Effectiveness of Simultaneous Stretching of Achilles Tendon & Plantar Fascia in Plantar Fasciitis.

Since the plantar fascia and the Achilles tendon are anatomically connected, it is plausible that stretching of both structures simultaneously will result in a better outcome for plantar fasciitis.

Fifty participants aged 40 to 60 years with a history of plantar fasciitis greater than 1 month were recruited. They were prospectively randomized into 2 groups. Group 1 was instructed to stretch the Achilles tendon while group 2 simultaneously stretched the Achilles tendon and plantar fascia.

After 4 weeks of both stretching protocols, participants in group 2 demonstrated a significantly greater pressure pain threshold than participants in group 1 ( P = .040) with post hoc analysis. No significant differences between groups were demonstrated in other variables ( P > .05). Concerning within-group comparisons, both interventions resulted in significant reductions in pain at first step in the morning and average pain at the medial plantar calcaneal region over the past 24 hours, while there were increases in the pressure pain threshold, visual analog scale-foot and ankle score, and range of motion in ankle dorsiflexion ( P < .001). More participants in group 2 described their symptoms as being much improved to being completely improved than those in group 1.

The simultaneous stretching of the Achilles tendon and plantar fascia for 4 weeks was a more effective intervention for plantar fasciitis. Patients who reported complete relief from symptoms at the end of the 4-week intervention in the simultaneous stretching group (n = 14; 56%) were double that of the stretching of the Achilles tendon-only group (n = 7; 28%).

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Not having access to full text of this article my comments are based on reading information in abstract. The abstract does not report whether there was change in range of motion of first MTP joint (length test for plantar aponeurosis. Chang has reported there is greater peak first MTPJ dorsiflexion when walking in individuals with plantar heel pain compared to controls 51.2° to 39°. [1] This raises the question whether objective signs of increased motion in subjects with painful heels warrant stretching the plantar aponeurosis. Majority of controlled clinical trials regarding plantar heel pain as well as this study fail to use a control group which does not stretch. [2]

This study did measure pressure pain threshold, or level of tolerance. Majority of controlled clinical trials regarding plantar heel pain use outcome measure of a self-report pain measure or self-report perceived disability measure. Weppler has proposed the positive benefits from stretching exercises may be modifying the individual’s sensation as opposed to increasing muscle extensibility. [3] The positive results from aggressive stretching for plantar heel pain may be “it hurts so bad it feels good”. Can we achieve faster results if we avoid stretching exercises if the evidence is the first MTPJ dorsiflexion and ankle dorsiflexion are normal or loose? Arguments can occur as to what are best methods of measurement and what normal values of dorsiflexion, are, but at a minimal level of evidence compare the range of motion values to the non-symptomatic side if available.

A better outcome measure would be pain measure during observed physical performance measurement. This concept has been applied to other joints the Dynamic Weight Bearing Pain Assessment Test for Knee. [4] Saban has proposed a performance measure for individuals with plantar heel pain that can be observed. [5] Standardized, valid, reliable, efficient physical performance measures which include pain measurement during the data collection are needed for plantar heel pain and foot problems.

1. Chang R, Rodrigues PA, Van Emmerik RE, Hamill J: Multi-segment foot kinematics and ground reaction forces during gait of individuals with plantar fasciitis. J Biomech 2014, 47(11):2571-2577.
2. Sweeting D, Parish B, Hooper L, Chester R: The effectiveness of manual stretching in the treatment of plantar heel pain: a systematic review. J Foot Ankle Res 2011, 4:19.
3. Weppler CH, Magnusson SP: Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther 2010, 90(3):438-449.
4. Klokker L, Christensen R, Waehrens EE, Bandak E, Bartholdy C, Bliddal H, Henriksen M: Dynamic weight-bearing assessment of pain in knee osteoarthritis: construct validity, responsiveness, and interpretability in a research setting. Health Qual Life Outcomes 2016, 14:91.
5. Saban B, Masharawi Y: Three single leg standing tests for clinical assessment of chronic plantar heel pain syndrome: static stance, half-squat and heel rise. Physiotherapy 2016.

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