Jospt 2008 0302

Clinical Guidelines
THOMAS G. MCPOIL, PT, PhD HE8HEOB$C7HJ?D"PT, PhDC7HAM$9EHDM7BB" PT, PhD

:7D;A$MKA?9>"MD@7C;I@$?HH=7D=PT, PhD@EI;F>@$=E:=;I"DPT
Heel Pain—Plantar Fasciitis:

Clinical Practice Guidelines
Linked to the International Classification
Downloaded from www.jospt.org at on February 22, 2023. For personal use only. No other uses without permission.
of Function, Disability, and Health from

the Orthopaedic Section of the
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
American Physical Therapy Association

J Orthop Sports Phys Ther. 2008:38(4):A1-A18. doi:10.2519/jospt.2008.0302
RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
Journal of Orthopaedic & Sports Physical Therapy®
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
CLINICAL GUIDELINES:
Impairment Function-Based Diagnosis . . . . . . . . . . . . . . . . . . . A4
Examinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A8
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A11
SUMMARY OF RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A16
AUTHOR/REVIEWER AFFILIATIONS & CONTACTS . . . . . . . . . . A17
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A17
H;L?;M;HI0Anthony Delitto, PT, PhDJohn Dewitt":FJAmanda Ferland":FJHelene Fearon, PT

Joy MacDermid, PT, PhDPhilip McClure, PT, PhDPaul Shekelle, MD, PhDA. Russell Smith, Jr., PT, EdDLeslie Torburn, PT
For author, coordinator, and reviewer affiliations see end of text. ©2008 Orthopaedic Section, American Physical Therapy Association (APTA), Inc, and the Journal of
Orthopaedic & Sports Physical Therapy. The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to the photocopying of
this guideline for educational purposes. Address correspondence to Joseph J. Godges, DPT, ICF Practice Guidelines Coordinator, Orthopaedic Section APTA, Inc,
2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: icf@orthopt.org
journal of orthopaedic & sports physical therapy | volume 37 | number 1 | january 2007 | a1
H e e l Pa i n — P l a n t a r Fa s c i i t i s : A C l i n i c a l P r a c t i c e G u i d e l i n e
Recommendations*
F7J>E7D7JEC?97B<;7JKH;I0 Clinicians should assess for ;N7C?D7J?EDÆ79J?L?JOB?C?J7J?EDC;7IKH;I0 Clinicians should

impairments in muscles, tendons, and nerves, as well as the utilize easily reproducible activity limitation and participation
plantar fascia, when a patient presents with heel pain. (Recom- restriction measures associated with the patient’s heel pain/
mendation based on expert opinion.) plantar fasciitis to assess the changes in level of function over
the episode of care. (Recommendation based on expert opinion.)
H?IA<79JEHI0 Clinicians should consider limited ankle dorsi-
flexion range of motion and a high body mass index in nonath- ?DJ;HL;DJ?EDIÆCE:7B?J?;I0 Dexamethasone 0.4% or acetic
letic populations as predisposing factors for the development of acid 5% delivered via iontophoresis can be used to provide
heel pain/plantar fasciitis. (Recommendation based on moder- short-term (2 to 4 weeks) pain relief and improved function.
ate evidence.) (Recommendation based on moderate evidence.)
:?7=DEI?I%9B7II?<?97J?ED0 Pain in the plantar medial heel ?DJ;HL;DJ?EDIÆC7DK7BJ>;H7FO0Ma^k^blfbgbfZeôb]^g\^

region; most noticeable with initial steps after a period of inac- to support the use of manual therapy and nerve mobilization
tivity but also worse following prolonged weight bearing; and procedures to provide short-term (1 to 3 months) pain relief and
often precipitated by a recent increase in weight-bearing activ- improved function. Suggested manual therapy procedures in-
ity are useful clinical findings for classifying a patient with heel \en]^mZeh\knkZechbgmihlm^kbhkèb]^%ln[mZeZkchbgmeZm^kZeèb]^%
pain into the International Statistical Classification of Diseases Zgm^kbhkZg]ihlm^kbhkèb]^lh_ma^ÖklmmZklhf^mZmZklZechbgm%
and Related Health Problems (ICD) category of plantar fasciitis ln[mZeZkchbgm]blmkZ\mbhgfZgbineZmbhg%lh_mmblln^fh[bebsZ-
and the associated International Classification of Functioning, tion near potential nerve entrapment sites, and passive neural
Disability, and Health (ICF) impairment-based category of heel mobilization procedures. (Recommendation based on theoreti-
pain (b28015, Pain in lower limb; b2804, Radiating pain in a cal/foundational evidence.)
segment or region).
?DJ;HL;DJ?EDIÆIJH;J9>?D=0 Calf muscle and/or plantar fas-
In addition, the following physical examination measures may cia-specific stretching can be used to provide short-term (2-4
be useful in classifying a patient with heel pain into the ICD months) pain relief and improvement in calf muscle flexibility.
category of plantar fasciitis and the associated ICF impair- Ma^]hlZ`^_hk\Ze_lmk^m\abg`\Zg[^^bma^k,mbf^lZ]Zrhk+
ment-based category of heel pain. (Recommendation based on times a day utilizing either a sustained (3 minutes) or intermit-
moderate evidence.) tent (20 seconds) stretching time, as neither dosage produced a
IZeiZmbhgh_maîkhqbfZeieZgmZk_Zl\bZbgl^kmbhg better effect. (Recommendation based on moderate evidence.)

:\mbo^Zg]iZllbo^mZeh\knkZechbgm]hklb×^qbhgkZg`^
of motion ?DJ;HL;DJ?EDIÆJ7F?D=0 Calcaneal or low-Dye taping can be
Ma^mZklZemnggêlrg]khf^m^lm used to provide short-term (7-10 days) pain relief. Studies indi-
Ma^pbg]eZllm^lm cate that taping does cause improvements in function. (Recom-
Maêhg`bmn]bgZeZk\aZgè^ mendation based on weak evidence.)
:?<<;H;DJ?7B:?7=DEI?I0 Clinicians should consider diagnostic ?DJ;HL;DJ?EDIÆEHJ>EJ?9:;L?9;I0 Prefabricated or custom

classifications other than heel pain/plantar fasciitis when the foot orthoses can be used to provide short-term (3 months) re-
patient’s reported activity limitations or impairments of body ]n\mbhgbgiZbgZg]bfikho^f^gmbg_ng\mbhg'Ma^k^Zii^Zkmh
function and structure are not consistent with those presented be no differences in the amount of pain reduction or improved
in the diagnosis/classification section of this guideline, or, when function created by custom foot orthoses in comparison to pre-
the patient’s symptoms are not resolving with interventions _Z[kb\Zm^]hkmahl^l'Ma^k^bl\nkk^gmerghôb]^g\^mhlniihkm
aimed at normalization of the patient’s physical impairments. the use of prefabricated or custom foot orthoses for long-term (1
(Recommendation based on expert opinion.) year) pain management or function improvement. (Recommen-
dation based on strong evidence.)
;N7C?D7J?EDÆEKJ9EC;C;7IKH;I0 Clinicians should use
validated self-report questionnaires, such as the Foot Function ?DJ;HL;DJ?EDIÆD?=>JIFB?DJI0 Night splints should be consid-
Index (FFI), Foot Health Status Questionnaire (FHSQ), or the ered as an intervention for patients with symptoms greater than
?hhmZg]:gde^:[bebmrF^Zlnk^!?::F"%[^_hk^Zg]Z_m^kbgm^k- /fhgmalbg]nkZmbhg'Ma^]^lbk^]e^g`mah_mbf^_hkp^Zkbg`
ventions intended to alleviate the impairments of body function ma^gbàmliebgmbl*mh,fhgmal'Ma^mri^h_gbàmliebgmnl^]
and structure, activity limitations, and participation restrictions (ie, posterior, anterior, sock-type) does not appear to affect the
associated with heel pain/plantar fasciitis. Physical therapists outcome. (Recommendation based on moderate evidence.)
lahne]\hglb]^kf^Zlnkbg`\aZg`^ho^kmbf^nlbg`ma^?::F
as it has been validated in a physical therapy practice setting. *These recommendations and clinical practice guidelines are based on the scientific
(Recommendation based on strong evidence.) literature published prior to May 2007.
a2 | april 2008 | number 4 | volume 38 | journal of orthopaedic & sports physical therapy
H e e l Pa i n — P l a n t a r Fa s c i i t i s : C l i n i c a l P r a c t i c e G u i d e l i n e s
Introduction
7?CE<J>;=K?:;B?D; Ikhob]^Z]^l\kbimbhgmhiheb\rfZd^kl%nlbg`bgm^kgZmbhgZeer
Ma^HkmahiZ^]b\L^\mbhgh_ma^:f^kb\ZgIarlb\ZeMa^kZir:l- accepted terminology, of the practice of orthopaedic physi-
lh\bZmbhg!:IM:"aZlZghg`hbg`^ühkmmh\k^Zm^ôb]^g\^&[Zl^] cal therapists
practice guidelines for orthopaedic physical therapy manage-
ment of patients with musculoskeletal impairments described Ikhob]^bg_hkfZmbhg_hkiZr^klZg]\eZbflkôb^p^klk^`Zk]-
bgma^Phke]A^ZemaHk`ZgbsZmbhgÍlBgm^kgZmbhgZe<eZllbÖ\Zmbhg ing the practice of orthopaedic physical therapy for common
of Functioning, Disability, and Health (ICF).22 musculoskeletal conditions
Maînkihl^lh_ma^l^\ebgb\Ze`nb]êbg^lZk^mh3 <k^Zm^Zk^_^k^g\în[eb\Zmbhg_hkhkmahiZ^]b\iarlb\Ze
therapy clinicians, academic instructors, clinical instructors,
=^l\kb[^ôb]^g\^&[Zl^]iarlb\Zema^kZirikZ\mb\^bg\en]- students, interns, residents, and fellows regarding the best
ing diagnosis, prognosis, intervention, and assessment of current practice of orthopaedic physical therapy
outcome for musculoskeletal disorders commonly managed
by orthopaedic physical therapists IJ7J;C;DJE<?DJ;DJ
Mabl`nb]êbg^blghmbgm^g]^]mh[^\hglmkn^]hkmhl^ko^ZlZ
<eZllb_rZg]]^Ög^\hffhgfnl\nehldê^mZe\hg]bmbhgl standard of medical care. Standards of care are determined on

