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Commentary and Perspective   |    
Commentary on an article by J.D. Rompe, MD, et al.: “Plantar Fascia-Specific Stretching Versus Radial Shock-Wave Therapy as Initial Treatment of Plantar Fasciopathy”
Victor R. Prisk, MD
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The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Nov 03;92(15):e26 1-2. doi: 10.2106/JBJS.J.01258
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Plantar fasciitis is the most common cause of plantar heel pain. It has been estimated that as much as 15% of all foot complaints requiring medical attention can be related to this condition1. The pathology of this condition has been attributed to intrinsic factors, such as increased body mass index, a tight gastrocnemius muscle, poor muscle strength, and systemically decreased healing capacity2. Extrinsic factors, such as poor footwear, changes in activity level or duration, and repetitive trauma, have also been proposed as causes of plantar fasciitis. As Rompe et al. have appropriately acknowledged, the histopathology of this condition and the lack of response to nonsteroidal anti-inflammatory drugs suggest that the term plantar fasciopathy is more appropriate to describe a condition of degenerative changes with fibroblastic proliferation.
Many treatments have been described for the treatment of plantar fasciopathy. Custom or nonprescription orthoses, heel cups, dorsiflexion night splints, gastrocnemius and plantar fascial stretching, extracorporeal shock-wave therapy, corticosteroid injections, and surgery have all been shown to have some effectiveness in the treatment of chronic plantar fasciopathy. However, Rompe et al. have nicely addressed the patient who has more acute symptoms of less than six weeks’ duration. As physicians, we look for Level-I evidence to support treatment of conditions, both acute and chronic, as they present. The nature of plantar fasciopathy likely changes with increasing chronicity, much like the proliferative response of Achilles tendinopathy.
Shock-wave therapy has been shown to be useful in a number of chronic conditions involving tendons. It appears to work by stimulating a stagnant healing process and by decreasing nociception3. Chronic tendinopathy and chronic plantar fasciopathy, whether intrinsic or extrinsic in cause, are conditions that result from a disruption of the normal healing process. As Rompe et al. have pointed out, the possible reason for failure of shock-wave therapy to improve two and four-month outcomes in plantar fasciopathy may be that these patients with acute symptoms have not gone on to an unsuccessful healing process. During the acute phase of the condition, the plantar fascia may be attempting to heal, but, rather than having a need for further stimulation, it may instead have a need only for direction.
One could say that the jury is still out on the use of shock-wave therapy in the treatment of acute plantar fasciopathy, as there are many permutations of the energy, frequency, and duration of treatment that may alter the effectiveness of treatment. Considering the time and cost involved in the performance of this treatment, it will be necessary to perform further randomized controlled trials before this treatment can be recommended for acute heel pain.
Plantar fascia-specific stretching programs are headed in the right direction with regard to the treatment of plantar fasciopathy. DiGiovanni and colleagues demonstrated the effectiveness and long-term relief of patients with chronic plantar fasciitis4,5. At a time when limiting the cost of health care is being brought to the forefront in the minds of physicians and the general public alike, the plantar fascia-specific stretching program is acceptable ammunition in the armamentarium against plantar fasciopathy. Rompe et al. have demonstrated that a plantar fascia-specific stretching program is also quite effective in the treatment of acute plantar fasciopathy and may limit the need for more costly interventions that are being used for treatment of the chronic condition. The technique is easy to learn, and patients find it helpful to revert back to the stretching exercises when symptoms recur.
Some may look at the data offered by Rompe et al. and wonder why as many as two-thirds of the patients found a need to revert back to the stretching exercises on a daily or intermittent basis to maintain a satisfactory outcome. Does the plantar fascia-specific stretching program not cure plantar fasciopathy? The answer to this question lies in both the intrinsic and extrinsic underlying causes of plantar fasciopathy. Many patients and physicians would like to find a treatment plan that can give rapid pain relief and patient satisfaction but that takes little time and energy expenditure. However, this condition often results from processes that take time, in combination with multiple other factors, to develop; as an example, consider the morbidly obese patient who overeats, the athlete who overtrains, and the shoes that are overworn. This study shows that an active healing process is accelerated by the patient's active involvement in that process. Perhaps additional counseling with regard to the ways in which extrinsic and intrinsic factors contribute to the development of plantar fasciopathy would further enhance this active healing process as well.
In conclusion, in their carefully planned, randomized parallel treatment, and observer-blinded Level-I study, Rompe et al. demonstrated that a plantar fascia-specific stretching program was superior to repetitive shock-wave therapy at two and four months after treatment in patients who were being treated for acute proximal plantar fasciopathy. Further studies with placebo or sham treatment are needed to understand the potentially self-limiting nature of acute heel pain and the effect of early interventions on long-term outcomes. Furthermore, studies to evaluate the time and economic expense of treatments for acute and chronic heel pain are needed. An "active patient" approach may be the simplest and cheapest treatment plan without accounting for the cost of the patient's time. Spending time to educate patients on how they can treat themselves with a daily exercise or therapy program builds rapport and gives patients a sense of self-responsibility for their condition.
Ibrahim  MI;  Donatelli  RA;  Schmitz  C;  Hellman  MA;  Buxbaum  F. Chronic plantar fasciitis treated with two sessions of radial extracorporeal shock wave therapy. Foot Ankle Int.  2010;31:391-7.[PubMed][CrossRef]
 
League  AC. Current concepts review: plantar fasciitis. Foot Ankle Int.  2008;29:358-66.[PubMed]
 
Ochiai  N;  Ohtori  S;  Sasho  T;  Nakagawa  K;  Takahashi  K;  Takahashi  N;  Murata  R;  Takahashi  K;  Moriya  H;  Wada  Y;  Saisu  T. Extracorporeal shock wave therapy improves motor dysfunction and pain originating from knee osteoarthritis in rats. Osteoarthritis Cartilage.  2007;15:1093-6.[PubMed]
 
DiGiovanni  BF;  Nawoczenski  DA;  Lintal  ME;  Moore  EA;  Murray  JC;  Wilding  GE;  Baumhauer  JF. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am.  2003;85:1270-7.[PubMed]
 
DiGiovanni  BF;  Nawoczenski  DA;  Malay  DP;  Graci  PA;  Williams  TT;  Wilding  GE;  Baumhauer  JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am.  2006;88:1775-81.[PubMed]
 

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References

Ibrahim  MI;  Donatelli  RA;  Schmitz  C;  Hellman  MA;  Buxbaum  F. Chronic plantar fasciitis treated with two sessions of radial extracorporeal shock wave therapy. Foot Ankle Int.  2010;31:391-7.[PubMed][CrossRef]
 
League  AC. Current concepts review: plantar fasciitis. Foot Ankle Int.  2008;29:358-66.[PubMed]
 
Ochiai  N;  Ohtori  S;  Sasho  T;  Nakagawa  K;  Takahashi  K;  Takahashi  N;  Murata  R;  Takahashi  K;  Moriya  H;  Wada  Y;  Saisu  T. Extracorporeal shock wave therapy improves motor dysfunction and pain originating from knee osteoarthritis in rats. Osteoarthritis Cartilage.  2007;15:1093-6.[PubMed]
 
DiGiovanni  BF;  Nawoczenski  DA;  Lintal  ME;  Moore  EA;  Murray  JC;  Wilding  GE;  Baumhauer  JF. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am.  2003;85:1270-7.[PubMed]
 
DiGiovanni  BF;  Nawoczenski  DA;  Malay  DP;  Graci  PA;  Williams  TT;  Wilding  GE;  Baumhauer  JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am.  2006;88:1775-81.[PubMed]
 
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