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Plantar Fascia-Specific Stretching Exercise Improves Outcomes in Patients with Chronic Plantar FasciitisA Prospective Clinical Trial with Two-Year Follow-Up
Benedict F. Digiovanni, MD1; Deborah A. Nawoczenski, PhD, PT2; Daniel P. Malay, MSPT3; Petra A. Graci, DPT4; Taryn T. Williams, MSPT5; Gregory E. Wilding, PhD6; Judith F. Baumhauer, MD1
1 Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 665, Rochester, NY 14620. E-mail address for B.F. DiGiovanni: benedict_digiovanni@urmc.rochester.edu. E-mail address for J.F. Baumhauer: judy_baumhauer@urmc.rochester.edu
2 Department of Physical Therapy, Ithaca College, University of Rochester Campus, 300 East River Road, Rochester, NY 14623. E-mail address: dnawoczenski@ithaca.edu
3 Department of Physical Medicine and Rehabilitation, SUNY Upstate Medical University, University Hospital, 750 East Adams Street, Syracuse, NY 13210. E-mail address: danielmalay@yahoo.com
4 Physical Medicine and Rehabilitation, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140. E-mail address: petra_graci@hotmail.com
5 Physical Therapy Department, Saint Joseph Regional Medical Center, 415 6th Street, P.O. Box 816, Lewiston, ID 83501. E-mail address: taryntefft@yahoo.com
6 Department of Biostatistics, University at Buffalo, State University of New York, 3435 Main Street, Building 26, Buffalo, NY 14214. E-mail address: gwilding@buffalo.edu
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive 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.
Investigation performed at the Center for Foot and Ankle Research, Department of Physical Therapy, Ithaca College, University of Rochester Campus, Rochester, New York

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Aug 01;88(8):1775-1781. doi: 10.2106/JBJS.E.01281
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Abstract

Background: In a previous investigation, eighty-two patients with chronic proximal plantar fasciitis for a duration of more than ten months completed a randomized, prospective clinical trial. The patients received instructions for either a plantar fascia-stretching protocol or an Achilles tendon-stretching protocol and were evaluated after eight weeks. Substantial differences were noted in favor of the group managed with the plantar fascia-stretching program. The goal of this two-year follow-up study was to evaluate the long-term outcomes of the plantar fascia-stretching protocol in patients with chronic plantar fasciitis.

Methods: Phase one of the clinical trial concluded at eight weeks. At the eight-week follow-up evaluation, all patients were instructed in the plantar fascia-stretching protocol. At the two-year follow-up evaluation, a questionnaire consisting of the pain subscale of the Foot Function Index and an outcome survey related to pain, function, and satisfaction with treatment was mailed to the eighty-two subjects who had completed the initial clinical trial. Data were analyzed with use of a mixed-model analysis of covariance for each outcome of interest.

Results: Complete data sets were obtained from sixty-six patients. The two-year follow-up results showed marked improvement for all patients after implementation of the plantar fascia-stretching exercises, with an especially high rate of improvement for those in the original group treated with the Achilles tendon-stretching program. In contrast to the eight-week results, the two-year results showed no significant differences between the groups with regard to the worst pain or pain with first steps in the morning. Descriptive analysis of the data showed that 92% (sixty-one) of the sixty-six patients reported total satisfaction or satisfaction with minor reservations. Fifty-one patients (77%) reported no limitation in recreational activities, and sixty-two (94%) reported a decrease in pain. Only sixteen of the sixty-six patients reported the need to seek treatment by a clinician.

Conclusions: This study supports the use of the tissue-specific plantar fascia-stretching protocol as the key component of treatment for chronic plantar fasciitis. Long-term benefits of the stretch include a marked decrease in pain and functional limitations and a high rate of satisfaction. This approach can provide the health-care practitioner with an effective, inexpensive, and straightforward treatment protocol.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Joel A. Radford
    Posted on September 19, 2006
    Stretching for chronic plantar fasciitis: more evidence is needed.
    School of Biomedical & Health Sciences, University of Western Sydney, AUSTRALIA

    EDITOR'S NOTE: The corresponding author of the article was invited to respond to this letter, but to date has not done so.

