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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE January 2022 Examining the Necessity of Prescribing Joint Mobilization for Plantar Fasciitis by Rachele Jones, PTA, ATC, CAFS Clinical Scenario...What would you do? A 58 yr old male developed gradual onset of R plantar foot and heel pain over the course of 2+ months while continuing to participate in 3mi distance running BIW-TIW, which he’s done for the last six years. He also has mild+ R knee OA that is painful but not preventing him from running. He’s tried OTC arch supports without relief. Plain films are WNL. Tenderness locally at the calcaneal tuberosity plantar fascia insertion and along the medial band of fibers into the longitudinal arch. MTP extension is WNL. NWB ankle DF is WNL both knee flexed and extended. He does have R early heel rise with (B) squat testing. A quick balance assessment shows asymmetric overpronation on his L foot. His morning sx upon 1st wb and local tenderness suggest plantar fasciitis/fasciosis. My clinical thinking is: A. Recommend two visits of Physical Therapy for HEP instruction in simple traditional protocol of stretching the plantar fascia/calf muscles. B. Prescribe a course of NSAID’s and then if not better in 4 wks consider steroid injection. C. Order a night splint to stretch out the plantar fascia. Follow up in 3-4 wks to reassess. D. Prescribe PT Eval/Treat (including Laser, manual therapy as needed, functional strengthening and dynamic balance work) . E. Obtain further diagnostic studies (either diagnostic US or an MRI). CURRENT EVIDENCE Anat Shashua et al, The Effect of Additional Ankle and Midfoot Mobilizations on Plantar Fasciitis: A Randomized Controlled Trial. Journal of Orthopedic & Sports Physical Therapy 45:4, 2015 265- 272. https://www.jospt.org/doi/full/10.2519/jospt.2015.5155?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Plantar fasciitis, or fasciosis as it is more accurately often referred, is a common condition causing heel/arch-foot pain seen by physicians and physical therapists. Determining appropriate referral practices is dependent on evidence based findings. Plantar fascitis(PF) is commonly treated with stretching based approaches, including joint mobilization techniques, however, clinically we more commonly find overpronation issues as a contributing factor, resulting in “overstretch” of the tissue rather than abnormal local fascial tightness in the foot. Dorsiflexion loss is thought to be one of the kinetic chain issues that might underlie PF. This single blinded RCT examined the addition of a standard set of ankle-foot mobilizations to a routine stretching + ultrasound treatment to determine efficacy of joint mobilizations. While subjects in either group who had limited dorsiflexion showed (+) gains from joint mobilizations, the intervention group did not show improved outcomes on self-report foot scales or algometry or overall group improvements in WB DF ROM. We feel this study cannot be used as a basis to disclude foot-ankle mobilizations from high quality care of PF cases due to heterogeneity of the groups regarding tissue healing phase and limited number of cases with noted DF (or other) ankle ROM and a lack of clarity in maintaining STJ neutral positioning that is authentic to late stance biomechanics demands during testing, stretches, and mobilizations in order to control for compensatory overpronation. Mobilizations should not be assessed in isolation because clinically any gains in ROM should be immediately followed by proprioceptive/strengthening exercises to integrate new mobility into function. Also, the limited BIW x 4 wks treatment time was potentially inadequate for the wide range of chronicity in the sample, ranging from 1 month to 24 months. Physicians should expect high quality physical therapy include specific matching of applied mobilization techniques to joints tested to have limited ROM. This study’s conclusion more accurately should indicate that limited simple joint mobilization techniques applied to cases of PF both with and without proven joint restrictions do not demonstrate group benefits over simple stretching and ultrasound alone. Background: Plantar fasciitis (PF) is a chronic degenerative process to the plantar fascia, better referred to as fasciosis, which affects approximately 10% of people in their lifetime. Ankle dorsiflexion limitations is thought to be a common contributing factor to the development of plantar fascia. Methods: Randomized controlled trial using 50 participants (23-73 yr) who had heel pain generated by pressure, increased pain of 3+ on the NPRS scale in the morning with first few steps or after prolonged non-weight bearing, diagnosed with PF. All participants received 8 treatments at BIW frequency including a stretching program and ultrasound. The intervention group also received manual