Point-Counterpoint: Stretching: Is It Beneficial For Plantar Fasciitis?

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Lisa M. Schoene, DPM, ATC, FACFAS, and Stephen Pribut, DPM, FACFAS

   The first person to suggest that over-stretching could lead to problems was Schuster. While puzzling over survey data indicating that more stretching led to more injury, Schuster suggested that over-stretching might lead to a higher incidence of injury.17 More recently, D’Amico has suggested that initial treatment of plantar fasciitis should stop all stretching.18 D’Amico also suggested using a shoe with a rigid shank and a heel lift.

What Should You Recommend To Patients?

Recommend quadratus plantae and intrinsic muscle strengthening in most cases of plantar fasciopathy. These muscles function parallel with the plantar fascia along the plantar surface of the foot. There is enough evidence that intrinsic muscle strengthening should become the major recommended intervention for plantar fasciitis. There are no clinical studies that I am aware of but they would be easy to do. Strengthening the plantar muscles should reduce the strain along the plantar fascia.

   There are several ways to perform intrinsic muscle strengthening exercises. I prefer performing the exercises in a manner similar to the way patients use the muscles while walking or running. I recommend rhythmic contractions without holding the contraction for long. Patients tolerate this exercise well and it is a great adjunct to other recommendations.

   Gentle stretching of the posterior muscle groups can be helpful. Patients should discontinue stretching that is too vigorous or causes pain during or after the stretch.

   Advise patients to avoid open back shoes and flat shoes. Use a heel lift. Beware of those running shoes that used to have a 12 mm heel drop and now have an 8 mm drop. These all increase strain at the Achilles tendon which, translated through the calcaneus, causes increased strain in the plantar fascia.12

   Avoid over-stretching of the calf and plantar fascia. Consider a heel lift to lessen the pull on the calcaneus by the calf muscles.

In Conclusion

Do not make an orthotic with a low heel cup and “wipe out” the flexible plantarflexed first ray in your casting. Check the latest evidence-based literature on orthotics and consider a valgus post if appropriate.

   Read the current literature. The old literature was wrong on many things. The current literature represents an approach that is subject to revision. Tomorrow’s literature will offer different solutions and promise better results.

   Treatment often requires a nuanced approach. While we have a pro and a con side presented in these Point-Counterpoint articles, I really hope we have inspired you to think about the solutions you present and the study design in the articles you read. n

   Dr. Pribut is a Clinical Assistant Professor of Surgery at the George Washington University School of Medicine and Health Sciences in Washington, DC. He is a Fellow of the American College of Foot and Ankle Surgeons.

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