December 2009

The Home Stretch: Paths to pain relief

by Cary Groner

Stretching and splinting have long been treatment strategies for plantar fasciitis. However, new research and ongoing clinical experience are calling into question older methodologies and providing evidence for some new approaches.

“There are different opinions about the relative value of stretching and night splinting,” said Michael Trepal, DPM, vice president and dean of academic affairs at the New York College of Podiatric Medicine. “Stretching is a tried-and-true method that a lot of people employ, but there are a variety of techniques. It’s important to remember that stretching be sustained, not jerky, and that splinting is just another form of stretching that happens to be sustained overnight.”

Trepal prefers to treat acute plantar fasciitis pain with medication. Only when those symptoms have resolved does he introduce patients to stretching. First are the posterior calf muscles, which are stretched by keeping the foot flat and the knee straight as the patient leans into a wall. Second is the plantar fascia itself, which is best stretched by sitting and crossing the legs so that one ankle rests on top of the opposite thigh, just behind the knee. The patient then grasps the foot and eases it into dorsiflexion while pulling back on the toes.

Trepal is satisfied with his results but remains skeptical of the mechanism by which they occur.

“I’m not aware of any study that shows an actual lengthening of the plantar fascia as a result of stretching,” he said. “But you do want to get the patient involved in their own care, even if it just helps psychologically.”

Night splints are designed to counter the body’s natural tendency to point the toes and shorten the fascia during sleep. It is because of this reflex that fasciitis is often worst early in the morning.

“You want a splint that dorsiflexes the ankle and the toes, so you are stretching both the fascia and the posterior muscles simultaneously,” Trepal said.

He noted, however, that patient compliance is an issue with both stretching regimens and night splints.

“With stretching the results are not instantaneous or dramatic, and many people find night splints uncomfortable,” he said. “People often give up after a week or two.”

Some clinicians advise stretching the calf muscles and the fascia together rather than separately. Michael Gross, PT, PhD, a professor of physical therapy at the University of North Carolina, espouses this view.

“I believe the most effective stretch is a standing calf stretch with something under the toes to extend them,” he said. “Most people don’t add that to the traditional calf stretch, and it can help.”

Research published in the Journal of Bone & Joint Surgery in July 2003 and August 2006 concluded that localized, non–weight-bearing, plantar-fascia–specific exercises improved outcomes. Benedict DiGiovanni, MD, and colleagues at the University of Rochester found that 92% of patients reported either total satisfaction, or satisfaction with minor reservations, with the approach at two-year follow-up.

Irene Davis, PT, PhD, professor of physical therapy and director of the Running Research Laboratory at the University of Delaware, said that effective stretching regimens consider the anatomical link between the termination of the Achilles tendon at the top of the calcaneus and the insertion point of the plantar fascia on the plantar surface of the heel below.

“People sometimes think of them as separate, but there’s a fascial connection,” Davis said. “You’ll get a good stretch with your ankle dorsiflexed because you tighten the fascial connection between the calcaneus and the plantar fascia. Then, when you pull your toes back, you get an even better stretch.”

Davis takes the best of both worlds, in fact. Like Gross, she prefers that her patients dorsiflex the toes while they do calf stretches. But, like DiGiovanni, she also wants them to take the weight off the leg by sitting when they stretch or massage the plantar fascia directly.

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