nlbg`ma^Phke]A^ZemaHk`ZgbsZmbhgÍlm^kfbgheh`rkêZm^] the basis of all clinical data available for an individual patient
to impairments of body function and body structure, activity Zg]Zk^ln[c^\mmh\aZg`^Zll\b^gmbÖ\dghpe^]`^Zg]m^\aghe-
limitations, and participation restrictions h`rZ]oZg\^Zg]iZmm^kglh_\Zk^ôheo^'Ma^lîZkZf^m^klh_
ikZ\mb\^lahne][^\hglb]^k^]`nb]êbg^lhger':]a^k^g\^mh
B]^gmb_rbgm^ko^gmbhgllniihkm^][r\nkk^gm[^lmôb]^g\^mh them will not ensure a successful outcome in every patient, nor
address impairments of body function and structure, activ- should they be construed as including all proper methods of
ity limitations, and participation restrictions associated with care or excluding other acceptable methods of care aimed at
common musculoskeletal conditions ma^lZf^k^lneml'Ma^nembfZm^cn]`f^gmk^`Zk]bg`ZiZkmb\neZk
clinical procedure or treatment plan must be made in light of
B]^gmb_rZiikhikbZm^hnm\hf^f^Zlnk^lmhZll^ll\aZg`^l the clinical data presented by the patient and the diagnostic
resulting from physical therapy interventions in body func- and treatment options available. However, we suggest that
tion and structure, as well as in activity and participation of significant departures from accepted guidelines should be docu-
the individual mented in the patient’s medical records at the time the relevant
clinical decision is made.
Methods
<hgm^gm^qi^kmlp^k^Ziihbgm^][rma^HkmahiZ^]b\L^\mbhg% diagnostic categories based on International Statistical Classifi-
:IM:%Zl]ôêhi^klZg]Znmahklh_\ebgb\ZeikZ\mb\^`nb]êbg^l cation of Diseases and Health Related Problems (ICD)23 termi-
for musculoskeletal conditions of the ankle and foot that are nology would not be useful for these ICF-based clinical practice
\hffhgermk^Zm^][riarlb\Zema^kZiblml'Ma^l^\hgm^gm^qi^kml guidelines, as most of the evidence associated with changes in
were given the task to identify impairments of body function levels of impairment or function in homogeneous populations
and structure, activity limitations, and participation restric- blghmk^Z]berl^Zk\aZ[e^nlbg`ma^\nkk^gmm^kfbgheh`r'MablZi-
tions, described using ICF terminology, that could (1) categorize proach, although less systematic, enabled the content experts to
patients into mutually exclusive impairment patterns upon search the scientific literature related to classification, outcome
which to base intervention strategies, and (2) serve as measures measures, and intervention strategies for musculoskeletal con-
of changes in function over the course of an episode of care. ditions commonly treated by physical therapists.
Ma^l^\hg]mZld`bo^gmhma^\hgm^gm^qi^kmlpZlmh]^l\kb[^
interventions and supporting evidence for specific subsets of Mabl`nb]êbg^pZlblln^]bg+))1[Zl^]nihgin[eb\Zmbhglbg
patients based upon the previously chosen patient categories. It ma^l\b^gmbÖ\ebm^kZmnkîkbhkmhFZr+))0'Mabl`nb]êbg^pbee
pZlZelhZ\dghpe^]`^][rma^HkmahiZ^]b\L^\mbhg%:IM:%maZm be considered for review in 2012, or sooner if new evidence
a systematic search and review of the evidence related to [^\hf^lZoZbeZ[e^':grni]Zm^lmhma^`nb]êbg^bgma^bgm^kbf
i^kbh]pbee[^ghm^]hgma^HkmahiZ^]b\L^\mbhg%:IM:p^[lbm^3
www.orthopt.org.
continued
journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | a3
H;L?;MFHE9;II
Methods (continued) Ma^HkmahiZ^]b\L^\mbhg%:IM:Zelhlê^\m^]\hglnemZgml_khf
the following areas to serve as reviewers of the early drafts of
mabl\ebgb\ZeikZ\mb\^`nb]êbg^3
B;L;BIE<;L?:;D9; <eZbflkôb^p
Individual clinical research articles were graded according to <h]bg`
\kbm^kbZ]^l\kb[^][rma^<^gm^k_hk>ob]^g\^&;Zl^]F^]b\bg^% >ib]^fbheh`r
Hq_hk]%Ngbm^]Dbg`]hf!MZ[e^*[êhp"' F^]b\ZeikZ\mb\^`nb]êbg^l
HkmahiZ^]b\iarlb\Zema^kZirk^lb]^g\r^]n\Zmbhg
Iarlb\Zema^kZirZ\Z]^fb\^]n\Zmbhg
Evidence obtained from high-quality randomized controlled
I Lihkmliarlb\Zema^kZirk^lb]^g\r^]n\Zmbhg
trials, prospective studies, or diagnostic studies
<hff^gml_khfma^l^kôb^p^klp^k^nmbebs^][rmaîkhc^\m
Evidence obtained from lesser-quality randomized coordinators to edit this clinical practice guideline prior to
controlled trials, prospective studies, or diagnostic submitting it for publication to the Journal of Orthopaedic &
II
studies (eg, improper randomization, no blinding, < 80% follow- Sports Physical Therapy.
up)
In addition, several physical therapists practicing in orthopae-
III Case controlled studies or retrospective studies dic and sports physical therapy settings were sent initial drafts
IV Case series of this clinical practice guideline, along with feedback forms
mh]^m^kfbg^bmlnl^_neg^ll%oZeb]bmr%Zg]bfiZ\m':eek^mnkg^]
V Expert opinion
feedback forms from these practicing clinicians described this
\ebgb\ZeikZ\mb\^`nb]êbg^Zl3
Ê>qmk^fêrnl^_neË
=H7:;IE<;L?:;D9; :gÊZ\\nkZm^kîk^l^gmZmbhgh_maî^^k&kôb^p^]ebm^kZmnk^Ë
Ma^ho^kZeelmk^g`mah_ma^ôb]^g\^lniihkmbg`k^\hff^g]Z-
:`nb]êbg^maZmpbeeaZo^ZÊln[lmZgmbZeihlbmbo^bfiZ\mhg
tions made in this guideline will be graded according to guide- hkmahiZ^]b\iarlb\Zema^kZiriZmb^gm\Zk^Ë
lines described by Sackett19Zlfh]bÖ^][rFZ\=^kfb]Zg]
Z]him^][rma^\hhk]bgZmhkZg]kôb^p^klh_mablikhc^\m'Bgmabl 9B7II?<?97J?ED
fh]bÖ^]lrlm^f%ma^mrib\Ze:%;%<%Zg]=`kZ]^lh_ôb]^g\^ MaîkbfZkrB<=&*)\h]^Zg]\hg]bmbhgZllh\bZm^]pbmaa^ê
have been modified to include the role of consensus expert pain is M72.2 Plantar fascial fibromatosis/Plantar fasciitis.23Hma^k%
opinion and basic science research to demonstrate biological or secondary ICD-10 codes and conditions associated with heel
[bhf^\aZgb\ZeieZnlb[bebmr!MZ[e^+[êhp"' pain are G57.5 Tarsal tunnel syndrome and G57.6 Lesion of plantar
nerve(FhkmhgÍlf^mZmZklZe`bZ'23Ma^\hkk^lihg]bg`B<=&2<F
GRADES OF RECOMMENDATION STRENGTH OF EVIDENCE \h]^lZg]\hg]bmbhgl%pab\aZk^nl^]bgma^NL:%Zk^0+1'0*
Plantar fascial fibromatosis/Contracture of plantar fascia,

Strong evidence A preponderance of level I and/or level IeZgmZk_Zl\bbmbl!mkZnfZmb\"%,..'.MZklZemnggêlrg]khf^%
A II studies support the recommendation. Zg],..'/E^lbhgh_ieZgmZkg^ko^(FhkmhgÍlf^mZmZklZe`bZ%
This must include at least 1 level I study g^nkZe`bZ%hkg^nkhfZ'Ma^\ebgb\Ze_^Zmnk^lmaZm]bü^k^gmb-
Moderate evidence A single high-quality randomized con- ate pathology of the plantar fascia, plantar nerves near the
B trolled trial or a preponderance of level proximal plantar fascia, or tissues of the tarsal tunnel, are often
II studies support the recommendation overlapping because it is difficult to selectively load the tissues
hypothesized to be the source of a patient’s heel pain during
Weak evidence A single level II study or a preponder- physical examination2 and treatment procedures.11,38
ance of level III and IV studies including
C MaîkbfZkrB<?[h]r_ng\mbhg\h]^lZllh\bZm^]pbmaieZgmZk
statements of consensus by content
experts support the recommendation fasciitis, tarsal tunnel syndrome, and plantar nerve lesions
Zk^ma^l^glhkr_ng\mbhglkêZm^]mhiZbg'Ma^l^[h]r_ng\mbhg
Conflicting evidence Higher-quality studies conducted on codes are b28015 Pain in lower limb and X(.&*HWZ_Wj_d]fW_d_dW
this topic disagree with respect to their i[]c[djehh[]_ed.
D
conclusions. The recommendation is
based on these conflicting studies MaîkbfZkrB<?[h]rlmkn\mnk^\h]^lZllh\bZm^]pbmaieZgmZk
fasciitis are i-+&()B_]Wc[djiWdZ\WiY_W[e\Wdab[WdZ\eej and
Theoretical/ A preponderance of evidence from
i-+&(.IjhkYjkh[ie\Wdab[WdZ\eej"d[khWb.
foundational evidence animal or cadaver studies, from
E conceptual models/principles, or from MaîkbfZkrB<?Z\mbobmb^lZg]iZkmb\biZmbhg\h]^lZllh\bZm^]
basic sciences/bench research support with plantar fasciitis are Z*+&&MWba_d]iêhjZ_ijWdY[i, d4501
this conclusion MWba_d]bed]Z_ijWdY[i, and Z*'+*CW_djW_d_d]WijWdZ_d]fei_j_ed.
Expert opinion Best practice based on the clinical MaîkbfZkrZg]l^\hg]ZkrB<=&*)Zg]B<?\h]^lZllh\bZm^]
F experience of the guidelines develop- pbmaa^êiZbgZkîkhob]^]bgMZ[e^,hgma^_Z\bgìZ`^'
ment team
B<=&*)Zg]B<?<h]^l:llh\bZm^]PbmaA^êIZbg
INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS

Primary ICD-10 M72.2 Plantar fascial fibromatosis
Plantar fasciitis
Secondary ICD-10 G57.5 Tarsal tunnel syndrome

G57.6 Lesion of plantar nerve
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH

PRIMARY ICF CODES
Body functions b28015 Pain in lower limb
b2804 Radiating pain in a segment or region
Body structure s75023 Ligaments and fascia of ankle and foot
s75028 Structures of ankle and foot, neural

Activities and d4500 Walking short distances
participation d4501 Walking long distances
d4154 Maintaining a standing position
SECONDARY ICF CODES

Body functions b7100 Mobility of a single joint (increase or decrease in mobility)
b7101 Mobility of several joints (increase or decrease in mobility)
b7203 Mobility of tarsal bones (increase or decrease in mobility)
b7300 Power of isolated muscles and muscle groups (weakness of intrinsics)
b7401 Endurance of muscle groups
b770 Gait pattern functions (antalgic gait)
Body structure s75020 Bones of ankle and foot (calcaneus/heel spur)

s75022 Muscles of ankle and feet (extensor digitorum brevis, abductor hallucis, abductor digiti quinti,
gastrocnemius/soleus)
s75028 Structure of ankle and foot, specified as tarsal tunnel/flexor retinaculum
s198 Structure of the nervous system, specified as tibial nerve and branches
Activities and d4101 Squatting
participation
d4104 Standing
d4106 Shifting the body’s centre of gravity
d4302 Carrying in arms (object)
d4303 Carrying on shoulders, hip, and back
d4350 Pushing with lower extremities
d4351 Kicking
d4502 Walking on different slopes
d4503 Walking around obstacles
d4551 Climbing
d4552 Running
d4553 Jumping
d4600 Moving around within the home
d4601 Moving around within buildings other than home
d4602 Moving around outside the home or other buildings
CLINICAL GUIDELINES
Impairment-/Function-based
Diagnosis
FH;L7B;D9; tar nerves while traveling through the tarsal tunnel. Both the
Plantar fasciitis is the most common foot condition medial plantar, lateral plantar, and their respective nerve
treated by healthcare providers. It has been estimated that [kZg\a^l\Zg[^ln[c^\mmh^gmkZif^gme^Z]bg`mhÊmZklZemng-
ieZgmZk _Zl\bbmbl h\\nkl bg ZiikhqbfZmêr + fbeebhg :f^kb- gêlrg]khf^'ËMablbg\en]^lZl^\hg][kZg\ah_maêZm^kZe
cans each year and affects as much as 10% of the population ieZgmZkg^ko^%Zelhk^_^kk^]mhZlÊ;Zqm^kÍlg^ko^%Ëpab\a\Zg
over the course of a lifetime.48Bg+)))ma^?hhmZg]:gde^ also be entrapped.17Ma^k^Zii^Zklmh[^ZgZgZmhfb\Ze\hg-
Li^\bZe Bgm^k^lm @khni h_ ma^ HkmahiZ^]b\ L^\mbhg% :IM:% g^\mbhg[^mp^^gma^:\abee^lm^g]hgZg]maîeZgmZkZihg^n-

