When it comes to patients presenting with plantar heel pain, clinicians routinely recommend a home treatment program, which usually includes stretching of the plantar fascia, the calf musculature and the Achilles tendon.1,2 The question is: would outcomes be better if a physical therapist supervised these stretching exercises and also implemented other interventions?
The American College of Foot and Ankle Surgeons (ACFAS) clinical practice guidelines for plantar heel pain recommend referral for supervised physical therapy, but only if six weeks of an unsupervised home treatment program fails to lead to improvement.3 One may also combine this home treatment of stretching with corticosteroid injections, taping and orthotic therapy, according to the ACFAS guidelines.
A recent study provides insight into the benefits of a supervised physical therapy program implementing multiple interventions in comparison to a patient-directed home treatment program of stretching and strengthening alone.4 Cil and coworkers conducted a randomized prospective trial comparing two rehabilitation protocols in 47 patients treated for plantar heel pain. One group (“home group”) received patient education and instructions for strengthening the hip, ankle and foot as well as stretching the hamstring, gastroc-soleus, Achilles and plantar fascia. The patients performed these strengthening and stretching exercises seven days per week for eight weeks in the home setting.
The other group (“outpatient group”) performed the same hip, ankle and foot strengthening and stretching exercises as the home group, seven days per week, but also went to the physical therapy clinic two days per week for additional treatment by the physical therapist. This treatment consisted of myofascial releases as well as soft tissue and joint mobilization, which has gained credibility in the rehabilitation community.5,6 The physical therapist performed myofascial release on the soleus, gastrocnemius and plantar fascia. The joint and soft tissue mobilization procedures focused on stretching the plantar fascia and flexor hallucis longus tendon as well as mobilization of rearfoot eversion, anterior-posterior mobility of the talocrural joint, mobilization of the intertarsal joints and the posterior tibial nerve. The myofascial release, soft tissue and joint mobilization treatments lasted 45 minutes and physical therapists performed these treatments twice weekly for eight weeks.4
All study participants had follow-up evaluation at eight weeks and at six months. Visual analogue scales (VAS), functional scoring with the foot function index (FFI) and testing for balance, proprioception and overall flexibility improved in both groups at eight weeks in comparison to baseline assessments. In comparing both groups, the researchers found the supervised outpatient group had significant improvements over the self-directed home treatment group in the areas of range of motion, balance, proprioception, foot function index scoring and VAS scores. The study authors also noted the foot function index and VAS scores at the sixth month were superior in the outpatient group.4
Making The Case For A Supervised Regimen Of Stretching And Strengthening
I believe there are three reasons why supervised outpatient rehabilitation is superior to a self-directed home treatment program of stretching and strengthening for treating plantar heel pain.
- The outpatient program in the study by Cil and colleagues implemented a program of myofascial release, soft tissue and joint mobilization, which a patient cannot properly perform in the home setting.4 Manual therapy has gained credibility as a proven intervention for a number of lower extremity musculoskeletal pathologies, including plantar heel pain.7-9 One study showed that the combination of myofascial release with stretching was more effective in treating plantar heel pain than stretching combined with foot orthotic therapy.10 This is not to say that manual therapy should replace foot orthotic therapy. My suggestion is to consider bringing all modalities to the table if they have proven benefit in the treatment of plantar heel pain.
- With supervised physical therapy, the opportunity to design and modify the rehabilitation program specific to the patient offers significant advantage over a simple generic home treatment program taught with a handout. Individual tailoring of the rehabilitation program specific to the deficits of the patient has already shown benefit to patients with plantar heel pain in the outpatient setting. McClinton and coworkers described how the physical therapist can identify diverse impairments related to plantar heel pain specific to the individual patient.11 In many cases, the impairment was proximal to the foot and ankle. The authors implemented evidenced-based interventions that included a combination of manual therapy, patient education, stretching, resistance training and neurodynamic interventions. Treatment progressed from a focus on symptom modulation initially to increased load tolerance of involved tissues and graded activity. The outcomes were very favorable at one- and two-year follow up.
- When a patient engages regularly with a health care professional, it may encourage better compliance with all aspects of the treatment program for plantar heel pain. At the initial evaluation, clinicians will educate the patient about the etiology of plantar heel pain and then recommend activity and footwear modification as well as stretching and strengthening exercises. Adherence to these recommendations may wane if the provider does not follow the patient for four to six weeks, which may unfortunately be common in some clinical settings.12,13 Effective treatment of plantar heel pain often requires lifestyle changes from the patient. Enrolling them in a supervised rehabilitation program from the outset might be the key step to successfully implementing those changes.
When a group of physical therapists joined my practice 20 years ago, I noticed an immediate improvement in outcomes for patients treated in a supervised setting in comparison to a self-directed home treatment program. In particular, I became a believer in the benefits of manual therapy, particularly in patients with plantar heel pain. It is encouraging to see a growing body of published evidence in the medical literature which validates these observations.
Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons.
- 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(8):1775-1781.
- Martin RL, Davenport TE, Reischl SF, et al. Heel pain— plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014;44(11):A1-A33.
- Thomas J, Christensen J, Kravitz S, et al. The diagnosis and treatment of heel pain: a clinical practice guideline–revision. J Foot Ankle Surg. 2010;49(3 Suppl):S1-S19.
- Cil ET, Sayli U, Subasi F. Outpatient vs home management protocol results for plantar fasciitis. Foot Ankle Int. 2019;40(11):1295-1303.
- Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-272.
- Meltzer KR, Cao TV, Schad JF, King H, Stoll ST, Standley PR. In vitro modeling of repetitive motion injury and myofascial release. J Bodyw Mov Ther. 2010;14(2):162-171.
- Cleland JA, Abbott JH, Kidd MO, et al. Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2009;39(8):573–585.
- Looney B, Srokose T, Fernandez-de-Las-Peñas C, Cleland JA. Graston instrument soft tissue mobilization and home stretching for the management of plantar heel pain: a case series. J Manipulative Physiol Ther. 2011;34(2):138–142.
- Ajimsha M, Binsu D, Chithra S. Effectiveness of myofascial release in the management of plantar heel pain: a randomized controlled trial. Foot. 2014;24(2):66-71.
- Renan-Ordine R, Alburquerque-Sendin F, de Souza DP, Cleland JA, Fernandez-de-Las-Peñas C. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41(2):43–50.
- McClinton S, Heiderscheit B, McPoil TG, Flynn TW. Physical therapist decision-making in managing plantar heel pain: cases from a pragmatic randomized clinical trial. Physiother Theory Pract. 2018:1-25. DOI: 10.1080/09593985.2018.1490941.
- McClinton SM, Flynn TW, Heiderscheit BC, et al. Comparison of usual podiatric care and early physical therapy intervention for plantar heel pain: study protocol for a parallel group randomized clinical trial. Trials. 2013;14:414.
- Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int. 1994;15:97–102.