therapy mobilizations of the ankle and midfoot joints. Primary measures were from three outcomes: numeric pain rating scale (NPRS), Lower Extremity Functional Scale ( LEFS) and algometry. Dorsiflexion was measured twice at the beginning and the end of treatment. Participants were evaluated at baseline, after 4 sessions, end of treatment ( 4 weeks) and a 6 week follow-up via telephone for NPRS and LEFS but only twice for algometry and dorsiflexion ROM were measured at baseline and at end of treatments. Findings: No significant differences in finding between groups and outcomes. Both groups showed significant differences in NPRS and LEFS and improved dorsiflexion ROM. All data analysis was conducted using the intention-to-treat approach. Author's Conclusion: Results suggest that the addition of manual joint mobilizations of the ankle and foot to improve dorsiflexion ROM is not any more effective than stretching and ultrasound alone. The association between limited DF and plantar fascia is most probably due to soft tissue limitations vs joint restriction. THE PEAK PERFORMANCE PERSPECTIVE Physicians deciding on best practices for the care of their patients with Plantar Fascitis (PF) often must discern both whether Physical Therapy will be ordered but also more specifically appreciate what appropriate treatments will be included in what they might expect to be “excellent” care. Joint mobilizations are commonly incorporated in physical therapy treatments. The question at hand is whether patients with plantar fascitis will benefit from and if appropriate physical therapy care “should” include joint mobilizations. This study by Shashau et al had good intentions and measuring properties but in the long run does not completely support the authors’ conclusion that ankle/midfoot mobilization therapy is not effective for plantar fascitis. First, some key foundational questions physicians and therapists alike must ask are… “Does everyone who has heel pain/ plantar fasciitis have DF restrictions and need ankle and foot mobilizations?” and “Is there a ‘protocol’ - like treatment plan that works well for all plantar fasciitis cases regardless of being acute or chronic or regardless of underlying patient-specific causes?” Let’s begin with the general question/concept of PF that we see first clinically - plantar fasciitis cases generally fall into two groups: excessive PF tightness (supinated or high arched foot) related and excessive lengthening (ie often overpronation) related. In our experience we tend to see more cases involving overstretch mechanism related, oftentimes due to overpronation. Interestingly, most PF “protocols” tend toward treating this as a “PF tightness” problem and focus on further stretching the connective tissue and related muscles. Many “failed PT” cases we see with PF diagnosis have overpronated feet (and overstretched plantar fascia) that were treated with stretching exercises for the plantar fascia. If, as we often see in the clinic, a patient demonstrates considerable or asymmetric overpronation on dynamic testing (ie mini squats balancing, rotational balancing, lunge testing, impact hop testing) that is associated with the plantar fascia being overly lengthened. If the overload is stretch or length that traumatized and irritated the tissue in the first place then why would more stretching be the treatment? On the other hand, if a patient has a high arched foot or compensatory supination (often due to a forefoot valgus or plantarflexed first ray) then that plantar fascia is typically short/tight and the rigors of ADL, or especially athletics, can place more lengthening demand on that foot to comply with change of direction or pronation force dampening (ie shock absorption) than the tissue can accommodate to…leading to stress and eventual pain. Those feet certainly need stretching exercises to improve that foot’s adaptability to shock absorption needs. So, right from the start we find this study’s premise a bit to overgeneralized. This is common in many studies, connecting a diagnosis with a singular potential causative factor. This, of course, leads to underwhelming statistical findings because the group is too heterogeneous if actually there are multiple contributing factors. That seems to be the case here as well. This study provided joint mobilizations to everyone in the intervention/experimental group whether they needed it or not. The groups were not matched regarding DF ROM status nor split based on DF loss. Manual therapy joint mobilization techniques in the real-world clinic setting are used (or should only be used) when a significant limitation of normal motion exists that is determined to be both contributing to the condition/symptoms and is likely joint based rather than merely soft tissue based. This is a key shortcoming to Shashua et al’s study, in that it was not powered based on finding enough