surveyed over 500 members and received responses from rosis. Snow et al51 reported an anatomical continuity of the
117 therapists.47 H_ mahl^ k^lihg]bg`% *)) bg]b\Zm^] maZm Ö[^kl[^mp^^gma^:\abee^lm^g]hgZg]maîeZgmZk_Zl\bZbg
plantar fasciitis was the most common foot condition seen in ma^_^^mh_\Z]Zo^kl'Ma^rghm^]maZmma^k^pZlZ\hgmbgnhnl
their clinic.47 Rome et al49 reported that plantar fasciitis ac- ]bfbgnmbhgh_ma^gnf[^kh_Ö[^kl\hgg^\mbg`ma^:\abee^l
counts for 15% of all adult foot complaints requiring profes- tendons and plantar fascia as the foot aged.
sional care and is prevalent in both nonathletic and athletic
ihineZmbhgl'MZngmhg^mZe54 conducted a retrospective case- Ma^fhlm\hffhglbm^h_Z[ghkfZebmrbgbg]bob]nZel\hf-
control analysis of 2002 individuals with running-related in- plaining of heel pain diagnosed as plantar fasciitis is near
cnkb^lpahp^k^k^_^kk^]mhma^lZf^lihkmlf^]b\bg^\^gm^k' the origin or enthesis of the central band of the plantar apo-
Ma^rkîhkm^]maZmieZgmZk_Zl\bbmblpZlma^fhlm\hffhg g^nkhlblZmma^f^]bZeieZgmZkmn[^k\e^h_ma^\Ze\Zg^nl'Hg
condition diagnosed in the foot and represented 8% of all occasion, individuals will complain of pain and symptoms in
bgcnkb^l' ma^fb]&ihkmbhgh_ma^\^gmkZe[Zg]%cnlmikbhkmhbmliebmmbg`
into the 5 slips.
F7J>E7D7JEC?97B<;7JKH;I Plantar fasciitis occurs as an enthesopathy in patients with

The plantar aponeurosis or fascia consists of 3 bands: a seronegative arthropathy. Generally symptoms are present
lateral, medial, and central. It is the central band that origi- bilaterally in these cases. In systemic rheumatic diseases,
nates from the medial tubercle on the plantar surface of the enthesitis (insertitis) can occur as a result of endogenous,
calcaneus and that travels toward the toes as a solid band unknown causes.16 Plantar fascia insertitis can be associated
h_ mblln^ ]bob]bg` cnlm ikbhk mh ma^ f^mZmZklZe a^Z]l bgmh . with Reiter’s syndrome, psoriatic arthropathy, ankylosing
slips. Each slip then divides in half to insert on the proximal spondylitis, and enteropathic spondyloarthopathy. 30,56
iaZeZgqh_^Z\amh^':lZk^lnemh_ma^\^gmkZe[Zg]hgerZm-
taching to the calcaneus and the proximal phalanx of each Clinicians should assess for impairments in mus-
toe, when the toes are extended, the plantar fascia is func-
tionally shortened as it wraps around each metatarsal head.
F cles, tendons, and nerves, as well as the plantar fas-
cia, when a patient presents with heel pain.
Hicks20 was the first to describe this functional shortening as
ma^Êpbg]eZll^ü^\mËh_maîeZgmZk_Zl\bZ'Ma^pbg]eZll^ü^\m
can assist in supinating the foot during the latter portion of H?IA<79JEHI
the stance phase. The specific cause of plantar fasciitis is poor-
Ma^_heehpbg`bgmkbglb\fnl\e^lh_ma^_hhmaZo^ma^
II ly understood and is multifactorial. Riddle et al48
determined risk factors for plantar fasciitis in a
III same insertion as the central band of the plantar
_Zl\bZ3 ×^qhk ]b`bmhknf [kôbl% Z[]n\mhk aZeen\bl%
nonathletic population using a matched case-control design
pbma+\hgmkhel_hk^Z\aiZmb^gm':mhmZeh_.)iZmb^gmlpbma
Zg]ma^f^]bZea^Z]h_ma^jnZ]kZmnlieZgmZ^'F^]bZe\Ze\Z- ngbeZm^kZeieZgmZk_Zl\bbmblf^mma^bg\enlbhg\kbm^kbZ'Ma^Zn-
neal branches from the tibial nerve innervate the plantar heel thors concluded that the risk of plantar fasciitis increased as
iZ]'Ma^mb[bZeg^ko^]bob]^lbgmhma^f^]bZeZg]eZm^kZeieZg- Zgde^]hklb×^qbhgkZg`^h_fhmbhg]^\k^Zl^]'Hma^k_Z\mhkl
that increased the risk of developing plantar fasciitis in this the morning with the first steps after waking or after a pe-
lmn]rihineZmbhgp^k^li^g]bg`ma^fZchkbmrh_ma^phkd]Zr riod of inactivity.
on the feet and a body-mass index of greater than 30 kg/m2. Bg lhf^ \Zl^l% ma^ iZbg bl lh lô^k^ maZm bm k^lneml bg Zg
While ankle dorsiflexion, obesity, and work-related weight antalgic gait.
bearing were reported to be independent risk factors, reduced MaîZmb^gmpbeenlnZeerkîhkmmaZmmaâ^êiZbgpbeee^ll^g
ankle dorsiflexion appeared to be the most important.48 with increasing levels of activity (ie, walking, running), but
will tend to worsen toward the end of the day.
In a recent systematic review examining risk factors MaâblmhkrnlnZeerbg]b\Zm^lmaZmma^kâZl[^^gZk^\^gm
II associated with chronic plantar heel pain, Irving et
al24 reported a strong association between a body-
change in activity level, such as increased distance with
walking or running, or an employment change that re-
mass index of 25 to 30 kg/m2 and a calcaneal spur in a non- quires more time standing or walking.
Zmae^mb\ihineZmbhg'Ma^rkîhkm^]Zp^ZdZllh\bZmbhg_hkma^ Bgfhlm\Zl^lmaîZmb^gmpbeebgbmbZeer\hfieZbgh_laZki%
development of plantar fasciitis with increased body-mass localized pain under the anteromedial aspect of the plantar
index in an athletic population, increased age, decreased an- surface of the heel, with paresthesias being uncommon.
de^ ]hklb×^qbhg% ]^\k^Zl^] Öklm f^mZmZklhiaZeZg`^Ze chbgm
extension, and prolonged standing. Irving and colleagues24 Pain in the plantar medial heel region; most notice-
noted that the relationship between static foot posture as well

as dynamic foot motion and the development of plantar fas-
B able with initial steps after a period of inactivity but
also worse following prolonged weight bearing; and
ciitis was inconclusive. often precipitated by a recent increase in weight bearing ac-
tivity are useful clinical findings for classifying a patient with
Ma^Ög]bg`lh_Bkobg`^mZe24 with regard to static heel pain into the ICD category of plantar fasciitis and the
II
foot posture and dynamic foot motion are of inter- associated ICF impairment-based category of heel pain
est because the high incidence of plantar fasciitis in (b28015 Pain in lower limb; b2804 Radiating pain in a seg-
runners has been anecdotally attributed to repetitive micro- ment or region).
mkZnfZZllh\bZm^]pbma^q\^llboîkhgZmbhg'F^llb^kZg]Ibm-
tala37 as well as Wearing et al58 have assessed dynamic foot In addition, the following physical examination measures
motion retrospectively in both runners and walkers with may be useful in classifying a patient with heel pain into the
plantar fasciitis. Both studies reported no differences be- ICD category of plantar fasciitis and the associated ICF im-
tween case and control groups, but the sample size evaluated pairment-based category of heel pain (b28015 Pain in lower
in these studies were small. limb; b2804 Radiating pain in a segment or region).
IZeiZmbhgh_maîkhqbfZeieZgmZk_Zl\bZbgl^kmbhg
Clinicians should consider limited ankle dorsiflex- :\mbo^Zg]iZllbo^mZeh\knkZechbgm]hklb×^qbhgkZg`^
B ion range of motion and a high body-mass index in
nonathletic populations as factors predisposing
of motion
Ma^mZklZemnggêlrg]khf^m^lm
patients to the development of heel pain/plantar fasciitis. Ma^pbg]eZllm^lm
Maêhg`bmn]bgZeZk\aZgè^
9B?D?97B9EKHI;
Based on long-term follow-up data in case series :?<<;H;DJ?7B:?7=DEI?I
comprised primarily of patients seen in an orthopaedic out- Ma^_heehpbg`]bü^k^gmbZe]bZ`ghl^laZo^[^^gln``^lm^]_hk
patient setting, the clinical course for most patients was posi- plantar heel pain4,83
tive, with 80% reporting resolution of symptoms within a <Ze\Zg^Zelmk^ll_kZ\mnk^
12-month period.34,60 ;hg^[knbl^
?ZmiZ]Zmkhiar
MZklZemnggêlrg]khf^
:?7=DEI?I%9B7II?<?97J?ED Lh_m&mblln^%ikbfZkr%hkf^mZlmZmb\[hg^mnfhkl
The diagnosis of plantar fasciitis is made with IZ`^m]bl^Zl^h_[hg^
II a reasonable level of certainty on the basis of a clini-
cal assessment alone.4,5,8,10
Lô^kÍl]bl^Zl^
K^_^kk^]iZbgZlZk^lnemh_ZgL*kZ]b\nehiZmar
IZmb^gmlmrib\ZeerkîhkmZgbglb]bhnlhgl^mh_iZbgng]^k
the plantar surface of the heel upon weight bearing after a
period of non-weight bearing.
MabliZbgbgmaîeZgmZka^êk^`bhgblfhlmghmb\^Z[e^bg
Clinicians should consider diagnostic classifications in doubt.8BgZk^\^gmlmn]r%Hl[hkg^^mZe41 utilized lateral

F other than heel pain/plantar fasciitis when the pa-
tient’s reported activity limitations or impairments
radiographs to assess radiographic changes in 27 patients di-
agnosed with plantar fasciitis in comparison to 79 controls.
of body function and structure are not consistent with those :lbgè^[ebg]^]^qZfbg^kôZenZm^]maîeZbgghgÈp^bàm&
presented in the diagnosis/classification section of this guide- bearing films. Calcaneal spurs were observed in 85% of the
line, or, when the patient’s symptoms are not resolving with individuals with plantar fasciitis and in 46% of those in the
interventions aimed at normalization of the patient’s impair- control group. Plantar fascia thickness and fat pad abnor-
ments of body function. malities were the 2 best factors for group differentiation of
plantar fasciitis, with a sensitivity of 85% and a specificity of
2.'Ma^l^Znmahkl\hg\en]^]maZm\Ze\Zg^Zelinklp^k^ghm
?C7=?D=IJK:?;I a key radiographic feature to distinguish differences between
Imaging studies are typically not necessary for the diagnosis ma^ + `khnil Zg] maZm Z eZm^kZe ghgÈp^bàm&[^Zkbg` kZ]bh-
of plantar fasciitis.8,39 Imaging would appear to be most use- graph to assess soft tissue changes should be the first choice
ful to rule out other possible causes of heel pain or to establish if imaging is desired.41
a diagnosis of plantar fasciitis if the healthcare provider is
CLINICAL GUIDELINES
Examination
EKJ9EC;C;7IKH;I 79J?L?JOB?C?J7J?EDC;7IKH;I
While the majority of the studies reviewed There are no activity limitation measures
I for this guideline have utilized the Foot Function
Index (FFI), Foot Health Status Questionnaire
V specifically reported in the literature associated with
heel pain/plantar fasciitis—other than those that
!?ALJ"%hkma^?hhmZg]:gde^:[bebmrF^Zlnk^!?::F"Zl are part of the self-report questionnaires noted in this guide-
_ng\mbhgZehnm\hf^jn^lmbhggZbk^l%hgerma^?::FaZl[^^g ebg^Íl Hnm\hf^ F^Zlnk^l l^\mbhg' Ahpô^k% ma^ _heehpbg`
validated in a physical therapy practice setting.33Ma^?::F measures are options that a clinician may use to assess chang-
\hglblmlh_Z+*&bm^fZ\mbobmb^lh_]Zberebobg`!:=E"Zg]Zg es in a patient’s level of function over an episode of care.

