Thank you for your interest in our editorial in the British Journal of Sports Medicine: ”Load me up Scotty”: mechanotherapy for plantar fasciopathy (formerly known as plantar fasciitis)”. However, we find your letter to the editor (published in this recent blog) somewhat hit-and-miss with regards to the main “swings” (critique points) provided by you and your colleagues.
- Your main critique was not related to our editorial, but more so to the original study published in Scandinavian Journal of Medicine & Science in Sports (SJMSS )(Read it HERE )
- We were criticised for promoting our own work in an unbalanced way, and in an incomplete form.
In reverse order, our response to these 2 main “swings” are:
Yes, you can rightfully claim that we highlight some of our own work, but as this was an important part of the task given by the BJSM (in a requested editorial), your criticism seems a little off target. Point taken, although, we do not share you and your colleagues concern, as we believe that most BJSM readers will know that editorials are narratives (Expert opinion, Level 5), and therefore not high-level evidence, in itself. The BJSM editorial format limits of 800 words and 8-10 references, also plays a role as to why the comprehensiveness of most subjects is usually limited in some way, shape or form.
We therefore urge people to read the original study in SJMSS, as an a priori justification and rationale for the primary outcome and endpoint (including sample size justification) is provided in the methods section of this study, and the relevance of this is discussed in detail in the manuscript. Furthermore, this specific study has been referred to in this blog in BJSM, where the methodological issues are more thoroughly discussed.
We chose 3 months as the primary endpoint because the exercise protocol lasted three months, and therefore the effects of exercise were most relevant to that time point — when there is no wash-out of the exercise effect. We agree that most patients do not only care about their status at 3 months, but also at other time points. However, patients in both groups were better at 6 and 12 months (and not different as your blog suggests), than before initiating treatment, with no differences between the groups. So, if you your patients prefer to wait till 6 months, instead of 3 months, before a substantial improvement kicks in, then the traditional approach with stretching and inserts seems equally effective, as suggested by the secondary analyses of the study.
With this answer we have addressed the main points in your blog/letter. We agree that our work is only the first indication that high-load strength training is an effective treatment for plantar fasciopathy, and that replication studies should follow. We have no interest in panaceas, and have therefore extensively studied different musculoskeletal conditions and specific exercise interventions in several RCTs, during the past 5 years, and we will be the first ones to abandon interventions that show no clinically meaningful promise.
Finally, we are also admittedly very enthusiastic and passionate people, especially with regards to our clinical research and work, but the intention was never to offend you and your colleagues, only to promote a novel and interesting modality for people to consider to include in their clinical tool box. As previously stated in the blog post on the BJSM website “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.”
Who knows, maybe future randomised trials within fasciopathy or other tendinopathies will be initiated from an interest sparkled by this enthusiastic editorial on the importance of loading. If so, we believe ”Load me up, Scotty….” has certainly done it’s job, as the current level of evidence for the modalities often used in treating plantar fasciopathy is still low, and therefore often based upon low-level evidence, as documented in a recent Clinical Practice Guideline (Read it HERE).
Michael Skovdal Rathleff & Kristian Thorborg