participants with defined DF ROM loss where the use of mobilization vs no mobilization could be examined specifically. Certainly, performing mobilizations on a patient with plantar fascitis who has no DF loss would not be expected to produce superior outcomes. Clinically speaking, it is necessary to examine each person’s foot-ankle ROM and biomechanics individually to see where the limitations are and address those limitations specifically. In this study they generically applied joint mobilizations unrelated to any particular deficit or need. In terms of joint functional biomechanics and musculoskeletal conditions, while limited dorsiflexion has been identified as being an intrinsic factor potentially contributing to plantar fasciitis this cannot be viewed as a direct “causal” relationship. All people with plantar fasciitis do not have dorsiflexion limitations. As is true with most orthopedic conditions, we see the literature evidence base pointing to “multifactorial” underlying causes rather than singular “if then, therefore” type relationships. The compensations that a lack of DF may cause could include early heel rise or overpronation, both of which would lead to abnormal loading of the plantar fascia. We believe this study design leads to the results not truly reflecting the efficacy of adding joint mobilizations with PF conditions because both the control and intervention groups both contained some patients who “lacked” normal dorsiflexion - they were too heterogeneous. And, their definition of less than 350 being a deficit does not jive clinically with what we see. That seems to be a high threshold for normal dorsiflexion. Typically we see normal WB dorsiflexion in the 25-300 ranges. The patients in this study had inclinometer values of 39.68 to 41.80 with standard deviations in the control group of + 5.99 - 6.140 and intervention group of 8.96 -9.630 - hardly substantial deficits compared to our real-world experiences. So, there were fewer patients with significant DF loss available for comparison of the mobilization treatment efficacy. There is a chance also that by performing the mobilizations to everyone in the intervention group that it could have made them hypermobile, potentially leading to greater stresses. Remember that dorsiflexion mob’s were not the only type - treatment also included subtalar joint (STJ) inversion and eversion mobilizations along with midtarsal joint (MTJ) inversion and eversion. Forefoot inversion is associated with a WB overpronated foot and forefoot eversion is associated with a supinated or high arched foot in WB at the MTJ. No measurement or assessment of each patient’s MTJ function was mentioned. The generic application of all possible mobilizations to the entire group again waters down the ability to truly discern whether the mobilizations, properly applied ONLY to the sites and directions where both limitations exist AND biomechanical kinetic chain understandings can “connect the dots” to PF overload was effective or not. Yet in this study they did mobilizations in both directions to the STJ and MTJ without regard for specific needs. The study did utilize several different hands-on techniques,some of which we use here in the clinic. But, both their WB testing (another issue that lowers the strength of their findings and conclusion) and mobilizations do not specify any attempt to control for STJ positioning. The STJ has returned to neutral or actually slightly inverted just prior to heel rise when maximum dorsiflexion is needed. During testing, stretches, and mobilizations if the STJ is allowed to be everted (foot pronating) then the “path of least resistance” for functional dorsiflexion in walking and running can be habituated into overpronation and therefore overstretch the plantar fascia in late stance phase. Though they did include mobilizations in WB position for dorsiflexion as well there wasn’t any specific attention given to the STJ positioning in the addendum notes. This potential lack of control of and variability of the foot position certainly impacts the expected reliability of measurements between three PT’s but also disregards the functional gait mechanics the dorsiflexion specifically relates to. We find many patients “know” the typical soleus and gastroc stretches associated with improving dorsiflexion mobility but too often were not instructed in that specific STJ positioning desired for normal gait mechanics and forces. One treatment aspect that cannot be forgotten is that anytime mobilization or stretching is done it is necessary to supplement with appropriate strengthening exercises. Their focus was only on ROM (which may not have been warranted since most were measuring at >300) - the risk then is that ROM is gained without concurrent muscular control, leading to essential functional instability that increases local tissue strain and even downstream