1&bm^flihkmlln[l\Ze^'FZkmbg^mZe33oZeb]Zm^]ma^?::F_hk I^k\^gmh_mbf^^qi^kb^g\bg`Zgde^%_hhm%hka^êiZbgho^k
test content, internal structure, score stability, as well as re- the previous 24 hours
lihglbo^g^llnlbg`*.*iZmb^gml_hkma^:=Eln[l\Ze^Zg]*,) IZbgeôêpbmabgbmbZelmîlZ_m^klbmmbg`hkerbg`
patients for the sports subscale over a 4-week treatment pe- IZbgeôêpbmalbgè^&e^`lmZg\^
kbh]'Ma^m^lm&k^m^lmkêbZ[bebmrpZl)'12Zg])'10_hkma^:=E IZbgeôêpbmalmZg]bg`_hkZli^\bÖ^]i^kbh]h_mbf^%ln\a
Zg]lihkmlln[l\Ze^l%k^li^\mboêr'FZkmbg^mZe33 reported that as 30 minutes
ma^fbgbfZeer\ebgb\ZeerbfihkmZgm]bü^k^g\^l_hkma^?::F IZbg eôê Z_m^k pZedbg` Z li^\bÖ^] ]blmZg\^% ln\a Zl
p^k^1ihbgml_hkma^:=Eln[l\Ze^Zg]2ihbgml_hkma^lihkml 1000 m
subscale.
In addition, the Patient-Specific Functional Scale is a ques-
Clinicians should use validated self-report questionnaire that can be used to quantify changes in activity
A mbhggZbk^l%ln\aZlma^??B%?ALJ%hk?::F%[^-
fore and after interventions intended to alleviate
limitations and level of participation for patients with heel
pain.53 Mabl l\Ze^ ^gZ[e^l ma^ \ebgb\bZg mh \hee^\m f^Zlnk^l
the impairments of body function and structure, activity limi- related to function that may be different than the measures
tations, and participation restrictions associated with heel that are components of the self-report questionnaires noted
pain/plantar fasciitis. Physical therapists should consider bgma^Hnm\hf^F^Zlnk^ll^\mbhgh_mabl`nb]êbg^'
f^Zlnkbg`\aZg`^ho^kmbf^nlbg`ma^?::FZlbmaZl[^^g
validated in a physical therapy practice setting. Clinicians should utilize easily reproducible activity
F limitation and participation restriction measures
associated with their patient’s heel pain/plantar fas-
ciitis to assess the changes in the patient’s level of function
over the episode of care.
F>OI?97B?CF7?HC;DJC;7IKH;I
Active and Passive Ankle Dorsiflexion
ICF category Measurement of impairment of body function: mobility of a single joint
Description The amount of active ankle dorsiflexion range of motion measured with the knee extended
Measurement method The patient is positioned in prone with feet over the edge of the treatment table. The examiner asks the patient to dorsiflex the ankle
for an active measurement, or the examiner passively dorsiflexes the ankle, while ensuring that the foot does not evert or invert
during the dorsiflexion maneuver. At the end of the active or passive dorsiflexion range of motion, the examiner aligns the stationary
arm of the goniometer along the shaft of the fibula and aligns the moving arm of the goniometer along the shaft of the
5th metatarsal.
Nature of variable Continuous
Units of measurement Degrees
Measurement properties There is ample evidence to support the intrarater reliability of dorsiflexion range of motion measurements (reported intraclass
correlation coefficient (ICC) for active assessment varies from 0.64 to 0.92; ICC for passive assessment varies from 0.74 to 0.98). There
is some evidence to support interrater reliability with reported ICC varying from 0.29 to 0.81.35
The Dorsiflexion-Eversion Test

f or D iagnosis of Tarsal Tunnel Syndrome
ICF category Measurement of impairment of structure of the nervous system, other specified
Description In non-weight bearing, dorsiflexion of the ankle, eversion of the foot, and extension of all of the toes is maintained for 5 to 10 seconds
to determine if the patient’s symptoms are elicited
Measurement method With the patient sitting, the examiner maximally dorsiflexes the ankle, everts the foot, and extends the toes maintaining the position
for 5 to 10 seconds, while tapping over the region of the tarsal tunnel to determine if a positive Tinel sign is present or if the patient
complains of local nerve tenderness.
Nature of variable Nominal
Units of measurement None
Measurement properties Kinoshita et al25 performed this test on 50 normal and on 37 patients (44 feet) treated operatively for tarsal tunnel syndrome. In the
normal group no signs or symptoms were produced by the test. In the 44 symptomatic feet, the test increased numbness or pain in 36
feet and the Tinel sign became more pronounced in 41 feet.
Diagnostic accuracy indices for 95% Confidence Interval

increased numbness, based on
the study by Kinoshita et al* Sensitivity 0.81 0.67 - 0.90
Specificity 0.99 0.91 - 1.00
Positive likelihood ratio 82.73 5.22 - 1309.51
Negative likelihood ratio 0.19 0.10 - 0.35

more pronounced Tinel sign,
based on the study by Kinoshita Sensitivity 0.92 0.81 - 0.97
et al* Specificity 0.99 0.91 - 0.99
Cadaver model In 6 cadavers, Alshami et al2 reported that dorsiflexion-eversion of the ankle combined with extension of the metatarsophalangeal
joints significantly increased strain in the tibial nerve, lateral plantar nerve, and medial plantar nerve. However, this maneuver
also significantly increased strain in the plantar fascia. During this investigation, both components (dorsiflexion-eversion and
metatarsophalangeal joint extension) resulted in significant strain increases. This maneuver also resulted in significant excursion of
the tibial (6.9 mm, P = .016) and lateral plantar (2.2 mm, P = .032) nerves in the distal direction.
*Using Altman’s convention for diagnostic studies with a zero count in the 2-by-2 contingency table (adding 0.5 to all 4 cells) 4
Windlass Test
ICF category Measurement of impairment of body structure: fascia and ligaments of the foot
Description Extension of the first metatarsophalangeal joint in both weight bearing and non-weight bearing to cause the windlass effect of the
plantar fascia and determine if the patient’s heel pain is reproduced
Measurement method The test is performed in 2 positions: non-weight bearing and weight bearing.
NON-WEIGHT BEARING: With the patient sitting, the examiner stabilizes the ankle joint in neutral with 1 hand placed just behind the
first metatarsal head. The examiner then extends the first metatarsophalangeal joint, while allowing the interphalangeal joint to flex.
Passive extension (ie, dorsiflexion) of the first metatarsophalangeal joint is continued to its end of range or until the patient’s pain is
reproduced.
WEIGHT BEARING: The patient stands on a step stool and positions the metatarsal heads of the foot to be tested just over the edge of the
step. The subject is instructed to place equal weight on both feet. The examiner then passively extends the first metatarsophalangeal
joint while allowing the interphalangeal joint to flex. Passive extension (ie, dorsiflexion) of the first metatarsophalangeal joint is
continued to its end of range or until the patient’s pain is reproduced.
Nature of variable Nominal

Units of measurement None
Measurement properties De Garceau et al13 performed the test on 22 patients with plantar fasciitis and 43 other patients who served as a control group. None
of the patients in the other foot pain or control groups reported pain or symptoms in either weight bearing or non-weight bearing.
Seven (31.8%) of the 22 patients with plantar fasciitis had pain during the weight-bearing test, while only 3 had pain during the
non–weight-bearing test. While the Windlass test had a high specificity (100%), the sensitivity of the test was poor (< 32%) for both
the weight-bearing and non–weight-bearing tests

the weight-bearing test, based on
the study by De Garceau et al* Sensitivity 0.33 0.17 - 0.53
Specificity 0.99 0.91 - 1.00
Diagnostic accuracy indices 95% Confidence Interval

for the non–weight-bearing
test, based on the study by Sensitivity 0.18 0.07 - 0.40
De Garceau et al* Specificity 0.99 0.91 - 1.00

Cadaver model In 6 cadavers, Alshami et al2 reported that extension of all metatarsophalangeal joints significantly increased strain in the plantar
fascia (+0.4%, P = .016). However, this maneuver also significantly increased strain in the tibial nerve (+0.4%, P = .016).
*Using Altman’s convention for diagnostic studies with a zero count in the 2-by-2 contingency table (adding 0.5 to all 4 cells) 4
Longitudinal Arch Angle
ICF category Measurement of impairment of body function: mobility of a multiple joints
Description The angle formed by 1 line projected from the midpoint of the medial malleolus to the navicular tuberosity in relation to a second line
projected from the most medial prominence of the first metatarsal head to the navicular tuberosity
Measurement method With the patient standing with equal weight on both feet, the midpoint of the medial malleolus, the navicular tuberosity, and the most
medial prominence of the first metatarsal head are identified using palpation and marked with a pen. A goniometer is then used to
measure the angle formed by the 3 points with the navicular tuberosity acting as the axis point.
Nature of variable Continuous
Units of measurement Degrees
Measurement properties McPoil and Cornwall36 reported that the longitudinal arch angle (LAA), a static measure of foot posture, was highly predictive of
dynamic foot posture during walking. In their study, digital photographs of the medial aspect of both feet for 50 subjects were recorded
and used to calculate the LAA. These authors also reported that the LAA demonstrated acceptable intra and interrater reliability. To
date, the LAA has only been shown to serve as an accurate threshold for determining the level of risk for developing medial tibial stress
syndrome.52 The LAA provides a measure of foot structure and function that could be related to the development of plantar fasciitis.
CLINICAL GUIDELINES
Interventions
Numerous interventions have been described for the treat- iZmb^gml]bZ`ghl^]pbmaieZgmZk_Zl\bbmbl'Ma^rZll^ll^]ma^
ment of plantar fasciitis, but few high-quality randomized, hnm\hfîkbhkmhbgc^\mbhgZg]Zm+p^^dl%+fhgmal%Zg]*
controlled trials have been conducted to support these r^Zkihlmbgc^\mbhgnlbg`ZgZe`hf^m^kmhZll^llm^g]^kg^ll
therapies.12 at the painful site and pain using a visual analog scale. Both
tenderness and pain scale scores were significantly improved
bg[hma`khnil+p^^dlZ_m^kbgc^\mbhg'Ma^kZm^h_k^\nkk^g\^
7DJ?#?D<B7CC7JEHO7=;DJI of plantar fasciitis, however, was significantly higher in the
Although anti-inflammatory agents, including non- palpation-guided group (6/13) in comparison to the ultra-
steroidal Zgmb&bg×ZffZmhkr ]kn`l !GL:B=l" Zg] lm^khb] sound-guided group (1/12).55
bgc^\mbhgl%Zk^ghm\hffhgerpbmabgmaînkob^ph_iarlb-
cal therapist practice, patients often seek advice from their
therapist as to whether or not they should utilize anti-inflam- CE:7B?J?;I
matory agents in the management of plantar fasciitis. While Gudeman et al18 performed a double-blinded,
a^Zema\Zk^ ikhob]^kl h_m^g ik^l\kb[^ GL:B=l _hk iZmb^gml II ieZ\^[h\hgmkhee^]lmn]rbgpab\a,2ln[c^\ml!--
with plantar fasciitis, randomized clinical trials evaluating _^^m"p^k^Zllb`g^]mh*h_+mk^Zmf^gm`khnil':e-

ma^nl^h_GL:B=lbgblheZmbhgaZo^ghm[^^g\hg]n\m^]' though 4 feet were eliminated for various reasons, 20 feet
were assigned to the placebo group, which had iontophoresis
Ma^k^blebfbm^]ôb]^g\^mhlniihkmma^nl^h_lm^khb]bgc^\- electrodes attached to the feet with only phosphate buffered
tion to provide short-term pain relief.12:fZchk\hg\^kgpbma lZebg^Z]fbgblm^k^]'Ma^+)_^^mbgma^mk^Zmf^gm`khnik^-
lm^khb]bgc^\mbhgaZl[^^gma^kbldh_ln[l^jn^gmieZgmZk_Zl\bZ ceived iontophoresis with 0.4% dexamethasone sodium
knimnk^Zg]ieZgmZk_ZmiZ]]^`^g^kZmbhg':\ô^]hZg];^- iahliaZm^NLI';hma`khnilZelhk^\^bo^]/l^llbhglh_iarl-
skin1 in a retrospective review of 765 patients diagnosed with ical therapy in addition to the iontophoresis over a 2- to 3-
plantar fasciitis reported that of the 122 patients who had re- week period, which consisted of ice, plantar fascia and calf
\^bo^]Zlm^khb]bgc^\mbhg%--iZmb^gml!,/"aZ]Z_Zl\bZekni- muscle stretching, and the use of viscoelastic heel orthoses.

