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14 Articles in Volume 21, Issue #5
Analgesics of the Future: Interleukin-17 Inhibitors for Treating Psoriatic Arthritis
Ask the PharmD: What evidence exists for metformin in treating rheumatoid arthritis pain?
Case Chat: Spasms vs. Spasticity and Muscle Relaxant Options
CDC Opioid Prescribing Guideline Updates Are in the Works: Will the Changes be Enough?
Chronic Pain Management in Marginalized Populations: How to Rebalance the Provider-Patient Relationship
Dantrolene: The Forgotten Molecule for Outpatient Spasticity
Forgotten Analgesics: The Drugs Pain Practitioners Need to Reconsider
Machine Learning Predicts Patient Response to Rheumatoid Arthritis Therapy
Perspective: Where Have All the Rheumatologists Gone?
Rheumatoid Arthritis and Bridge Therapy: Primary Care Considerations
Root Cause of Plantar Fasciitis: Three-Step Exercise Protocol
Shoulder Pain and Rotator Cuff Injuries: Emerging Treatments
Special Report: The Evolution of Rheumatoid Arthritis Treatment, from Gold to Gene Therapy
Transfer of Care: Barriers and Solutions in Chronic Pain Management

Root Cause of Plantar Fasciitis: Three-Step Exercise Protocol

A case report on the successful treatment of plantar fasciitis using simple non-invasive exercises and a night splint.

Numerous procedures performed every year to relieve plantar fasciitis are invasive and painful as it is one of the most common complaints seen in podiatry and physical therapy practices in the US and around the world.1 The author has appeared to have identified the root cause of plantar fasciitis as being tightness in the gastrocnemius/soleus muscle group and a hypomobility of the posterior joint capsule of the talocrural joint and, herein, outlines an effective three-step protocol for treating this condition. The author developed this protocol in 2012 to treat plantar fasciitis without invasive interventions while working with patients in his clinic; results are provided here.

See also, Dr. Whelton’s paper Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol

 

Plantar Fasciitis Diagnosis and Common Treatment Interventions

A diagnosis of plantar fasciitis is typically made based on history and physical exam.2 The practitioner will typically rule out any other potential conditions such as arthritis, nerve entrapment, tendonitis, or cysts before a diagnosis of plantar fasciitis is made.2 Most patients experience pain around the medial tubercle of the plantar aspect of the foot and may feel pain with palpation and/or movement and they typically report increased pain in the morning when first stepping on the foot.2 1 in 10 people will develop this condition in their lifetime, with younger male athletes and overweight middle-aged females statistically most likely to develop it.2 Ninety percent of plantar fasciitis injuries heal within 10 months using home remedies or conservative treatment aiming to relieve pain and restore normal function.2  Some of these remedies include night splints, anti-inflammatory medications, orthotics, resting the foot, and stretching.2 Without some change in activity level or other intervention plantar fasciitis is unlikely to go away on its own.2

 

3-Step Exercise Protocol for Treating Plantar Fasciitis

Methods

Varying exercises are used to treat plantar fasciitis. The protocol developed by the author (described below) consists of:

  • two stretches
  • a joint mobilization technique
  • nightly use of a night splint

Examination of twelve plantar fasciitis patients were included in this study; 5 of the 12 patients were diagnosed with plantar fasciitis in both feet, making 17 cases treated in all. All 12 patients were fully informed of treatment to be rendered and safety of the approach. Most of the patients had failed several forms of conservative and invasive treatments; some were recommended to have surgery. All 12 patients were found to have a hypomobility of the posterior joint capsule of the talocrural joint and tight/restricted gastrocnemius and soleus muscles. The patients were placed on the following protocol and all achieved full active ankle range of motion and normal mobility of the posterior capsule of the talocrural joint. All 12 patients experienced total elimination of plantar fasciitis symptoms using this protocol within 13 weeks, while 11 out of the 12 were pain free in 7 weeks. They experienced no pain while walking and returned to normal activities without any reports of pain or discomfort. Each of the patients were instructed to rest during the treatment course, no extraneous activity, and to stay off their feet as much as possible to allow for the plantar fascia to heal.3 They also were instructed to wear a plantar fasciitis night splint/boot while sleeping to allow the plantar fascia to heal in a lengthened position.4 The patients were instructed to perform the following protocol in a pain-free range of motion 2 to 3 times a day until symptoms were eliminated. All 12 patients were instructed to not put themselves in pain while performing the exercises to avoid further injury to the plantar fascia.

