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Plantar fasciitis – important new research by Michael Rathleff

15 Sep, 14 | by BJSM

Blog by @MichaelRathleff 

Introduction by Tom Goom @TomGoom

Originally posted on the Running Physio blog

Plantar fasciitis can be a nuisance to treat and, to date, we’ve had little high quality evidence to guide us. Today’s blog represents an exciting new direction in treating this stubborn condition. For some time we’ve noted the similarities between plantar fascial problems and tendinopathy. Back in 2006 Scott Wearing wrote an excellent paper on how the two structures shared similar pathology and similar response to load. However, no one has tested whether we might be able to treat plantar fasciitis like a tendinopathy, that is until now… Michael Rathleff and colleagues have just published an exciting new paper that is the first of its kind and represents a new treatment approach for plantar fasciitis, so I was delighted when Michael very kindly agreed to share his findings with us in a guest blog. Michael’s work includes excellent papers on hip strength and patellofemoral pain and patellofemoral pain in adolescents. To find out more about Michael’s research check out his Google Scholar Profile and follow him on Twitter via @MichaelRathleff.

Most of us who have experienced plantar fasciitis know first hand how debilitating and frustrating it can be. Every morning resembles being forced to walk on broken glass and you quickly become grumpy and dissatisfied. The prevalence in the general population is estimated to range from 3.6% to 7% [1 2], and may account for as much as 8% of all running-related injuries [3 4]. The life time prevalence may be as high as 10% which means that quite a big proportion of us will at some point be affected by plantar fasciitis or see these patients in the clinic.

Most previous treatment studies on plantar fasciitis have used a combination of orthotics, plantar specific stretching or similar non-exercise intervention. These interventions have proven successful to some degree and we know they are superior to placebo treatment. However a large proportion of patients still have symptoms two years after the initial diagnosis. Most clinicians who see these patients in the clinic will agree that they can be quite the challenge – especially if they have a long symptom duration. So we definitely need to start thinking about new effective treatments. An interesting thing is that we are starting to realise that there are some similarities between plantar fasciitis and tendinopathy. We know from the literature that high-load strength training appears to be effective in the treatment of tendinopathy [5]. A similar approach to plantar fasciitis therefore seems to be relevant to test. We recently completed a study where we investigated the effect of a high-load strength-training program compared to a standard plantar specific stretching program in the treatment of plantar fasciitis.[6]

Our main question before initiating the trial was how we could induce high tensile forces across the plantar fascia to resemble the loads induced to the patella tendon during e.g. single leg squat. Our approach was to exploit the windlass mechanism during single-leg calf-raises by using a towel to dorsal flex the toes. In theory, the windlass-mechanism would cause a tightening of the plantar fascia during dorsal flexion of the metatarsophalangeal joints while high-loading of the Achilles tendon is transferred to the plantar fascia because of their close anatomical connection [7-9].

We recruited 48 patients with ultrasonography verified plantar fasciitis. They were randomised to either high-load strength training or plantar specific stretching. In addition both groups received a short patient information sheet and gel heel-inserts. The patient information sheet covered information on plantar fasciitis, advice on pain management; information on how to modify physical activity; how to return slowly to sports and information on how to use the gel heel-inserts. On a side note, I think that one of the key things in successful management of plantar fasciitis is to educate the patient. The advice we used can be seen below in table 1.

Table 1: Advice given to the patients

The plantar-specific stretching protocol was identical to that of Digiovanni (2003) [10]. Patients were instructed to perform this exercise whilst sitting by crossing the affected leg over the contralateral leg (Figure 1). Then, while using the hand on the affected side, they were instructed to place the fingers across the base of the toes on the bottom of the foot (distal to the metatarsophalangeal joints) and pull the toes back toward the shin until they felt a stretch in the arch of the foot. They were instructed to palpate the plantar fascia during stretching to ensure tension in the plantar fascia. As in Digiovanni, patients were instructed to perform the stretch 10 times, for 10 seconds, three times per day [10].

Figure 1: Plantar-specific stretching

High-load strength training consisted of unilateral heel-raises with a towel inserted under the toes to further activate the windlass-mechanism (Figure 2). The towel was individualised, ensuring that the patients had their toes maximally dorsal flexed at the top of the heel-rise. The patients were instructed to perform the exercises every second day for three months. Every heel-rise consisted of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise). The high-load strength training was slowly progressed throughout the trial as previously reported by Kongsgaard et al. [11]. They started at 12 repetition maximum (RM) for three sets. After two weeks, they increased the load by using a backpack with books and reduced the number of repetitions to 10RM, simultaneously increasing the number of sets to four. After four weeks, they were instructed to perform 8RM and perform five sets. They were instructed to keep adding books to the backpack as they became stronger.