    To The Editor:

    We read with interest the two-year follow up by DiGiovanni et al. (1) comparing plantar fascia and Achilles tendon stretching for plantar fasciitis. We wish to congratulate the authors for attempting to evaluate the effectiveness of such treatments for a condition that has received little rigorous evaluation. However, unfortunately the trial update is plagued by a fundamental methodological flaw - the failure to include a placebo or control group for comparison. Accordingly, the conclusion from the trial that the “long-term benefits of the stretch include a marked decrease in pain and functional limitations and a high rate of satisfaction” is incorrect.

    The importance of including a comparison group was highlighted by Buchbinder in her excellent evidence-based review(2). Long-term follow-up data from large case series revealed that the clinical course for most patients with plantar fasciitis is favourable, with resolution of symptoms in more than 80 percent of patients within 12 months. This is a vital factor that must be considered in trials evaluating interventions for plantar fasciitis. A more powerful example of this natural resolution can be found in the results of recent randomised trials that have included a control or placebo group. Such trials report large improvements in pain in control groups over the duration of the intervention period(3-6). Changes over time in a placebo or control group may be due to three important effects: (i) the natural resolution of the condition being studied, (ii) the placebo effect, and (iii) the Hawthorne effect. All can explain some of the magnitude of the effect of an intervention when used for plantar fasciitis.

    Because DiGiovanni’s long term trial(1) did not compare those participants that were stretching to a control group, the authors cannot attribute the changes in symptoms to the stretches performed. As previously mentioned, such improvements may have been due to the natural progression of the disorder or to the placebo or Hawthorne effects. Indeed the long-term improvement may even have been a result of the orthotic therapy the participants were encouraged to continue using from the earlier trial(7).

    In conclusion, researchers conducting plantar fasciitis intervention trials must include placebo or control groups (i.e. a group or groups to compare the intervention against) if they wish to conclude that an intervention is truly effective.

    The author(s) of this letter to the editor did not receive payment 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 author(s) are affiliated or associated.

    References:

    1. Digiovanni, B. F.; Nawoczenski, D. A.; Malay, D. P.; Graci, P.; Williams, T. T.; Wilding, G. E.; and Baumhauer, J. F.: Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. Journal of Bone and Joint Surgery. American Volume, 88(8): 1775-1781, 2006.

    2. Buchbinder, R.: Plantar fasciitis. New England Journal of Medicine, 350(21): 2159-2166, 2004.

    3. Landorf, K. B.; Keenan, A.-M.; and Herbert, R. D.: Effectiveness of three foot orthoses for plantar fasciitis: a randomised trial. Archives of Internal Medicine, 166(12): 1305-1310, 2006.

    4. Radford, J. A.; Landorf, K. B.; Buchbinder, R.; and Cook, C.: Effectiveness of low-Dye taping for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskeletal Disorders, 7(1): 64, 2006.

    5. Buchbinder, R.; Forbes, A.; and Ptasznik, R.: Shock wave therapy for treatment of plantar fasciitis. Journal of the American Medical Association, 289(2): 172-178, 2003.

    6. Winemiller, M. H.; Billow, R. G.; Laskowski, E. R.; and Harmsen, W. S.: Effect of magnetic vs sham-magnetic insoles on plantar heel pain: A randomized controlled trial. Journal of the American Medical Association, 290(11): 1474-1478, 2003.

    7. DiGiovanni, B. F.; Nawoczenski, D. A.; Lintal, M. E.; Moore, E. A.; Murray, J. C.; Wilding, G. E.; and Baumhauer, J. F.: Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. Journal of Bone and Joint Surgery. American Volume, 85(7): 1270-1277, 2003.

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