Plantar fasciopathy (PF) is a common condition in runners and middle-aged females. Stretching of the feet, calves and plantar fascia is a common treatment for PF. Will stretching get your PF patients better?
Is there evidence for stretching in plantar fasciopathy?
Recent research shows that stretching will help PF, and when stretching was compared to strengthening and stretching, there was no additional benefit of strengthening (Kamonseki, D. H., Gonçalves, G. A., Liu, C. Y., & Júnior, I. L., 2016). So is stretching all that is required for PF?
Patients often present after performing self-directed stretches for the PF, foot and calf, often with very little benefit. It is quite possible this may be a biased population, consisting entirely of that haven’t responded to stretches, however there is a pretty good chance that the patients you see in your clinic will also have tried giving their plantar fascia a good stretch before coming to see you.
Have your patients just been doing their stretches all wrong? That is possible, but there really isn’t a lot to get wrong - you just pull your toes and foot back, or use a wall or step to achieve the same effect, which isn’t what I normally think of as rocket science. Is there another factor we need to look at? Let’s look at the development of PF for clues.
Why does plantar fasciopathy develop?
The plantar fascia behaves like a tendon, and similar to tendinopathy, PF is a load management and load capacity issue . Patients have often increased their load, running or amount of time on their feet, or had spikes in their load, and with low load capacity of the plantar fascia, PF develops (Rathleff, M. & Thorborg, K., 2015). Is stretching likely to increase the load capacity of the plantar fascia?
Stretching may help to improve the range of movement of the foot or ankle, but it is unlikely to improve the load capacity of the foot or plantar fascia (Rathleff, M. & Thorborg, K., 2015).
Is all plantar fascia strengthening created equal?
Why did Kamonseki et al. (2016) find no benefit with the addition of strengthening? Strengthening performed in the study was bilateral heel raises, placing the equivalent of 50% of bodyweight on each leg, which is a low level exercise that has an extremely limited potential to increase strength. Any potential “strength” or load tolerance gains achieved will not be close the the load tolerance required for running or even walking.
It is important to build up the strength to cope with the load placed on the plantar fascia with daily activities, walking and running. Rathleff et al., (2015) found support for high load strength training for PF in the first 12 weeks, the period where most patients are motivated to perform their exercises. Patients strength was challenged, their plantar fascia was placed under increasing load each week, creating adaptation and increased load tolerance with a graduated strength program.
How can you get better results with plantar fasciopathy?
Don’t rely on pointless therapies such as rolling on a frozen water bottle, needling or rubbing the plantar fascia. By all means incorporate plantar fascia stretches in your treatment, but the main focus of your treatment should be to challenge your patients strength gradually and progressively, so they can increase their plantar fascia load tolerance and get back to running, walking or work.
In our next episode of the 5 minute Physio tips, I will take you through ways you can practically implement strength training in your PF patients.
Kamonseki, D. H., Gonçalves, G. A., Liu, C. Y., & Júnior, I. L. (2016). Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomized controlled single-blind clinical trial. Manual therapy, 23, 76–82.
Rathleff, M. S., Mølgaard, C. M., Fredberg, U., Kaalund, S., Andersen, K. B., Jensen, T. T., … & Olesen, J. L. (2015). High‐load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12‐month follow‐up. Scandinavian journal of medicine & science in sports, 25(3), e292-e300.