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Treating plantar fasciitis; American Physical Therapy Association guidelines

Discussion in 'Biomechanics, Sports and Foot orthoses' started by scotfoot, Dec 4, 2023.

  1. scotfoot

    scotfoot Well-Known Member

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    Heel Pain – Plantar Fasciitis: Revision 2023

    Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health from the Academy of Orthopaedic Physical Therapy and American Academy of Sports Physical Therapy of the American Physical Therapy Association
    Summary of Recommendations


    [​IMG] Clinicians should use manual therapy directed at the joints and soft tissue structures of the lower extremity to address relevant joint and flexibility restrictions, decrease pain, and improve function in individuals with plantar heel pain/plantar fasciitis.

    [​IMG] Clinicians should use plantar fascia-specific and gastrocnemius/soleus stretching to provide short- and long-term pain reduction, as well as to improve short- and long-term function and disability.

    [​IMG] Clinicians should use foot taping techniques, either rigid or elastic, in conjunction with other physical therapy treatments for short-term improvements in pain and function in individuals with plantar fasciitis.

    [​IMG] Clinicians should not use orthoses, either prefabricated or custom fabricated/fitted, as an isolated treatment for short-term pain relief in individuals with plantar fasciitis.
    [​IMG] Clinicians may use orthoses, either prefabricated or custom fabricated/fitted, when combined with other treatments in individuals with heel pain/plantar fasciitis to reduce pain and improve function.

    [​IMG] Clinicians should prescribe a 1- to 3-month program of night splints for individuals with heel pain/plantar fasciitis who consistently have pain with the first step in the morning.

    [​IMG] Clinicians should not use ultrasound to enhance the benefits of stretching treatment in those with plantar fasciitis.

    [​IMG] Clinicians should use low-level laser therapy as part of a rehabilitation program in those with acute or chronic plantar fasciitis to decrease pain in the short term.

    [​IMG] Clinicians may use phonophoresis with ketoprofen gel to reduce pain in individuals with heel pain/plantar fasciitis.

    [​IMG] Clinicians may use manual therapy, stretching, and foot orthoses instead of electrotherapeutic modalities to promote shot-term and long-term improvements in clinical outcomes for individuals with heel pain/plantar fasciitis. Clinicians may use iontophoresis or premodulated interferential current electrical stimulation as a second line of treatment.

    [​IMG] Clinicians may provide education and counseling on exercise strategies to gain or maintain optimal lean body mass for individuals with heel pain/plantar fasciitis. Clinicians may also refer individuals to an appropriate health care practitioner to address nutrition issues.

    [​IMG] Clinicians should prescribe therapeutic exercise that includes resistance training for the musculature of the foot and ankle.

    [​IMG] Clinicians should use dry needling to MTrP in the gastrocnemius, soles, and plantar muscles of the foot for short- and long-term pain reduction, as well as long-term improvements in function and disability.
  2. scotfoot

    scotfoot Well-Known Member

    This review does not consider toe flexor weakness associated with plantar fasciitis . Whether toe flexor weakness is caused by plantar fasciitis or is the the cause of plantar fasciitis ( some studies use muscle size as a proxy here) , the deficiency should, IMO, be corrected as part of any treatment plan, since weaker toe flexor power is associated with falls.

    I don't contest that there is a real paucity of evidence that specific toe flexor muscle strengthening can reduce pain from plantar fasciitis.

    The American Physical Therapy Association guidelines do state "Clinicians should prescribe therapeutic exercise that includes resistance training for the musculature of the foot and ankle" .

    Interestingly, the guidelines also state "Clinicians should not use orthoses, either prefabricated or custom fabricated/fitted, as an isolated treatment for short-term pain relief in individuals with plantar fasciitis. " with a moderate level of certainty.
  3. scotfoot

    scotfoot Well-Known Member

    Ah, now I get it. I have often wondered, posting on podiatry arena, why foot strengthening gets such a negative response. Now ,having listened to Mat Dilnot, a senior and distinguished Pod from Oz, talking to Jason Agosta on a podcast, I realise what's going on.
    Jason and Mat agreed that they where not taught about foot strengthening during their podiatry training and Mat went on to say that even today podiatrists are scared of using techniques that they don't understand.

    I have spoken to some UK physiotherapists, and it would appear that they are generally not taught much about the foot and prefer to leave this part of the body to podiatrists. So they are not that well clued up on the importance of foot musculature and strengthening techniques either.

    Podiatrists, particularly old timers, don't accept foot strengthening as a key element of being a foot specialist because that is how they have been trained to think.

    Geez. This needs sorted!
  4. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Plantar Fasciitis is a symptom, not a structural deformation. Instead of treating the symptom, a better approach would be to isolate the etiology and treat that cause directly.
  5. scotfoot

    scotfoot Well-Known Member

    True best treat the cause. But you can treat the cause and treat the symptoms.

