wedges were assessed to see if any of them decreased tension in the plantar fascia. The only type of heel wedge that provided any support was one with a shank wedge that simulated a high-heeled shoe (Kogler et al., 2001). It has been suggested that a semi-rigid prefabricated orthosis with the most support at the apex of the arch is a good recommendation for patients with plantar fasciitis. However, if these are not well tolerated, a lateral forefoot or shank wedge could be used. Iontophoresis and electrical stimulation Iontophoresis with either dexamethasone or acetic acid at 40 mA/min is commonly used in the treatment of pain associated with plantar fasciitis. Unfortunately, the research does not support these to be effective treatments for the condition. One study compared pain scores between a group receiving stretching and manual therapy to a group receiving stretching and iontophoresis (Cleland et al., 2009). The scores were similar between groups, but scores favored the group receiving manual therapy. In another study, both groups received foot orthoses and stretching exercises (Stratton et al., 2009). One group also received electrical stimulation. Both groups reported significant improvements in VAS scores, but there was no statistical advantage to using the electrical stimulation. While iontophoresis and/or low-dose electrical stimulation may provide some short-term relief from symptoms, they are not truly an effective treatment of plantar fasciitis. Ultrasound and phonophoresis A review of multiple studies found that ultrasound was no more effective than sham treatment for heel pain (Shanks et al., 2010). One study found mild evidence to support that phonophoresis does decrease pain in small, though statistically significant, amounts compared to use of ultrasound (Jasiak et al., 2007). While use of ultrasound is not recommended for plantar fasciitis, phonophoresis with ketoprofen may have a limited usefulness to decrease pain. Remembering that plantar fasciitis is not an inflammatory condition when explaining the rationale for use of phonophoresis to the patient, the therapist should emphasize that it helps to reduce pain, not inflammation. Dry needling The 2014 clinical pathways guidelines from the Academy of Orthopedic Physical Therapy did not recommend the use of dry needling in the treatment of plantar fasciitis because of limited evidence to support its efficacy (Tong & Furia, 2010). However, since this was published, there have been additional studies to support the use of dry needling for pain. In a small study published in 2016, twenty patients were randomized to receive either dry needling or no treatment (Eftekharsadat, et al., 2016). Researchers found that dry needling had no effect in improvement of range of motion in the foot and ankle but did provide a significant benefit in decreasing pain both immediately following 4 weeks of treatment and 4 weeks afterward. A review of acupuncture modalities found dry needling was more effective than sham treatment for the treatment of plantar fasciitis (Cox et al., 2016). Muscle trigger points in the following muscles may affect the symptoms of plantar fasciitis: abductor digiti minimi, abductor hallucis, adductor hallucis, quadratus plantae, flexor digitorum brevis, lumbricales, interossei, soleus, gastrocnemius, flexor hallucis longus, flexor digitorum longus, peroneus longus, peroneus brevis, tibialis anterior, extensor hallucis longus, extensor digitorum longus, gluteus maximus, gluteus medius, gluteus minimus, piriformis, tensor fascia latae, adductor longus, adductor magnus, adductor brevis, semitendinosis, semimembranosis and biceps femoris. While there is currently limited evidence for this modality, it appears that there could be a place for dry needling in the treatment of plantar fasciitis. Further research is needed to fully establish appropriate parameters and to prove its effectiveness. Weight loss As a high body mass index (BMI) is closely correlated with plantar fasciitis, it would seem that losing weight would decrease plantar fasciitis symptoms. The research does not provide much support for this theory; however, it does not disprove this as a treatment
review of the literature found that foot exercises, toe exercises against resistance, and minimalistic running shoes may contribute to improved intrinsic foot muscular function (Huffer et al., 2016). Ice Ice is commonly used as a treatment for plantar fasciitis, with the rationale being that it will help to diminish the inflammation. However, the research shows that plantar fasciitis is not a true inflammatory condition, but instead a degenerative condition. Therefore, ice will not help the treat the condition itself, though it can help to alleviate pain (Bleakley et al., 2004). Common applications include freezing a water bottle and rolling the frozen bottle under the plantar surface of the foot, ice baths with a focus on movement and increasing range of motion in the water, and a simple direct application of ice to the heel or the plantar surface of the foot, depending on where the patient’s pain is located. Taping Multiple studies and good evidence support the use of taping for treatment of plantar fasciitis, specifically a technique called low-dye, or anti- pronation taping (Poldosky & Kalichman, 2015). Essentially, three strips of non-stretchy tape are applied the lateral side of the fifth MTP joint, around the back of the heel and attached to the plantar surface of the foot near the MTP joints. Several pieces of tape are used to support the arch, by affixing the tape to the lateral side and pulling medially. Then another piece of tape is placed on the lateral side of the fifth MTP joint. The final piece of tape goes all the way around the ball of the foot to hold the edges in place. This taping technique supports the arch and helps to prevent over-pronation. It is most effective in the initial weeks (one to three weeks) to help reduce the pain, but in one study was not more effective than arch supports (Park et al., 2015). With this in mind, taping may be most effective to screen for patients that may be good candidates arch supports in the first weeks of treatment. Night Splints A study by Lee et al. (2012) found that night splints were most effective when used with foot orthoses during the day. Another study found that night splints were much more effective in reducing pain than traditional conservative treatment, especially at the two-month mark (Beyzadeoglu et al., 2007). The type of splint does not seem to have a significant effect on the decrease in pain; however, not all patients tolerate wearing a night splint. It is important to have a conversation about how effective this treatment is despite how uncomfortable it may initially feel at night. If the patient is involved with making the decision about the type of splint chosen, it may improve the likelihood that the patient will comply with the recommended treatment. Orthotics One of the major risk factors, and possible causes of plantar fasciitis, is over-pronation of the foot. With this in mind, arch supports, or orthotics, are an excellent way to treat this issue. In 2008, a Cochrane review of 11 randomized controlled trials examined the effectiveness of orthotics in the treatment of heel pain in plantar fasciitis (Hawke et al., 2008). The study found that custom orthoses were no more effective than prefabricated orthotics. However, orthotics do help to decrease pain and tension on the plantar fascia, so it is beneficial to recommend these to patients, especially if low-dye taping has provided some relief in symptoms. There are several different types of orthotics, and patients may ask for specific recommendations. Studies have been completed comparing three common brands of orthotics (Powerstep®, Superfeet®, and Sole®), and found that all three provided 30% relief of symptoms (Ferber & Hettinga, 2015). Another group of studies focused on types of orthotics and the amount of decrease in tension that each affected on the plantar fascia. The most effective orthotic provided the most support at the talonavicular joint, or the apex of the arch in the foot (Kogler et al., 1996). In the second study of this group, eight different combinations of support were studied. Only the lateral forefoot wedge provided an offloading support of the plantar fascia (Kogler et al., 1999). In the final study of this group, heel elevation
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