New Treatment Advice for Plantar Fasciitis
If you suffer from heel pain as a result of plantar fasciitis, you are not alone. An estimated two million adults in the United States experience significant heel pain every year. And over time, at least one in 10 Americans will report this common foot pain problem.

The problem may be more aptly named by calling it "plantar heel pain" because studies show there is no active inflammatory component. The tissue quit trying to self-repair long ago. Sharp pain without swelling, heat, or other signs of inflammation is the only symptom. But that pain can be very disabling affecting quality of life.

The standard treatment for plantar fasciitis includes actively stretching the gastrocnemius and soleus (calf) muscles and passively stretching the plantar fascia (connective tissue along the bottom of the foot). Other conservative measures often used include medications and steroid injections. In severe cases that don't respond to nonoperative treatment, surgery may be an option.

In this study, physical therapists from Brazil compare the use of stretching alone with a program of manual therapy combined with stretching. In this instance, manual therapy refers to the release of trigger points in the calf. This technique is done by the therapist's hands directly over the calf muscles and applying pressure and then light stroking to the soft tissue structures.

Trigger points are irritable areas in the muscle. The area becomes tight and stiff keeping the muscle from moving (and stretching) normally. It's that stiffness that these researchers thought might respond better to manual therapy along with stretching.

Stretching alone doesn't always stop the pain or alleviate the problem. In theory, until the trigger point has been released, the heel pain will continue (or come back as soon as the stretching stops).

The groups were randomly assigned to the two treatment groups. Group one performed stretching exercises prescribed by the physical therapist. Group two were actively treated with manual therapy by the therapist and then did the same stretching program as group one.

Everyone came to the physical therapy clinic four times each week for a month. At the beginning and end of treatment (i.e., four weeks later), patient levels of pain, function, and pressure pain thresholds (PPTs) were measured.

As the name suggests, pressure pain threshold is the amount of pressure applied to the heel needed to create a painful response. A special device called a mechanical pressure algometer was used to take this measurement.

Results showed greater improvement in all measures for the manual therapy plus stretching group. Patients in both groups got better but the manual therapy group had statistically significant improvements over the stretching only group.

The conclusion is that stretching is good but stretching with a little hands-on work is yields much better results. The exact mechanism by which this works isn't known. It could be that trigger point therapy as described here decreases pressure pain sensitivity. Perhaps it turns off a reflex that is triggering muscle tightness so that the stretching becomes more effective.

The next step for the researchers is to follow patients long-term to see if the effects last beyond the short-term period (four weeks) of this study. Additional study is recommended to see if there are better ways of doing the manual therapy that might be more effective.

This could include comparing Swedish massage, friction massage, myofascial release, acupressure, and other similar techniques with the manual therapy described in this study. Since we don't know if other types of touch (just placing the hands over the tissue) might also work well, this might be another technique included in the comparisons.
RĂ´mulo Renan-Ordine, PT, DO, et al. Effectiveness of Myofascial Trigger Point Manual Therapy Combined with a Self-Stretching Protocol for the Management of Plantar Heel Pain: A Randomized Controlled Trial. In Journal of Orthopaedic & Sports Physical Therapy. February 2011. Vol. 41. No. 2. Pp.43-51.