    So I have just learned what in Australia, 20 -30 years ago, university podiatry courses did not teach students about foot strengthening. Is the same true of American Universities?
    Were you taught any techniques as an undergraduate and if so what were they ? When I ask questions like that on the forum, I generally don't get a straight answer.
  6. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Our clinic had a PT who I used for foot strengthening. At the time my practice was mainly surgical and had little interest in that area of medicine.
  7. scotfoot

    scotfoot Well-Known Member

    So you were not taught about this aspect of foot care during your DPM degree ? Foot strengthening that is.
  8. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Taught, yes. However, little clinical application. Predominantly, I referred my patients to the PTs to help expedite their post-op recovery.
  9. scotfoot

    scotfoot Well-Known Member

    Great . Now can you tell us precisely what exercises you were taught to use?
  10. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Working with resistance bands, e.g., Reformer (Pilates) is my method of choice. Very effective for strengthening both the intrinsic and extrinsic foot muscles
  11. scotfoot

    scotfoot Well-Known Member

    You were taught that at University ?
  12. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    If my memory serves, it was during the residency program that different PT protocols for muscle rehab were presented.
  13. scotfoot

    scotfoot Well-Known Member

    Interesting. It would appear that around the time you were qualifying, foot strengthening exercises were not being taught in Australian podiatry schools.

    Until now strengthening the intrinsic foot muscles has been tricky, but no longer. Some interesting years ahead.
  14. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    The training for DPM degree in the US was, and may still be different, compared to the Australian training. In the US, training is now (after baccalaureate) typically 8 years - 4 years at DPM University, 3 years in post-degree residency.
  15. scotfoot

    scotfoot Well-Known Member

    Strengthening the skeletal muscles is not really a mystery .
    For example, if you want to improve your quads especially, you might use a seated leg extension machine and, after a warm up, do perhaps 3 sets of ten at 70% of your 1 rep max or basically until you feel the muscle fatigue and a bit of a burn in the quads.

    Strengthening the intrinsic foot muscles is no different. You want to be moving the toes from extended to retracted positions, against resistance, in such a way that 10 reps gives you a bit of a healthy "exercise burn" on the underside of your foot. If you feel the burn there then you know your hitting the intrinsics . You could be hopping /skipping for 30 mins and not fatigue the intrinsics and if you don't tax a muscle it want grow/get stronger.

    You can do 10 quick reps with the Novabow in 10 secs and feel the burn where we know the intrinsics to be. The patented Novabow is now on sale. Simple .
  16. scotfoot

    scotfoot Well-Known Member

    The exercise popularized by Rathleff et al 2014, puts the plantar fascia under strain but does not fatigue the intrinsic foot muscles . I have tried this exercise and it gives an exercise burn in the calf but not on the underside of the foot. Sure, during reps of this exercise something can be felt on the underside of the foot but this is strain in the plantar fascia. I found that if I do this for reps then immediately stand back and take stock of what my body is telling me, there is an intense burn in the calf but nothing under the foot.
    If you use the Novabow that muscle burn is found under the foot indicating that the intrinsic foot muscles are the primary muscle group used. It completely changes the game and will likely be a tool of enormous value to physicians treating foot and lower limb problems.

    Note ;I am not saying that calf raises don't activate the intrinsics to some degree, just that that it is a poor exercise for targeting this muscle group and recent research bears this out . Ten reps with the Novabow, going from extended to retracted, will give you a healthy fatigue /burn under the foot. All of the intrinsic muscles on the plantar surface of the foot flex the toes. Some flex and adduct, some flex and abduct, all flex.

    So in terms of Rathleff's exercise, or calf raises in general, or even repeated "functional" exercises like hopping or toe walking, if you don't get that burn under the foot what are you actually achieving?

  17. scotfoot

    scotfoot Well-Known Member

    Actually, to be fair to Rathleff et al, the exercise they helped popularized was never designed to strengthen the intrinsic foot muscles and in fact these are not mentioned in the paper. The main goal was putting the plantar fascia under stress via high loads. At some point people have looked at Rathleff et al and thought "great, strengthens the foot so that must also mean the intrinsic foot muscles " when in fact that was never the intention, and seems not to happen to any great degree.

    The effects of single leg, weighted, calf raises with dorsiflexed toes, has recently been studied by Daehlin et al 2023. Significant but modest gains were made in hallux flexion strength after 11 weeks but no gains in lesser toe flexor strength. 8 out of 25 people studied had no sig hallux strength gains. The single leg calf raise may have many benefits but, in terms of gains in toe flexor strength, it's a lot of effort and not much to show.

    If you want to strengthen the toe flexors then for goodness' sake flex the toes. You will not strengthen the toe flexors by simply loading the foot between the heel and the ball of the foot.

    Research has shown that strong toe flexors will take load away from the ball of the foot during heel off and increase load under the toes. This may relieve pain in this area if present.

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