mnk^ZlZk^lnemh_ma^bgc^\mbhg'H_ô^g`k^Zm^kbfihkmZg\^ Ma^FZkreZg]?hhmL\hk^pZlnl^]mhZll^llmk^Zmf^gmhnm-
was the fact that 50% of the patients who suffered a rupture come in relation to pain and functional changes pretreat-
reported only a fair or poor recovery at a 27-month follow-up.1 ment, after the 6 treatments, and at 1 month posttreatment.
Ma^`khnik^\^bobg`bhgmhiahk^lblaZ]lb`gbÖ\Zgmer`k^Zm^k
Fhk^ k^\^gm lmn]b^l aZo^ kîhkm^] fbgbfZe mh gh kbld _hk improvement between pretreatment and after 6 treatments
_Zl\bZknimnk^_heehpbg`Zlm^khb]bgc^\mbhg'@^g\^mZe15 per- bg\hfiZkblhgmhmaîeZ\^[h`khni':m*fhgmaihlmmk^Zm-
_hkf^]ZiZeiZmbhg&`nb]^]lm^khb]bgc^\mbhgmh-0a^êlh_,) ment there were no differences in pain or function between
patients with plantar fasciitis and assessed outcome using ma^+`khnil'Ma^Znmahkl\hg\en]^]maZm[^\Znl^ma^nl^h_
ultrasound examination as well as pain intensity at 1 and 6 iontophoresis did not have an effect on long-term pain or
fhgmal ihlmbgc^\mbhg' Mabkmr a^Zemar bg]bob]nZel l^ko^] Zl function, this modality should be considered for those patients
Z\hgmkheihineZmbhg_hkma^nemkZlhng]^qZfbgZmbhg'Ma^r who need an immediate reduction in pain symptoms.18
reported that while the initial ultrasound examination dem-
onstrated a significantly thicker plantar fascia in the patient BgZfhk^k^\^gmlmn]r%Hl[hkg^Zg]:eeblhg40 con-
group in comparison to the controls, the thickness of the
fascia and pain levels were significantly decreased 1 month
II ducted a double-blinded, randomized, controlled
trial that assigned 31 patients diagnosed with plan-
Z_m^kbgc^\mbhg':_nkma^k]^\k^Zl^bg_Zl\bZemab\dg^llbgma^ mZk _Zl\bbmbl bgmh * h_ , mk^Zmf^gm `khnil3 Z ieZ\^[h nlbg`
iZmb^gm`khnipZlZelhghm^]Zmma^/&fhgma_heehp&ni'Ma^r )'2lh]bnf\aehkb]^!*)ln[c^\ml"%bhgmhiahk^lblpbma)'-
also noted that gross fascia disruption or other side-effects ]^qZf^maZlhg^!**ln[c^\ml"%Zg]bhgmhiahk^lblpbma.Z\^-
p^k^ghmh[l^ko^]Z_m^klm^khb]bgc^\mbhg'15 mb\Z\b]!*)ln[c^\ml"'>Z\aiZmb^gmk^\^bo^]/mk^Zmf^gml^l-
sions over 2 weeks and was continuously taped using a
MlZb^mZe55 assessed both palpation-guided (n = 13) and ul- low-Dye method throughout the 2-week period. Patients
mkZlhng]&`nb]^]!g6*+"lm^khb]bgc^\mbhgbgmaâ^êlh_+. were also instructed to perform calf stretching. Pain and stiff-
ness were independently assessed using a visual analogue plantar fascia. Following 10 treatment sessions over a period
scale prior to starting treatment, at the conclusion of 2 weeks of 1 month, this patient’s heel pain resolved and his standing
of treatment, and 2 weeks following the conclusion of the Zg]pZedbg`mhe^kZg\^p^k^_neerk^lmhk^]':emahnà\Zl^l^-
mk^Zmf^gm' Ma^ k^lneml bg]b\Zm^] maZm [hma Z\^mb\ Z\b] Zg] ries provide a low level of evidence, the findings of Young et
dexamethasone, when delivered via iontophoresis in combi- al61Zg]F^r^k^mZe38 provide the foundation for future ran-
nation with low-Dye taping, provided good short-term relief domized, controlled clinical trials to assess the effectiveness
h_iZbgZg]_ng\mbhg':\^mb\Z\b]ikh]n\^]`k^Zm^kbfikho^- of manual therapy as an intervention for plantar fasciitis.
ments in morning pain than dexamethasone, but continued
relief of pain during the 2-week posttreatment period was Ma^k^ bl fbgbfZe ôb]^g\^ mh lniihkm ma^ nl^ h_
only observed in the dexamethasone group.40 E manual therapy and nerve mobilization procedures
to provide short-term (1 to 3 months) pain relief
Dexamethasone 0.4% or acetic acid 5% delivered and improved function. Suggested manual therapy proce-
B via iontophoresis can be used to provide short-term
(2 to 4 weeks) pain relief and improved function.
]nk^lbg\en]^3mZeh\knkZechbgmihlm^kbhkèb]^%ln[mZeZkchbgm
lateral glide, anterior and posterior glides of the first tarso-
f^mZmZklZechbgm%ln[mZeZkchbgm]blmkZ\mbhgfZgbineZmbhg%lh_m
tissue mobilization near potential nerve entrapment sites,
C7DK7BJ>;H7FO and passive neural mobilization procedures.

There is limited evidence to support the use
IV of manual therapy as an intervention for plantar
fasciitis. Young et al61 reported on 4 patients re- IJH;J9>?D=
ferred to physical therapy for plantar fasciitis or unilateral Numerous authors have recommended that calf
ieZgmZka^êiZbg'Ma^]nkZmbhgh_lrfimhfl_hkma^-iZ- stretching should be one of the interventions incorporated

mb^gmlkZg`^]_khf/mh.+p^^dl'Ma^Znmahklnl^]ZiZbg into the management program for patients with plantar fas-
rating scale and a self-reported function scale to assess out- ciitis.18,39,40,42,45 Ma^ \hgmbgnbmr h_ \hgg^\mbo^ mblln^ [^mp^^g
\hf^ho^kZi^kbh]h_*mh,fhgmal':ee-iZmb^gmlk^\^bo^] ma^:\abee^lm^g]hgZg]maîeZgmZk_Zl\bZ%ZlpêeZlma^_Z\mmaZm
fZgnZema^kZirZg]lmk^m\abg`'MphiZmb^gmlp^k^Zelhik^- decreased ankle dorsiflexion is a risk factor in the development
scribed foot orthoses and another patient received additional h_ieZgmZk_Zl\bbmbl%ikhob]^llhf^cnlmbÖ\Zmbhg_hk\Ze_lmk^m\abg`'
lmk^g`ma^gbg`^q^k\bl^l'Ma^fZgnZema^kZirm^\agbjn^lnmb-
ebs^] bg mabl \Zl^ l^kb^l bg\en]^] mZeh\knkZe chbgm ihlm^kbhk Porter et al43 conducted a prospective, randomized,
èb]^l%ln[mZeZkchbgmeZm^kZeèb]^l%Zgm^kbhk(ihlm^kbhkèb]^l II blinded study to assess the duration and frequency
h_ma^ÖklmmZklhf^mZmZklZechbgm%Zg]ln[mZeZkchbgm]blmkZ\- of calf stretching on improvement in ankle dorsi-