A key clinical point is that the calf-raises need to be done slowly to decrease the risk of symptom flaring.

Figure 2: High-load strength training

We used the Foot Function Index as our primary outcome after three months but also did follow-ups after 1,6 and 12 months. At our 3 months follow-up we saw that patients randomised to high load strength training had a 29 points lower Foot Function Index. This is far greater than the minimal relevant difference and suggests a superior effect of high-load strength training compared to plantar specific stretching. An important aspect is that we saw no difference between groups at 6 and 12 months indicating no superior long-term effect. However, if you ask patients to choose between two treatments that have similar long-term effect but one will give you a quicker reduction in pain, I am certain that all patients would choose the treatment, which provides them with the quickest reduction in pain.

There are still lots of unanswered questions about why high-load strength training may work in the treatment of plantar fasciitis. One explanation could be that high-load strength training may stimulate increased collagen synthesis which help normalise tendon structure, increase load tolerability of the plantar fascia and thereby improve patient outcomes. Another explanation may be that the exercise help improve ankle dorsal flexion range of motion as well as improving intrinsic foot strength and ankle dorsal flexion strength. When I completed the high-load strength training program as part of our pilot studies I developed good DOMS in the intrinsics which suggest they are active during the exercise. The questions are many and hopefully other researchers will take a critical look at our findings and confirm or contradict our findings.

The loading paradigm for treatment of plantar fasciitis is by no means a miracle treatment. However, it does provide us with the first evidence that high-load strength training may be the road towards more effective treatments for plantar fasciitis. The key message to the patients is that they need to perform the exercises (otherwise they are unlikely to work) and they need to be performed slowly (3s up, 2s pause at the top and 3s down) to decrease risk of symptom flaring and with enough load starting by 12RM for three sets and working their way down to 8RM for five sets.

References

1. Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res 2008;1(1):2 doi: 10.1186/1757-1146-1-2[published Online First: Epub Date]|.

2. Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004;159(5):491-8

3. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36(2):95-101

4. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987;15(2):168-71

5. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 2013;43(4):267-86 doi: 10.1007/s40279-013-0019-z[published Online First: Epub Date]|.

6. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Spor 2014:n/a-n/a doi: 10.1111/sms.12313[published Online First: Epub Date]|.

7. Stecco C, Corradin M, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. Journal of anatomy 2013;223(6):665-76 doi: 10.1111/joa.12111[published Online First: Epub Date]|.

8. Cheung JT, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon) 2006;21(2):194-203 doi: 10.1016/j.clinbiomech.2005.09.016[published Online First: Epub Date]|.

9. Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Int 2000;21(1):18-25

10. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 2003;85-A(7):1270-7

11. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports 2009;19(6):790-802 doi: 10.1111/j.1600-0838.2009.00949.x[published Online First: Epub Date]|.

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  • Plantar fasciitis RCT: high-load strength training higly efficient vs stretch at 3-months, but not at 1,6,12 months? ncbi.nlm.nih.gov/pubmed/25145882

  • Nick Webborn

    Although good to see researchers putting forward hypotheses for improving rehabilitation protocols I do believe there needs to be a balance of promoting your own work published in another journal (Scandinavian Journal of Medicine & Science in Sports) with incomplete presentation of the data in the BJSM editorial article. The original paper was titled “High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up”. In this paper there were no differences between groups at 1, 6, and 12 months. There was no mention of this in the editorial paper only in the subsequent un-peer reviewed blog. At 12 months, the Foot Function Index score was actually lower in the stretch group. So if all our patients were just interested in how they functioned at 3 months post commencement of treatment it may be more relevant. There could be a variety of reasons for this transient difference at 3 months including chance, the sensitivity of the instrument, sample size etc. There may have been no difference at 4 months and it was a transient ‘blip in the data. Perhaps an explanation of reported improvements at 3 months but not at 1,6 & 12 should have been hypothesised in relation to the high-load’ model.

    Too often we are told of the next great step in treatment based on limited science and then have to readjust it and confuse our patients yet again. If we are going to tell people “to boldly go where no man has gone before” we need to clear, and honest, as to why. It’s great to see this type of research but as authors you need to temper your enthusiasm for a new theory without the scientific rigour behind the results and accept the limitations of the study. 48 subjects randomised to two Rx groups is only 24 subjects per group and there are several reasons, as previously discussed, why there may be a difference at one time point, including chance, before we all jump on the bandwagon that this is the next new panacea. We all acknowledge that some form of loading is important during rehabilitation of injured structures but the evidence of this type of loading over other forms is still conjectural based on the current evidence. Maybe we need Dr ‘Bones’ McCoy’s medical tricorder device to assess it? “It may be science Jim, but not as we know it!”

