The Latest Systematic Review and Meta-Analysis Plantar Fasciosis: What Works
Researchers from universities in Brazil recently provided a systematic review and meta-analysis, offering increasing insight into what works for plantar fasciosis.1 Plantar
Plantar fasciosis (also known as plantar fasciitis) is a common and sometimes disabling source of heel pain.2 Despite being occasionally described as self-limiting, one in five cases remains symptomatic after a year. Additionally, high recurrence rates have been reported.3,4 Most cases that present to primary care are already chronic and not good candidates for a wait-and-see approach. Patients may average as much as eight months of symptoms before seeking medical attention. Prescribing wait-and-see on top of this has been linked with poorer clinical outcomes and a mistaken belief among pa-tients that healthcare has little to offer.5
Histopathological studies reveal that this pain does not involve inflammation. Rather, the pain stems from a chronic degenerative process and an overloaded healing response.6 It is well established that stretching programs can be effective in the management of plantar fascio-sis. While other conservative treatments show promise, research is ongoing regarding how and if they should be combined. This is the focus of the current systematic review and meta-analysis by Stachelski et al. Their ap-proach focused on stretching, strengthening, and promising electrical modalities, including therapeutic ultrasound, low-level laser, extra-corporeal shock wave, and low-frequency electrical stimulation. Stretching and strength-ening are discussed both separately and collectively under the term 'therapeutic exer-cise.'
Though heterogeneous, the data allowed for some meta-analysis, yielding the following conclusions:
- In reducing pain, therapeutic exercise has been better than therapeutic exercise plus these modalities.
- In reducing pain, extracorporeal shockwave plus exercise demonstrated no advantage over exercise alone.
- In improving function, exercise plus modali-ties showed a moderate advantage over exercise alone
- In systematic review, the conclusions of previ-ous studies add to the understanding of the meta-analysis.
- Strengthening and stretching both proved individually effective. This provides encour-agement for treatment plans that include both.
- In pain reduction, exercise proved equiva-lent to dexamethasone injection, leading to a preference for exercise as the first-line treatment, due to the preferable safety profile.
- While the meta-analysis provides caution over adding modalities to exercise in gen-eral, some specific modalities stood out as potentially advantageous in systematic review. For instance, therapeutic ultrasound was a likely top contributor to the improve-ment in function observed in the meta-analysis.
One limitation of this study was that therapeu-tic exercise was often delivered as self-care. However, a systematic review by Almubarak et al. finds that programs supervised by a physiotherapist achieve better results than programs that patients conducted inde-pendently.7 In future research, differentiating professionally supervised therapeutic exercise from self-care can further elucidate the most efficient path toward conservative therapy success.
References
1. Stachelski RA, Torrilhas B, Camboin FF, de Lima DF, Donin CB, Flor Bertolini GR, Buzanello MR. Therapeutic Exercise in Plantar Fasciitis: A Systematic Review with Meta-Analysis. Muscles, Liga-ments and Tendons Journal. 2024 Jan 1;14(1):29-45.
2. Trojian T, Tucker AK. Plantar fasciitis. American Family Physician. 2019 Jun 15;99(12):744-50.
3. Ramamoorthy EN, Daniels JM, Kukkar N. Challenges in Diagnosis of Plantar Fasciosis (Fasciitis). Ann Sports Med Res. 2016;3(7):1086.
4. Carcia CR, Martin RL, Houck J, Wukich DK, Altman RD, Curwin S, Delitto A, DeWitt J, Fearon H, Ferland A, MacDermid J. Achilles pain, stiffness, and muscle power deficits: achilles tendinitis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2010 Sep;40(9):A1-26.
5. Orchard J. Plantar fasciitis. BMJ. 2012; 345: e6603.
6. Ramamoorthy EN, Daniels JM, Kukkar N. Challenges in Diagnosis of Plantar Fasciosis (Fasciitis). Ann Sports Med Res. 2016;3(7):1086.
7. Almubarak AA, Foster N. Exercise therapy for plantar heel pain: A systematic review. Interna-tional Journal of Exercise Science. 2012;5(3):9.