ordine et al. found greater improvements in pain and disability among patients with heel pain who received manual therapy and exercise compared to exercise alone(1).

Authors report greater short and long term improvements in pain and disability
using a manual therapy and exercise approach compared to passive modalities such as ultrasound and exercise(2). See graph.

Heel pain, plantar fasciitis, evidence, manual therapy, physical therapy

Early studies on the impact of dry needling on heel pain have shown reductions in both pain and disability(7,8).

Exercise programs designed to restore flexibility to the leg, ankle, and foot, as well as, restore strength and control to the lower quarter are supported by the literature to reduce pain and abnormal loading at the foot. 

When to seek Physical Therapy care

1. Renan-Ordine R, et al. Effectiveness of Myofascial Trigger Point Manual Therapy Combined With a Self- Stretching Protocol for the Management of Plantar Heel Pain: A Randomized Controlled Trial. JOSPT. 2011;41(2):43-50

2. Cleland, J. et al. Manual Physical Therapy and Exercise versus Electrophysical Agents and Exercise in the Manage- ment of Plantar Heel Pain: A multicenter RCT. JOSPT. 2009. 39(8):573-585.

3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93:234-237.

4. Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int. 1998;19:91-97.

5. Sellman JR. Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int. 1994;15:376-381.

6. Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2003;

7. Cotchett, M. et al. Effectiveness of trigger point dry needling for plantar heel pain: A RCT. Phys Ther. 2014.

 8. Martin, R. et al. Heel Pain – Plantar Fasciitis: Revision 2014. Clinical Practice Guidelines. JOSPT. 2014;44(11):A1-A23.

9. Landorf KB, Menz HB. Plantar heel pain and fasciitis. Clin Evid (Online). 2008;2008:1111.

10. Brantingham JW, Bonnefin D, Perle SM, et al. Manipulative therapy for low- er extremity conditions: update of a literature review. J Manipulative Physi- ol Ther. 2012;35:127-166.