injury/inflammation. All gained motion must simultaneously be controlled. To discuss or make conclusions regarding the efficacy of joint mobilizations in isolation, not accompanied by functional strengthening, is a bit misleading because clinically we would never produce improved ROM without stimulating the proprioceptive system to control that new range for optimal ADL or work demand or athletic uses. We would submit that producing increased ROM without strength actually can be deleterious. High quality Physical Therapy for PF should include examining the kinetic chain with an appreciation for authentic function and biomechanics, at minimum testing the nearest proximal and distal joints surrounding the injured tissue for ROM limitations and strength deficiencies. Only then can a therapist develop a program to safely and effectively address those issues. Another important variable in researching the treatment of any dysfunction/ailment is the stage of the tissue irritability and healing phases - whether it is acute or chronic. The subjects in this study had symptoms ranging from 1 month to 2 years, a very large range and diverse group. While there is no clear clinical threshold for defining a PF case as being and “-itis” vs and “-osis” condition the treatment approach for a 1-2 month old recent onset versus a certainly 12-24 month old case may be different. This adds to the heterogeneity of the group. While that may form a more “real-world” sample it also waters down the ability to discern specific treatment approaches if they might not typically applied to that tissue irritability stage. This study used a global and generalized approach without regard to tissue healing phase/stage. That leads to the question also as to whether four weeks was an adequate time to expect substantial change. Especially cases that were 12-24 months old may require greater treatment time to see results compared to someone in the acute phase where tissues are more likely to “bounce back faster” and the recurring scarring from microtears and habitual compensations due to pain have had less time to occur. The following is a case of an older runner who developed problematic heel and plantar foot pain that prevented running and normal painfree ADL. THE PEAK PERFORMANCE EXPERIENCE Dennis says, “I’m walking 2-3 miles now with essentially no or only very min symptoms -- - feeling encouraged!” Hx: 68 yo active male developed left heel pain in mid July after running 3.5 miles 4x/wk, increasing over time to 6/10 NPRS and so the patient had to discontinue running. Other activities impacted include: walking, hiking, jogging, and some ladder climbing with work. Subjective: Pt reports immediate pain 5/10 with jogging, walking longer than five minutes, and stair/ ladder negotiation. Objective: Medial heel and plantar fascia attachment on calcaneal tuberosity tender along with fifth metatarsal, increased NWB L foot forefoot valgus, symptoms worse in the morning. Pt self reports 50% function with a Foot and ankle disability index score (FADI) of 61% function and FADI Sport Module at 28% function. * indicates pain Initial Eval Re- Eval (6wks Dec ) Foot and ankle disability index score (FADI) 61% 63% FADI Sport Module 28 % 31% WB Dorsiflexion (squat , STJ neutral) ROM (L/R) 200/300 260/300 NWB Dorsiflexion DF ( knee flexed) ROM ( L /R) 50/120 200/200 NWB DF knee ext ( L/R) 180/200 200/NT Calcaneal Eversion (L/R) 40/ 80 40/80 Opp Ant toe reach 60units x 15sec 10# wts NT 6.5x / 8x WB Hip extension ROM Moderate limitation (B) WB Hip flex ROM (L /R) 530/ 700 530/ NT Hip Internal Rotation ( prone L/R ) 360/450 450/450 SLB Rot Pronation control ( L /R ) < 5 sec (Poor, avoids pron) / 8 sec (Fair) NT PF reps FWB (L/R) L * 10# 31*x/ 30x Key Findings: L poor pronation control with single leg balance, decreased ROM in calcaneal eversion & DF w/ knee flex and ext, and limited hip mobility. Treatment: Manual mobilizations to (NWB and WB) ankle and (NWB) forefoot for increased DF ROM and forefootinversion. PROM/stretches to increase left soleus/gastrocnemius, and triplanar hip mobility ( psoas, hamstring, IR ). PRE’s for gastrocnemius, supinators of the foot and dynamic balance work for pronation control. Use of modalities for symptoms control and inflammation reduction - use of ultrasound and CLASS IV LASER. Twelve weeks into the program… progressed from a strength based program to a more functional impact and speed day for better preparation for patients goals of returning to running. Formal ReEval upcoming. Outcome: Pt continues to improve with reduction of pain sx’s, increased function, increased strength and ROM and has progressed to impact training and a “speed day” 1 out of 3 d/wk which includes specific deceleration/acceleration based exercises. The pt started the progression of a walk/jog program BIW - - - -> TIW. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com