mbhgfZgbineZmbhgl':ee-iZmb^gmlbgmabl\Zl^l^kb^lkîhkm^] flexion range of motion and patient outcome as determined
a rapid improvement in pain and function as a result of the nlbg`ma^:f^kb\Zg:\Z]^frh_HkmahiZ^]b\Lnk`^hgÍlEhp-
bgm^ko^gmbhglnmbebs^]'F^r^k^mZe38 reported on 1 patient re- ^kEbf[Zg]?hhmZg]:gde^Fh]ne^l'IZkmb\biZgmlbg\en]^]
ferred to physical therapy for plantar fasciitis with an 8- 54 patients with plantar fasciitis who performed a sustained
month history of subcalcaneal heel pain that limited standing stretch, 40 patients with plantar fasciitis who performed an
Zg]pZedbg`'MabliZmb^gmÍla^êiZbgpZlkîkh]n\^]pbma intermittent stretch, and 41 healthy individuals who served
the straight-leg raising (SLR) test in combination with ankle as controls. Participants were instructed to stretch their calf
dorsiflexion and eversion to sensitize the tibial nerve, sug- muscles standing at the edge of a step with the heel hanging
gesting that there was a neurogenic component to this pa- off the edge while keeping the knee straight and the foot in a
mb^gmÍl a^ê iZbg' Ma^ ^qZfbgZmbhg Ög]bg`l h_ mabl iZmb^gm g^nmkZeihlbmbhg!ghZ[]n\mbhghkZ]]n\mbhg"'Ma^bg]bob]n-
appear consistent with the findings of Coppieters and associ- als in the sustained stretch group stretched for 3 minutes at
ates11 who reported significant strain and excursion of the Zmbf^%,mbf^lZ]Zr'Mahl^bgma^bgm^kfbmm^gmlmk^m\a`khni
tibial nerve in 8 embalmed cadavers when ankle dorsiflexion stretched for five 20-second intervals, twice daily. Partici-
bl\hf[bg^]pbmama^LEKm^lm'MabliZmb^gmpbmaa^êiZbg pants in both the sustained and intermittent stretch groups
]^l\kb[^][rF^r^k^mZe38 received passive and active mobi- had ankle dorsiflexion range of motion and functional out-
lization aimed at restoring pain-free soft tissue mobility along comes assessed prior to starting treatment and once a month
ma^\hnkl^h_ma^f^]bZgg^ko^'MaîZllbo^g^nkZefh[bebsZ- for 4 consecutive months. Participants in the study were pro-
tion procedures were performed with the patient in the slump ob]^]pbmaghhma^kmk^Zmf^gmbgm^ko^gmbhgl':mma^^g]h_-
sitting position. Because restricted ankle dorsiflexion, exces- months, 40 patients remained in the sustained-stretch group
sive pronation, and posterior tibialis weakness were also and 26 patients remained in the intermittent-stretch group.
found, low-Dye taping and therapeutic exercises were uti- Ma^k^lnemlbg]b\Zm^]maZmpabe^ma^k^p^k^gh]bü^k^g\^lbg
lized to control excessive pronation and reduce stress on the outcome between the 2 stretching groups, both groups had
similar increases in ankle dorsiflexion. Furthermore, the in- phoresis combined with low-Dye taping provided relief of
crease in ankle dorsiflexion correlated with a decrease in pain pain and stiffness when assessed 4 weeks posttreatment.
for both groups.43
14
DiGiovanni et al conducted a prospective,
III Hyland et al21 conducted a prospective, randomized,
controlled trial to determine the effect of calcaneal
III randomized study to determine if a plantar fascia-
specific stretch would be more effective than calf
taping in comparison to sham taping and stretching. Forty-
one patients with a clinical diagnosis of plantar fasciitis were
lmk^m\abg`'Ma^l^Znmahklarihma^lbs^]maZmZieZgmZk_Zl\bZ& Zllb`g^]mh-`khnil3\Ze\Zg^ZemZibg`!g6**"%laZfmZibg`
specific stretch might have a greater amount of patient com- !g6*)"%lmk^m\abg`hger!g6*)"%Zg]Z\hgmkhe!g6*)"'Ma^
pliance as well as a greater improvement in functional stretching group was given both calf stretching and plantar
hnm\hf^l' Hg^ ang]k^] hg^ iZkmb\biZgml p^k^ bgbmbZeer _Zl\bZ&li^\bÖ\lmk^m\abg`^q^k\bl^l'Ma^\Ze\Zg^ZemZibgìkh-
Zllb`g^] mh + `khnil3 \Ze_ lmk^m\abg` !g 6 .)" Zg] ieZgmZk cedure was designed to invert the calcaneus, thus to improve
fascia-specific stretching (n = 51). Both groups received over- biomechanical position. Patient outcome was assessed using a
ma^&\hngm^k lh_m bglhe^l% Z ,&p^^d \hnkl^ h_ GL:B=L% Zg] visual analogue scale for pain and a patient-specific function
iZmb^gm^]n\Zmbhgk^`Zk]bgìeZgmZk_Zl\bbmbl'MaîeZgmZk_Zl- scale (PSFS) prior to treatment and after 1 week of treatment.
cia tissue-specific stretch was performed in sitting, with the While stretching and sham taping decreased pain, calcaneal
patient placing the fingers of one hand across the toes of the taping demonstrated a significantly greater decrease in pain
involved foot, then pulling the toes back (extension) toward than either stretching or sham taping. No differences with
ma^labgngmbelmk^m\abg`pZl_êmbgma^Zk\ah_ma^_hhm'Mh regard to function were found among the 4 groups, although
confirm that they were stretching the fascia, patients were calcaneal taping did have the greatest pretest versus posttest
instructed to use the opposite hand to palpate the tension of ]bü^k^g\^'Ng_hkmngZmêr%mabllmn]rpZlghm[ebg]^]%aZ]Z
ma^_Zl\bZhgma^[hmmhfh_ma^_hhm'Ma^\Ze_&lmk^m\abg``khni lfZeegnf[^kh_ln[c^\mlZllb`g^]mh^Z\a`khni%Zg]hger
was instructed to perform the stretch in standing while lean- provided a 1-week follow-up.21
ing into the wall with the nonaffected foot behind the leg be-
ing stretched. Patients in the calf-stretching group were Radford et al46 performed a participant-blinded,
asked to stand on their orthotics while stretching, in a slightly
toe-in stance. Both groups were instructed to hold each
III randomized trial to determine the effectiveness of
low-Dye taping for pain and improvement of func-
stretch for a count of 10, repeat the stretch 10 times, and mbhgbgiZmb^gmlpbmaieZgmZk_Zl\bbmbl':lZfie^lbs^h_2+iZ-
i^k_hkf ma^ lmk^m\a , mbf^l i^k ]Zr' H_ ma^ bgbmbZe *)* iZ- mb^gmlpZl]bob]^]bgmh+^jnZe`khnilh_-/3*`khnik^\^bobg`
tients, heel pain was either eliminated or much improved at low-Dye taping with sham ultrasound and the other group
8 weeks in 24 (52%) of the 46 patients who performed the k^\^bobg`laZfnemkZlhng]hger'Hnm\hf^f^Zlnk^lbg\en]^]

plantar fascia specific stretch, as compared to 8 (22%) out of first-step pain, assessed using a visual analogue scale, as well
36 patients who performed calf stretching. It is important to as the change in foot pain, foot function, and general foot
note, however, that this study was not blinded, a large per- health as determined using the Foot Health Status Question-
centage of patients dropped out of the study (28% calf gZbk^!?ALJ"'Hnm\hf^pZlZll^ll^]ikbhkmhma^bgbmbZmbhg
stretching, 10% plantar fascia stretch), and only the data for of treatment and after 1-week. Participants in the taping
those patients who completed the 8-week trial were group had their foot taped for a median of 7 days (range 3 to
analyzed.14 9 days). Similar to the findings reported by Hyland et al,21 the
low-Dye tape group reported a small but significant differ-
Calf muscle and/or plantar fascia-specific stretch- ence in first-step pain in comparison to the sham group. No
B ing can be used to provide short-term (2 to 4
months) pain relief and improvement in calf muscle
significant differences in FHSQ scores were found between
the 2 groups; however, limitations of this study include no
×^qb[bebmr'Ma^]hlZ`^_hk\Ze_lmk^m\abg`\Zg[^^bma^k,mbf^l control group and short-term follow-up of outcome
a day or 2 times a day utilizing either a sustained (3 minutes) measures.46
or intermittent (20 seconds) stretching time, as neither dos-
age produced a better effect. Calcaneal or low-Dye taping can be used to provide
C short-term (7 to 10 days) pain relief. Studies indicate
that taping does cause improvements in function.
J7F?D=
Adhesive strapping appears to provide short-term
relief of pain in patients with a clinical diagnosis of plan- EHJ>EJ?9:;L?9;I
mZk _Zl\bbmbl' :l ikôbhnler ghm^] bg ma^ ]bl\nllbhg hg Foot orthoses are frequently utilized as a component
fh]Zebmb^l% Hl[hkg^ Zg] :eeblhg40 reported that ionto- h_ma^\hgl^koZmbo^fZgZ`^f^gmieZg_hkieZgmZk_Zl\bbmbl'Ma^
cnlmbÖ\Zmbhg`bo^g_hkma^nl^h__hhmhkmahl^lblmh]^\k^Zl^ Pfeffer et al42 conducted a randomized multicenter

abnormal foot pronation that is thought to cause increased
lmk^llhgma^f^]bZe[Zg]h_maîeZgmZk_Zl\bZ'Mh]Zm^%ôb-
I trial involving 236 patients diagnosed with plan-
tar fasciitis recruited from 15 orthopaedic foot and
dence that establishes an association between plantar fasciitis Zgde^\ebgb\l'MaîZmb^gmlbgma^lmn]rp^k^nl^]mhôZenZm^
and foot motion is inconclusive.24 Studies conducted using .]bü^k^gmmk^Zmf^gml3!*"\Ze_lmk^m\abg`hger%!+"Zlbeb\hg^
cadaver specimens suggest that foot orthoses can reduce the heel pad and calf stretching, (3) a felt arch insert and calf
strain in the plantar fascia during static loading, reduce the stretching, (4) a rubber heel cup and calf stretching, and (5)
collapse of the medial longitudinal arch, and reduce elonga- Z\nlmhf%_ng\mbhgZe_hhmhkmahlblZg]\Ze_lmk^m\abg`'Ma^
tion of the foot associated with pronation.26,27,28 patients were followed for an 8-week period and they used
the pain subscale of the Foot Function Index (FFI) as their
Seven randomized, controlled clinical trials have been con- hnm\hf^ f^Zlnk^' Ma^r kîhkm^] maZm ma^ `khnil mk^Zm^]
ducted to determine the effectiveness of foot orthoses for the with the prefabricated inserts (silicone pad, felt arch insert,
mk^Zmf^gmh_ieZgmZk_Zl\bbmbl'Mphh_ma^l^lmn]b^lôZenZm^] rubber heel cup) had significantly better outcomes than the
the effect of magnetic insoles on plantar heel pain. 9,59 Both group treated with custom orthotics and the group treated
studies concluded that magnets do not provide an additional pbmalmk^m\abg`hger':emahnàma^1&p^^dbgm^ko^gmbhgi^-
benefit compared to nonmagnetic insoles for the treatment riod for this study was extremely short, the results indicate
of plantar heel pain. that prefabricated orthoses are effective and that stretching
and prefabricated orthoses are more effective than stretch-
Ma^ k^fZbgbg` . lmn]b^l _h\nl^] hg \hfiZkbg` ing alone.42
II various types of foot orthoses including customized,
prefabricated, felt arch pads, and heel cups or pads. FZkmbg ^m Ze32 evaluated custom foot orthoses in
II
Lynch et al31 compared the effectiveness of 3 types of conser- comparison to prefabricated arch supports and
oZmbo^ma^kZir_hkma^fZgZ`^f^gmh_ieZgmZk_Zl\bbmbl':mhmZe night splints in 255 patients with plantar fasciitis.
h_*),ln[c^\mlp^k^Zllb`g^]mh*h_,mk^Zmf^gm`khnil3Zgmb& Patients were randomly assigned to 1 of 3 treatment groups
bg×ZffZmhkrma^kZir\hglblmbg`h_Z\hkmb\hlm^khb]bgc^\mbhg and the primary outcome measures were self-reported first
Zg] GL:B=l !g 6 ,."% Zg Z\\hffh]Zmbo^ obl\hêZlmb\ a^ê step pain as well as pain during work, leisure, and exercise
cup (n = 33), and a mechanical treatment which consisted of Z\mbobmb^lnlbg`ZoblnZeZgZeh`n^l\Ze^'H_ma^+..iZmb^gml
an initial low-Dye taping followed by custom orthoses (n = initially enrolled in the study, only 193 were seen at the final
,."'MaîkbfZkrhnm\hf^f^Zlnk^pZliZbgkZmbg`[Zl^]hg 12-week follow-up visit. Patients in the prefabricated ortho-
a visual analogue scale and patients were followed for 3 ses group and the night splint group had the poorest compli-
fhgmal'Ma^Znmahklkîhkm^]maZmma^f^\aZgb\Zemk^Zmf^gm ance rates and the highest number of patients withdrawn,

