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1st Nov

2013

Advancement in Physical Therapy for Plantar Fasciitis

Plantar fasciitis, also referred to as plantar heel pain, is one of the most common musculoskeletal conditions, affecting 1 in 10 individuals in a lifetime. I previously wrote about this condition in the September 2009 newsletter, and reported research evidence of manual physical therapy and exercise being more effective for this condition, than traditional treatment with stretching, conventional strengthening and modality treatments such as iontophoresis (similar to ultrasound, to introduce pain relieving medications).

Over the last few years, we have in our clinic also incorporated higher intensity daily eccentric exercise for this condition, with promising results. This form of “lengthening muscle contraction” has been known to help chronic tendinitis (correctly referred to as tendinosis, or tendinopathy) conditions involving e.g. the Achilles, patellar, elbow epicondyle and rotator cuff tendons. Since plantar fasciitis is known to typically be a wear and tear degenerative condition of the plantar fascia, similar to what has been found in described tendons, it is logical to apply eccentric exercise also to this condition. I wrote about eccentric exercise for overuse tendinopathy in the October 2012 newsletter, which you can refer to, for more specifics.

Additional new research on plantar fasciitis now gives us more support for this form of exercise. Previous recent research and a brand new study out of China, have shown that patients with chronic plantar fasciitis (three months to two years in duration) have significantly thickened plantar fascia and increased number of blood vessels in the plantar fascia attachment onto the heel, which correlate with the degree of pain and functional impairment that patients report. This is what we also see in chronic tendinopathy conditions. Scandinavian research studies have in the past shown that eccentric exercise for Achilles tendinopathy, progressed over 12 weeks, results in elimination of such new blood vessels and reduced tendon thickening in patients who report pain relief and return to functional activities (the vast majority of patients responded favorably).

Since we know that the new blood vessels contain nerve endings which can cause pain, the researchers theorized that the eccentric exercises destroyed these blood vessels, and their nerve endings, explaining at least in part why the pain resolved. Although the research today is lacking to support this mechanism for plantar fasciitis, it would be logical to assume that this occurs also with eccentric exercise training for people with this condition.

Here are two examples of eccentric exercise for plantar fasciitis: One exercise is performed sitting, where you first lift up the bent leg and point the ankle down, then put the ball of the foot down on the floor and lean and push on the knee with your arms as you slowly lower the heel to the ground. This can be progressed by adding weight/pressure, and moving the heel further back. A more difficult exercise is to do the same thing in standing, and lifting your body weight up on the other leg (if no pain in this foot) or by using your arms on a counter, and slowly lower your full body weight down on the affected leg until the heel comes down. This can be progressed from two legs, to one leg only, to dropping off a small step, and by adding weight through e.g. a backpack worn, if indicated.

As I described in the September 2009 newsletter, protection of the plantar fascia is essential especially during the early rehabilitation process, in order to allow it to heal, and gradually get stronger through the exercise training. This usually entails wearing proper shoes at all times, adding a heel lift and at times orthotics, and limiting walking and weight-bearing activities. Such restrictions can be gradually removed as the condition improves.

Plantar fasciitis can easily become very chronic and recovery following treatment can take many months to up to a year, however without treatment, prognosis is typically poor in many cases.

I would like to wish you a wonderful Thanksgiving Holiday and continued good health.

Gunnar

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