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Tissue-Specific Plantar Fascia-Stretching Exercise Enhances Outcomes in Patients with Chronic Heel Pain

A Prospective, Randomized Study

Investigation performed at the Department of Physical Therapy, Ithaca College, University of Rochester Campus, Rochester, New York

Benedict F. DiGiovanni, MD
Judith F. Baumhauer, MD
Department of Orthopaedics, University of Rochester School of Medicine, 601 Elmwood Avenue, Box 665, Rochester, NY 14642. E-mail address for B.F. DiGiovanni: benedict_digiovanni{at}urmc.rochester.edu E-mail address for J.F. Baumhauer: judith_baumhauer@urmc.rochester.edu

Deborah A. Nawoczenski, PhD, PT
Joseph C. Murray, MSPT
Department of Physical Therapy, Ithaca College, University of Rochester Campus, 300 East River Road, Suite 1-102, Rochester, NY 14623. E-mail address for D.A. Nawoczenski: dnawoczenski@ithaca.edu

Marc E. Lintal, MSPT
Department of Physical Therapy, University Orthopedics Center, 101 Regent Court, State College, PA 16801

Elizabeth A. Moore, MSPT
Department of Physical Therapy, The Burke Rehabilitation Hospital, 785 Mamaroneck Avenue, White Plains, NY 10605

Gregory E. Wilding, PhD
Division of Biostatistics, Department of Social and Preventive Medicine, University at Buffalo, The State University of New York, 3435 Main Street, Building 26, Buffalo, NY 14214

In support of their research or preparation of this manuscript, one or more authors received grants or outside funding from the Research Designated Fund of the New York Physical Therapy Association. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. We hypothesized that patients with chronic plantar fasciitis who are managed with the structure-specific plantar fascia-stretching program for eight weeks have a better functional outcome than do patients managed with a standard Achilles tendon-stretching protocol.

Methods: One hundred and one patients who had chronic proximal plantar fasciitis for a duration of at least ten months were randomized into one of two treatment groups. The mean age was forty-six years. All patients received prefabricated soft insoles and a three-week course of celecoxib, and they also viewed an educational video on plantar fasciitis. The patients received instructions for either a plantar fascia tissue-stretching program (Group A) or an Achilles tendon-stretching program (Group B). All patients completed the pain subscale of the Foot Function Index and a subject-relevant outcome survey that incorporated generic and condition-specific outcome measures related to pain, function, and satisfaction with treatment outcome. The patients were reevaluated after eight weeks.

Results: Eighty-two patients returned for follow-up evaluation. With the exception of the duration of symptoms (p < 0.01), covariates for baseline measures revealed no significant differences between the groups. The pain subscale scores of the Foot Function Index showed significantly better results for the patients managed with the plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and item 2 (first steps in the morning; p = 0.006). Analysis of the response rates to the outcome measures also revealed significant differences with respect to pain, activity limitations, and patient satisfaction, with greater improvement seen in the group managed with the plantar fascia-stretching program.

Conclusions: A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. These findings provide an alternative option to the present standard of care in the nonoperative treatment of patients with chronic, disabling plantar heel pain.

Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

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