group had a greater reduction in pain and had fewer drop- pbma +*Zg]+/% k^li^\mboêr' :mma^*+&p^^d _heehp&ni
outs than the other 2 groups. In addition to the fact that pain visit, there was no significant difference in pain reduction
was the only outcome measure assessed, the foot orthoses [^mp^^gma^,`khnil'Ma^Znmahkl]b]bg]b\Zm^maZmiZmb^gm
group had the confounding short-term effect of taping. 31 compliance was greatest with the use of custom foot
orthoses.32
Mnkebd^mZe57 focused on the effect of foot orthoses
II alone by evaluating 60 patients with plantar fasci- Mh ]Zm^% ma^ fhlm ehg`&m^kf% \hfikâ^glbo^
itis, assigned to either a custom, functional foot or-
thosis group (n = 26), or a generic gel heel pad group (n = 34).
I clinical study of the effectiveness of foot ortho-
ses in the management of plantar fasciitis was
While the actual duration of the intervention was unclear, conducted by Landorf et al. 29Ma^r\hg]n\m^]ZiZkmb\b-
most patients were followed for at least 3 months, with 5 sub- pant-blinded, randomized trial utilizing 136 patients
c^\ml]khiibg`hnmh_maâ^êiZ]`khni'MhZll^lliZmb^gm with a clinical diagnosis of plantar fasciitis. Patients
outcomes, a 5-item outcome survey was developed by the au- p^k^kZg]hferZeeh\Zm^]mh*h_,mk^Zmf^gm`khnil3!*"
mahkl'Ma^Znmahklkîhkm^]maZmma^\nlmhf%_ng\mbhgZe_hhm a sham orthosis constructed of soft, thin foam (n = 46), (2) a
orthoses group had better outcomes than the heel pad group. prefabricated firm foam orthosis (n = 44); and (3) a custom,
Ng_hkmngZmêr%ma^Znmahk&]ôêhi^]hnm\hf^l\Ze^pZlghm l^fbkb`b]ma^kfhieZlmb\hkmahlbl!g6-/"'Ma^hnm\hf^f^Z-
evaluated for reliability or validity and the group assignment sure used was the pain and function domains of the Foot
was not blinded.57 A^Zema LmZmnl Jn^lmbhggZbk^ !?ALJ"' Hnm\hf^l p^k^ Zl-
sessed prior to initiation of treatment, at 3 months, and at 12
fhgmal':mma^,&Zg]*+&fhgma_heehp&nioblbml%^Z\a`khni
lost only 1 to 2 members to follow-up, so that the total num-
[^kh_iZmb^gmlkôb^p^]Zm*+fhgmalpZl*,*':_m^k,fhgmal%
FHSQ pain and function scores favored the use of prefabri- Fhlmgbàmliebgml%pa^ma^kZgm^kbhkhkihlm^kbhkbg
cated and custom orthoses over the sham orthoses, although
hgerma^^ü^\mlhg_ng\mbhgp^k^lb`gbÖ\Zgm'Ma^k^p^k^gh
III design, are fabricated using a rigid thermoplastic
material that can be uncomfortable for the patient
significant differences for pain and function scores among Zg]e^Z]mhghg\hfiebZg\^'Fhk^k^\^gmer%Zlh_m%lh\d&mri^
Zgrh_ma^,mk^Zmf^gm`khnilZmma^*+&fhgmakôb^p'Manl% night splint has been made commercially available that uti-
while the prefabricated and custom orthoses did produce a lizes a Velcro strap to position the ankle in neutral and the
short-term effect in pain and function, after 1 year of wear all toes in slight extension. Barry et al6 retrospectively analyzed
3 types of foot orthoses produced a similar patient the use of this type of night splint in comparison to stand-
outcomes.29 ing calf stretching in 160 patients with a clinical diagnosis of
ieZgmZk_Zl\bbmbl'Ma^f^Zg]nkZmbhgh_lrfimhfl_hkZee*/)
Prefabricated or custom foot orthoses can be used patients prior to the start of treatment was approximately 2
A to provide short-term (3 months) reduction in pain
Zg]bfikho^f^gmbg_ng\mbhg'Ma^k^Zii^Zklmh[^
fhgmal':emahnàma^k^Zk^gnf^khnlblln^lpbmamabllmn]r
bg\en]bg` ihhk \hgmkhe h_ bgmkh]n\mbhg h_ Z]cng\mbo^ mk^Zm-
no differences in the amount of pain reduction or improved ments, a 13% dropout of the patients receiving calf stretch-
function created by custom foot orthoses in comparison to ing, and the use of pain as the only outcome measure, the use
ik^_Z[kb\Zm^]hkmahl^l'Ma^k^bl\nkk^gmerghôb]^g\^mhlni- of the sock-type night splint did result in a shorter recovery
port the use of prefabricated or custom foot orthoses for long- time and fewer additional interventions.6:ikhli^\mbo^%kZg-
term (1 year) pain management or function improvement. domized controlled trial is required to validate this specific
type of night splint.
D?=>JIFB?DJI Night splints should be considered as an interven-

B
12
Crawford and Thomson in their Cochrane tion for patients with symptoms greater than 6
II review reported limited evidence to support the use
of night splints as an intervention for patients with
fhgmalbg]nkZmbhg'Ma^]^lbk^]e^g`mah_mbf^_hk
p^Zkbg`ma^gbàmliebgmbl*mh,fhgmal'Ma^mri^h_gbàm
ieZgmZk_Zl\bbmbleZlmbg`fhk^maZg/fhgmal':d^r\ebgb\Ze splint used (ie, posterior, anterior, sock-type) does not appear
issue is the duration of use once night splint therapy has been to affect the outcome.
initiated. Batt et al7 reported that between 9 and 12 weeks of
night splint wear time was required to achieve a good outcome
in 40 patients with chronic plantar fasciitis. Powell et al44
found that only 1 month of wearing the night splint was suffi-
cient to create an 88% improvement in 37 patients with

\akhgb\ieZgmZk_Zl\bbmbl'Ma^k^_hk^%[Zl^]hgebfbm^]ôb]^g\^%
it would appear that a night splint should be worn between 1
and 3 months to achieve adequate symptom improvement.
In a recent study, Roos et al50 investigated the ef-

II fects of foot orthoses and night splints, either indi-
vidually or combined, in a prospective, randomized
trial with a 1-year follow-up. Forty-three patients with a mean
duration of symptoms of 4.2 months were assigned to 1 of 3
`khnil3_hhmhkmahl^lhger!g6*,"%_hhmhkmahl^lZg]gbàm
splint (n = 15), or night splint only (n = 15). Follow-up data
were available on 38 patients after 1 year. While previous
studies had used a posterior night splint, Roos et al50 utilized
an anterior night splint. In addition to daily logs to monitor
\hfiebZg\^%ma^?hhmZg]:gde^Hnm\hf^L\hk^!?:HL"pZl
nl^]ZlZghnm\hf^f^Zlnk^'Ma^k^lnemlbg]b\Zm^]maZm\hf-
pliance to either the foot orthoses or night splint was good (at
least 75%) and all 3 groups had a reduction in pain as early
as 6 weeks and at the 1-year follow-up. Improvements in
_ng\mbhgZl]^m^kfbg^]nlbg`ma^?:HLlniihkm^]ma^nl^h_
foot orthoses over night splints.
CLINICAL GUIDELINES
Summary of Recommendations
F F7J>E7D7JEC?97B<;7JKH;I F ;N7C?D7J?ED0<KD9J?ED7BB?C?J7J?EDC;7IKH;I
Clinicians should assess for impairments in muscles, tendons, and Clinicians should utilize easily reproducible functional limitations
nerves, as well as the plantar fascia, when a patient presents with and activity restrictions measures associated with the patient’s heel
heel pain. pain/plantar fasciitis to assess the changes in the patient’s level of
function over the episode of care.
B H?IA<79JEHI
Clinicians should consider limited ankle dorsiflexion range of mo- B ?DJ;HL;DJ?EDI0CE:7B?J?;I
tion and a high body mass index in nonathletic populations as fac- Dexamethasone 0.4% or acetic acid 5% delivered via iontophoresis
tors predisposing patients to the development of heel pain/plantar can be used to provide short-term (2 to 4 weeks) pain relief and im-
fasciitis. proved function.
B :?7=DEI?I%9B7II?<?97J?ED E ?DJ;HL;DJ?EDI0C7DK7BJ>;H7FO
Functional limitations associated with pain in the plantar medial heel There is minimal evidence to support the use of manual therapy and
region, most noticeable with initial steps after a period of inactivity nerve mobilization procedures short-term (1 to 3 months) for pain
but also worse following prolonged weight bearing, and often pre- and function improvement. Suggested manual therapy procedures
cipitated by a recent increase in weight-bearing activity, are useful in include: talocrural joint posterior glide, subtalar joint lateral glide, an-
classifying a patient into the ICD category of plantar fasciitis and the terior and posterior glides of the first tarsometatarsal joint, subtalar
associated ICF impairment-based category of heel pain (b28015 Pain joint distraction manipulation, soft tissue mobilization near potential
in lower limb; b2804 Radiating pain in a segment or region). nerve entrapment sites, and passive neural mobilization procedures.
The following physical examination measures may be useful in B ?DJ;HL;DJ?EDI0IJH;J9>?D=

classifying a patient with heel pain into the ICD category of plantar Calf muscle and/or plantar fascia-specific stretching can be used to
fasciitis and the associated ICF impairment-based category of heel provide short-term (2 to 4 months) pain relief and improvement in
pain (b28015 Pain in lower limb; b2804 Radiating pain in a segment calf muscle flexibility. The dosage for calf stretching can be either 3
or region): times a day or 2 times a day utilizing either a sustained (3 minutes)
Iocfjech[fheZkYj_edm_j^fWbfWjehofheleYWj_ede\j^[fhen_cWb or intermittent (20 seconds) stretching time, as neither dosage pro-

plantar fascia insertion duced a better effect.
7Yj_l[WdZfWii_l[jWbeYhkhWbè_djZehi_Ô[n_edhWd][e\cej_ed
J^[jWhiWbjkdd[biodZhec[j[ij
J^[m_dZb[iij[ij C ?DJ;HL;DJ?EDI0J7F?D=
J^[bed]_jkZ_dWbWhY^Wd]b[ Calcaneal or low-Dye taping can be used to provide short-term (7 to
10 days) pain relief. Studies indicate that taping does cause improve-
F :?<<;H;DJ?7B:?7=DEI?I ments in function.
Clinicians should consider diagnostic classifications other than
heel pain/plantar fasciitis when the patient’s reported functional A ?DJ;HL;DJ?EDI0EHJ>EJ?9:;L?9;I
limitations or physical impairments are not consistent with those Prefabricated or custom foot orthoses can be used to provide short-
presented in the diagnosis/classification section of this guideline, or, term (3 months) reduction in pain and improvement in function.
the patient’s symptoms are not resolving with interventions aimed at There appear to be no differences in the amount of pain reduction
normalization of the patient’s physical impairments. or improvement in function created by custom foot orthoses in
comparison to prefabricated orthoses. There is currently no evidence
A ;N7C?D7J?ED0EKJ9EC;C;7IKH;I to support the use of prefabricated or custom foot orthoses for long-
term (1 year) pain management or function improvement.
Clinicians should use validated self-report questionnaires, such
as the Foot Function Index (FFI), Foot Health Status Questionnaire
(FHSQ), or the Foot and Ankle Ability Measure (FAAM), before and B ?DJ;HL;DJ?EDIÆD?=>JIFB?DJI
after interventions intended to alleviate the physical impairments, Night splints should be considered as an intervention for patients
functional limitations, and activity restrictions associated with heel with symptoms greater than 6 months in duration. The desired
pain/plantar fasciitis. Physical therapists should consider measuring length of time for wearing the night splint is 1 to 3 months. The type
change over time using the FAAM as it has been validated in a physi- of night splint used (ie, posterior, anterior, sock-type) does not ap-
cal therapy practice setting. pear to affect the outcome.
7<<?B?7J?EDI9EDJ79JI H;<;H;D9;I
7KJ>EHI H;L?;M;HI 1. Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated
with corticosteroid injection. Foot Ankle Int. 1998;19:91-97.
JêcWi=$CYFe_b" PT, PhD 7djêdo:[b_jje" PT, PhD
Regents’ Professor Professor and Chair 2. Alshami AM, Babri AS, Souvlis T, Coppieters MW. Biomechanical evalua-
Department of Physical Therapy School of Health and tion of two clinical tests for plantar heel pain: the dorsiflexion-eversion test
Northern Arizona University Rehabilitation Sciences for tarsal tunnel syndrome and the windlass test for plantar fasciitis. Foot
Flagstaff, Arizona University of Pittsburgh Ankle Int. 2007;28:499-505. http://dx.doi.org/10.3113/FAI.2007.0499
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HeXHeoB$CWhj_d" PT, PhD
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6. Barry LD, Barry AN, Chen Y. A retrospective study of standing gastroc-
john.dewitt@osumc.edu
nemius-soleus stretching versus night splinting in the treatment of plantar
CWhaM$9ehdmWbb" PT, PhD
fasciitis. J Foot Ankle Surg. 2002;41:221-227.
Professor 7cWdZW<[hbWdZ" DPT
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markcornwall@nau.edu aferland@mvppt.com 2004;350:2159-2166. http://dx.doi.org/10.1056/NEJMcp032745
:Wd[A$Mka_Y^" MD >[b[d[<[Whed" PT 9. Caselli MA, Clark N, Lazarus S, Velez Z, Venegas L. Evaluation of magnetic
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Assistant Professor of Resource Institute 10. Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of
Orthopaedic Surgery Phoenix, Arizona diagnosis and therapy. Am Fam Physician. 2005;72:2237-2242.
University of Pittsburgh hfearon123@cs.com
Medical Center 11. Coppieters MW, Alshami AM, Babri AS, Souvlis T, Kippers V, Hodges PW.
Pittsburgh, Pennsylvania @eoCWY:[hc_Z" PT, PhD Strain and excursion of the sciatic, tibial, and plantar nerves during a modi-
wukichdk@upmc.edu Associate Professor fied straight leg raising test. J Orthop Res. 2006;24:1883-1889. http://dx.doi.
School of Rehabilitation Science org/10.1002/jor.20210
@Wc[i@$?hh]Wd]" PT, PhD McMaster University 12. Crawford F, Thomson C. Interventions for treating plantar heelpain.
Director of Clinical Research Hamilton, Ontario, Canada Cochrane Database Syst Rev. 2003;CD000416. http://dx.doi
Department of Orthopaedic Surgery macderj@mcmaster.ca org/10.1002/14651858.CD000416

