Plantar Fasciitis -Active Release Techniques (ART)

Research- manual therapy for PF:

• The 2014 American Physical Therapy Association Guidelines for Plantar Fasciitis – found strong evidence that manual therapy, exercises, taping, and night splints were effective.
• Studies in 2014 and 2007  found myofascial release of the calf and plantar fascia more effective than just conventional therapy.
• 2015 study – Myofascial Release effective in treating PF. 
• 2015 study – mob / manips are effective in increasing ankle dorsiflexion
• 2014 study compared deep calf massage plus stretching and neural mobilization to ultrasound therapy plus stretching.  Massage / neural mobilization yielded much better results.
• 2011 study – trigger point therapy plus self-stretching resulted in superior short-term outcomes as compared to a self-stretching program alone.

Research- exercises and stretches:

• Cheung 2015-

  Intrinsic foot muscle volume in experienced runners with and without chronic plantar fasciitis –

  “There was significant greater rearfoot intrinsic muscle volume in healthy runners than runners with chronic plantar fasciitis “

• 2014 study –compared high load calf raise (video) (with Windlass mechanism -extended MTP joints) exercises to plantar specific stretching.  The high load group had better results, check out the study for pictures.   
• 2014 study – eccentric training for Achilles tendon insertion pain no better than conventional therapy.
• 2014 study -windlass stretch slightly more effective than myofascial release. 
• Exercise should focus on the gastrocnemius in isolation and in combination with the soleus. A 2011 study found that the gastrocnemius is tight in 57% of PF cases, the gastroc /soleus in 26%, and 17% had normal ROM.  Take away message, don’t forget the gastroc!
• A non-weight bearing plantar fascia stretching program may be more effective than standing calf stretches.  An at-home frequent seated stretch is worth trying for PF sufferers.
• 2014 study – PNF stretching better than a control for increasing gastrocnemius flexibility. A recent study found foam rolling before static stretching to be better at increasing ROM, than foam rolling or stretching alone at the hip.  Give it a try at the ankle.
• Where the flexor digitorum brevis attaches to the calcaneus is the most common site for heel spurs, not where the plantar fascia attaches.
• Strengthening the flexor digitorum brevis (FDB) and / or the  flexor hallucis brevis may take some pressure off of the plantar fascia.   The paper grip test (fig 4) is a good way to see if the FDB is weak.

Does prolonged standing cause PF?

Maybe!

A 2015 review of the literature of the topic found,  “low-quality evidence of an association between PF and weight-bearing tasks such as walking and standing on hard surfaces”. 

Putting it all together:

A combination of the above is required to help a majority of PF cases.  The order I usually use is myofascial release and foot joint mobilizations, and at home Windlass strengthening exercises. At home foam rolling the calves followed by static stretching. Fairly quickly, I begin having the patient do high load isometric exercises progressing to isotonics (concentrics plus eccentrics).

Exercise progression:  

• foam roll calves
• PNF stretching of the gastroc and soleus
• non-weight bearing static stretching
• high load isometric calf raises
• calf lowering eccentrics (it may be better to do isotonics)
• flexor digitorum and flexor hallucis tests /exercises
• Foot tripod exercises are great to add when the patient is ready.

For more go to – Manual Therapy UK  

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