  • Destiny Hale

    Living with Plantar Fasciitis can be hard, although through all my trial and error I finally found a permanent cure.Exercises and stretches ate one of the best ways to treat Plantar Fasciitis. When stretching stand about 12 inches from the wall depending on your height. Lean on it with both hands, bending your knees slightly with one leg in front. Do this for 30 to 60 seconds on each leg at least two times a day, watch video for a more detailed instructions. A remedy for temporary relief is to apply ice on the Plantar Fasciitis for 15 to 20 min. Three to four-times a day. Over the counter cushion inserts for shoe’s help as well when you’re doing physical activities. Using a splint at night helps stretch your Plantar Fasciitis by positioning it at 90° to your leg, I have provided a video on how splints actually work as well. Shortening certain activities help by reducing the amount of time that pressure is on the Plantar Fasciitis. Try shorting the time you walk or exercise and replace it with riding a bike or swimming for instance. Taping your foot or feet can be beneficial for instant relief, but can be very uncomfortable, and if not done right can cause blisters on your foot. If at some point the pain is unbearable you can ask if your doctor is able to prescribe naproxen or ibuprofen which helps to loosen the inflammatory. Your doctor may also suggest surgery or injections. The injections can be costly, but greatly reduces the pain caused by Plantar Fasciitis. These methods are good for temporary relief, but how do you cure it completely? Visit my site to find out how.

    I had the same problem three years ago. I shoped and brought different treatments from stores. I spent a lot of money on this thing. The stretches and everything makes it feel a lil better but it’s still there.. went to this website a lady name Kimberly had the same problem, and what worked for her cured mine completely too. so you can take my advice or just do the stretches. http://www.howtocureplantarfasciitis.org

  • Check out the plantar fasciitis survival guide for tons of treatment methods. Lots of articles and how to videos, and suggestions on footwear. 🙂

  • william prowse

    Really depends on the cause of the plantar fasciitis. If its from faulty hip tilt, then fix that. If its from only degeneration in the fascia, then align the foot bones so that blood can flow to the area. This is why different treatments help different people.

    William Prowse
    http://www.pfsurvivalguide.com

  • Ronald Selwyn

    After 3 1/2 years of having the plantar fascia soreness, it is finally gone.

    I was put on Voltaren (diclofenac) twice but the pain returned 7 days after the 15 or 30 day prescription. So the podiatrist suggested Orthotics but I did not like the idea of spending $600. Near the end of that 3 1/2 years I thought was going to have to live with it. What the podiatrist told me to do (like stretching it etc. only aggravated it).

    After I gave up hope for a cure, I got serious about praying for a solution. A coworker had a worse condition. He had plantar fasciitis plus an inoperable bone spur. To keep down the pain and inflammation, he told me he was taking three supplements. 1. Zyflamend made by New Chapter 2. Bio-Curcumin 400 mg from Life Extension and 3. Serrazimes (from Swanson Vitamins).

    I decided to try his supplements, and after taking them for a month, it suppressed the pain (reduced the inflammation).

    I took it for about 6 weeks and then stopped. Ten days passed and there was no pain so I stopped taking the supplements and my foot is OK now. I don’t have any more pain. Now I’ve been without the plantar fasciitis pain going on 2 years. What a relief.

    Just thought I would pass that on.

  • carin

    Does anyone have any comments about this particular loading strengthening exercise in this study, what structure are we are trying to strengthen with this exercise, as the plantar fascia is meant to be an inert structure, then is high tensile loading in this exercise really strengthening the plantar fascia? and is it changing the tendon degeneration /increasing collagen synthesis? or is the strengthening exercise here facilitating windlass mechanism ?

  • Ahmed Mohsin

    let me introduce you to a life changing product: The Soul Insole is an arch booster & can be added to a full length insole or placed into any shoe.It utilizes the existing structure of the shoe to increase support to your arch. As it is flexible, it will feel different in a shoe that has no support vs. a shoe that already has some arch support, and it reduces back pains. check out their website https://www.soulinsole.com

  • Hi Michael, I appreciate this article, as thoughtful research is badly needed. The single leg calf raise is one technique we recommended several years ago, in our first e-book. My recent research indicates an underlying nociceptive or neural reflex pathway. ‘So-called plantar fasciitis’ is apparently a progressive disease, or set of disease states, which involve initial nociceptive pain, due to a range of causes, leading eventually to biomechanical strains, ultimately resulting in organic tissue damage. More research is needed in the fields of nociception and biomechanics. For my latest, downloadable report, based in part on an ongoing survey study (financed by my retirement savings – so, don’t expect too much), click this link: https://dl.dropboxusercontent.com/u/85150966/FitOldDog%20PF%20Survey%20Data%20For%20Public%20Use/Reports/Plantar%20Fasciitis%20Report%20July%2011th%202016%20For%20Download.pdf

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