Leverage, positioning, and force are paramount with the Mulligan™ technique as significant force is required to stretch the posterior capsule with a bicycle inner tube. The method is based on a mobilization with movement principle to stretch tissue throughout an entire joint range of motion versus a sustained joint mobilization.5 The stretch cannot be achieved with a high degree of consistency without an inner tube and Mulligan technique.56 (The Mulligan Manual Therapy Concept was developed by physical therapist Brian Mulligan, and has been used by orthopedic practitioners for several decades throughout the world; the author attained permission from Mulligan to depict the ankle mobilization technique.)

Responsibility for all 12 patients in the study to purchase the bicycle inner tubes was their own. The patients were instructed on how to place the inner tube just above calcaneus bone and perform knee flexion with the heel on the ground. The tube was anchored around a bedpost or kitchen table. The mobilization, performed in this way, allowed the tibia to translate anteriorly on the calcaneus stretching the posterior capsule of the talocrural joint.  Figures 1-4 demonstrate the following stretches:

  • Gastrocnemius stretch (heel on the ground with knee straight) 3 x 30 seconds, 2 to 3 times a day
  • Soleus stretch (heel on the ground with knee slightly bent) 3 x 30 seconds, 2 to 3 times a day
  • Mulligan Self Mobilization Posterior Capsule Technique with bicycle inner tube, keep heel on ground and slightly bend the knee and then straighten the knee 90 reps, 2 to 3 times a day6

Figure 1. Gastrocnemius stretch. Figure 2. Soleus stretch.Figure 3. Mulligan posterior capsule stretch (knee slightly bent heel on ground). Figure 4. Mulligan posterior capsule stretch (knee straight heel on ground).

 

Results

Of the 12 patients that participated in the study, all 12 patients were able to achieve between 10 and 12 degrees of active dorsiflexion and normal posterior capsule joint mobility. Normal accepted dorsiflexion range of motion is between 0 and 20 degrees.All 12 patients had significantly diminished dorsiflexion upon evaluation as seen in Table I. Five of the 12 patients had plantar fasciitis in both feet making 17 cases of plantar fasciitis treated with this protocol for purposes of this study. All patients were followed up for several months after treatment and one was followed up 5 years after treatment. All 12 reported no pain or restriction in activity. All 12 patients also reported being able to complete all activities and independent activities of daily living without any complaints of pain.

View Table I as a PDF.

 

Plantar Fasciitis Treatment Protocol: Discussion and Practical Takeaways

One of the reasons people suffer from chronic plantar fasciitis is lack of understanding as to what causes this painful condition, which may lead to invasive and painful treatments that do not address the root cause. Obtaining active dorsiflexion of 10 to 12 degrees was found to be the therapeutic muscle length of the calf muscles and therefore must be attained along with normal joint mobility of the posterior capsule of the talocrural joint. Also, to note, is the level of restriction of the posterior capsule was found to be directly proportional to the level of pain and length of recovery period. The majority of patients reported immediate relief of pain after performing the Mulligan technique. It is crucial for the patient to rest and not stress the plantar fascia during the treatment course and wear the night splint every night to allow for proper healing.4 This protocol should be used as a first-line treatment for plantar fasciitis of all severities regardless of what the patient has tried before. The author has successfully used this protocol in his practice for the past 10 years on plantar fasciitis, shin splints, anterior tibialis tendonitis, and Achilles tendonitis patients as the author has identified the same imbalance that causes these conditions. The author has enjoyed the same success rate with all four conditions using this protocol. The author has also been successful in treating Sever’s disease and some lateral ankle conditions with this protocol as well. The night splint is necessary for the treatment of plantar fasciitis, however, the author does not use the night splint when treating shin splints, anterior tibialis tendonitis, Achilles tendonitis, or Sever’s disease. For these conditions the author only prescribes the gastrocnemius and soleus stretches as well as the Mulligan technique. In very rare cases with serious foot deformities, an orthotic may be necessary especially with shin splints in a hyper-pronated foot to mitigate the stress placed on the posterior tibialis tendon. This protocol should be done until the pain is eliminated. 

 

Conclusion

Treatments that are common for plantar fasciitis can be painful and invasive.8 The author contends that plantar fasciitis should be managed conservatively before any invasive procedure is used, recommending the three-step exercise protocol described herein. Once an invasive surgery is performed and anatomy is altered, resolution of symptoms may not be possible. As described, plantar fasciitis in 12 patients was found to be caused by a tight/restricted gastrocnemius and soleus muscles as well as a hypomobile posterior capsule of the talocrural joint. Seventeen plantar fasciitis cases in these 12 patients were successfully treated with simple noninvasive exercises. The patients also used a night splint and were required to rest during the treatment course. This protocol should be the first line of defense for plantar fasciitis.

The author would like to thank Mulligan™ for allowing the use of Mulligan technique to be depicted in this paper. The author has no financial ties to the company.

Last updated on: September 8, 2021
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Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
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