University of Pittsburgh
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Medical Center F^_b_fCY9bkh[" PT, PhD
tween diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int.
Pittsburgh, Pennsylvania Professor
2003;24:251-255.
irrgangjj@upmc.edu Department of Physical Therapy
Arcadia University 14. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific
@ei[f^@$=eZ][i" DPT Glenside, Pennsylvania plantar fascia-stretching exercise enhances outcomes in patients with
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Orthopaedic Section, APTA, Inc 2003;85-A:1270-1277.
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icf@orthopt.org Director ultrasonographic follow-up of plantar fasciitis patients treated with
Southern California steroid injection. Joint Bone Spine. 2005;72:61-65. http://dx.doi.
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Rand Corporation
Santa Monica, California 16. Geppert MJ, Mizel MS. Management of heel pain in the inflammatory
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Acting Chair Ankle Int. 2001;22:569-571.
Athletic Training and Physical Therapy
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University of North Florida
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@ CEH;?D<EHC7J?ED
WWW.JOSPT.ORG
INSTRUCTIONS
ERRATA
TO AUTHORS
CORRECTIONS In the September 2008 issue, on page rection also applies to the Table of Con-
551, for the article titled “Differential Di- tents of that issue.
I
n the April 2008 clinical guide-
lines “Heel Pain—Plantar Fasciitis” by agnosis of a Patient Referred to Physical Please accept our apology for these
McPoil et al, the table under “Levels of Therapy With Low Back Pain: Abdomi- errors. Corrected reprints of the articles
Evidence,” on page A4, row 2, the greater- nal Aortic Aneurysm,” the second au- are available to members and subscrib-
than sign (“”) should be a less-than sign thor’s name was misspelled. The correct ers for download on the JOSPT web site
(“”), to read “ 80% follow-up.” spelling is “Zachary Preboski.” This cor- (www.jospt.org). T
648 | october 2008 | volume 38 | number 10 | journal of orthopaedic & sports physical therapy

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Clinical Guidelines

THOMAS G. MCPOIL, PT, PhD HE8HEOB$C7HJ?D"PT, PhDC7HAM$9EHDM7BB" PT, PhD

Heel Pain—Plantar Fasciitis:

of Function, Disability, and Health from

American Physical Therapy Association

SUMMARY OF RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A16

AUTHOR/REVIEWER AFFILIATIONS & CONTACTS . . . . . . . . . . A17

H;L?;M;HI0Anthony Delitto, PT, PhDJohn Dewitt":FJAmanda Ferland":FJHelene Fearon, PT

F7J>E7D7JEC?97B<;7JKH;I0 Clinicians should assess for ;N7C?D7J?EDÆ79J?L?JOB?C?J7J?EDC;7IKH;I0 Clinicians should

:?7=DEI?I%9B7II?<?97J?ED0 Pain in the plantar medial heel ?DJ;HL;DJ?EDIÆC7DK7BJ>;H7FO0Ma^k^blfbgbfZe^ob]^g\^

  IZeiZmbhgh_ma^ikhqbfZeieZgmZk_Zl\bZbgl^kmbhg better effect. (Recommendation based on moderate evidence.)

:?<<;H;DJ?7B:?7=DEI?I0 Clinicians should consider diagnostic ?DJ;HL;DJ?EDIÆEHJ>EJ?9:;L?9;I0 Prefabricated or custom

  <eZllb_rZg]]^Ög^\hffhgfnl\nehld^e^mZe\hg]bmbhgl standard of medical care. Standards of care are determined on

Plantar fascial ﬁbromatosis/Contracture of plantar fascia,

INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS

Secondary ICD-10 G57.5 Tarsal tunnel syndrome

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH

s75028 Structures of ankle and foot, neural

SECONDARY ICF CODES

Body structure s75020 Bones of ankle and foot (calcaneus/heel spur)

Li^\bZe Bgm^k^lm @khni h_ ma^ HkmahiZ^]b\ L^\mbhg% :IM:% g^\mbhg[^mp^^gma^:\abee^lm^g]hgZg]ma^ieZgmZkZihg^n-

F7J>E7D7JEC?97B<;7JKH;I Plantar fasciitis occurs as an enthesopathy in patients with

noted that the relationship between static foot posture as well

Clinicians should consider diagnostic classiﬁcations in doubt.8BgZk^\^gmlmn]r%Hl[hkg^^mZe41 utilized lateral

\hglblmlh_Z+*&bm^fZ\mbobmb^lh_]Zberebobg`!:=E"Zg]Zg es in a patient’s level of function over an episode of care.

Active and Passive Ankle Dorsiflexion

ICF category Measurement of impairment of body function: mobility of a single joint

Nature of variable Continuous

Units of measurement Degrees

The Dorsiflexion-Eversion Test

f or D iagnosis of Tarsal Tunnel Syndrome

Nature of variable Nominal

Units of measurement None

Diagnostic accuracy indices for 95% Conﬁdence Interval

Diagnostic accuracy indices for 95% Conﬁdence Interval

Nature of variable Nominal

Units of measurement None

Diagnostic accuracy indices for 95% Conﬁdence Interval

Diagnostic accuracy indices 95% Conﬁdence Interval

Positive likelihood ratio 16.21 0.88 - 298.75

Longitudinal Arch Angle

ICF category Measurement of impairment of body function: mobility of a multiple joints

Nature of variable Continuous

Units of measurement Degrees

with plantar fasciitis, randomized clinical trials evaluating _^^m"p^k^Zllb`g^]mh*h_+mk^Zmf^gm`khnil':e-

\^bo^]Zlm^khb]bgc^\mbhg%--iZmb^gml!,/"aZ]Z_Zl\bZekni- muscle stretching, and the use of viscoelastic heel orthoses.

C7DK7BJ>;H7FO and passive neural mobilization procedures.

ieZgmZka^^eiZbg'Ma^]nkZmbhgh_lrfimhfl_hkma^-iZ- stretching should be one of the interventions incorporated

h_ma^ÖklmmZklhf^mZmZklZechbgm%Zg]ln[mZeZkchbgm]blmkZ\- of calf stretching on improvement in ankle dorsi-

8 weeks in 24 (52%) of the 46 patients who performed the k^\^bobg`laZfnemkZlhng]hger'Hnm\hf^f^Zlnk^lbg\en]^]

cnlmbÖ\Zmbhg`bo^g_hkma^nl^h__hhmhkmahl^lblmh]^\k^Zl^ Pfeffer et al42 conducted a randomized multicenter

fhgmal'Ma^Znmahklk^ihkm^]maZmma^f^\aZgb\Zemk^Zmf^gm ance rates and the highest number of patients withdrawn,

D?=>JIFB?DJI Night splints should be considered as an interven-

cient to create an 88% improvement in 37 patients with

In a recent study, Roos et al50 investigated the ef-

The following physical examination measures may be useful in B ?DJ;HL;DJ?EDI0IJH;J9>?D=

Iocfjech[fheZkYj_edm_j^fWbfWjehofheleYWj_ede\j^[fhen_cWb or intermittent (20 seconds) stretching time, as neither dosage pro-

and Ankle Surgery Rehabilitation Consulting and 1997;87:11-16.

Department of Orthopaedic Surgery macderj@mcmaster.ca org/10.1002/14651858.CD000416

THOMAS G. MCPOIL, PT, PhD HE8HEOB$C7HJ?D"PT, PhDC7HAM$9EHDM7BB" PT, PhD

H;L?;M;HI0Anthony Delitto, PT, PhDJohn Dewitt":FJAmanda Ferland":FJHelene Fearon, PT

F7J>E7D7JEC?97B<;7JKH;I0 Clinicians should assess for ;N7C?D7J?EDÆ79J?L?JOB?C?J7J?EDC;7IKH;I0 Clinicians should

:?7=DEI?I%9B7II?<?97J?ED0 Pain in the plantar medial heel ?DJ;HL;DJ?EDIÆC7DK7BJ>;H7FO0Ma^k^blfbgbfZe^ob]^g\^

IZeiZmbhgh_ma^ikhqbfZeieZgmZk_Zl\bZbgl^kmbhg better effect. (Recommendation based on moderate evidence.)

:?<<;H;DJ?7B:?7=DEI?I0 Clinicians should consider diagnostic ?DJ;HL;DJ?EDIÆEHJ>EJ?9:;L?9;I0 Prefabricated or custom

<eZllb_rZg]]^Ög^\hffhgfnl\nehld^e^mZe\hg]bmbhgl standard of medical care. Standards of care are determined on

Li^\bZe Bgm^k^lm @khni h_ ma^ HkmahiZ^]b\ L^\mbhg% :IM:% g^\mbhg[^mp^^gma^:\abee^lm^g]hgZg]ma^ieZgmZkZihg^n-

F7J>E7D7JEC?97B<;7JKH;I Plantar fasciitis occurs as an enthesopathy in patients with

Clinicians should consider diagnostic classiﬁcations in doubt.8BgZk^\^gmlmn]r%Hl[hkg^^mZe41 utilized lateral

\hglblmlh_Z+*&bm^fZ\mbobmb^lh_]Zberebobg`!:=E"Zg]Zg es in a patient’s level of function over an episode of care.

with plantar fasciitis, randomized clinical trials evaluating _^^m"p^k^Zllb`g^]mh*h_+mk^Zmf^gm`khnil':e-

\^bo^]Zlm^khb]bgc^\mbhg%--iZmb^gml!,/"aZ]Z_Zl\bZekni- muscle stretching, and the use of viscoelastic heel orthoses.

C7DK7BJ>;H7FO and passive neural mobilization procedures.

ieZgmZka^^eiZbg'Ma^]nkZmbhgh_lrfimhfl_hkma^-iZ- stretching should be one of the interventions incorporated

h_ma^ÖklmmZklhf^mZmZklZechbgm%Zg]ln[mZeZkchbgm]blmkZ\- of calf stretching on improvement in ankle dorsi-

8 weeks in 24 (52%) of the 46 patients who performed the k^\^bobg`laZfnemkZlhng]hger'Hnm\hf^f^Zlnk^lbg\en]^]

cnlmbÖ\Zmbhg`bo^g_hkma^nl^h__hhmhkmahl^lblmh]^\k^Zl^ Pfeffer et al42 conducted a randomized multicenter

fhgmal'Ma^Znmahklk^ihkm^]maZmma^f^\aZgb\Zemk^Zmf^gm ance rates and the highest number of patients withdrawn,

D?=>JIFB?DJI Night splints should be considered as an interven-

The following physical examination measures may be useful in B ?DJ;HL;DJ?EDI0IJH;J9>?D=

Iocfjech[fheZkYj_edm_j^fWbfWjehofheleYWj_ede\j^[fhen_cWb or intermittent (20 seconds) stretching time, as neither dosage pro-