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encouraging stretching study results

Posted by Bill S on 7/10/03 at 14:12 (123952)

Take a look at: http://www.pslgroup.com/dg/23619e.htm for some interesting results re: stretching the plantar fascia vs. Achilles tendon.

Bottom line is that stretching the plantar fascia by hand might be a good approach - especially before arising from bed or a long sit.

I'm going to try it for a while....along with my IbuCream that arrived yesterday.

Good luck to all....Bill

Re: encouraging stretching study results

Scott R on 7/10/03 at 16:19 (123961)

this looks like a new and important thing. i'll modify the book.

Re: encouraging stretching study results

BrianJ on 7/10/03 at 17:44 (123991)

Clinically, the plantar fascia is supposed to have virtually no extensibility. In other words, it doesn't stretch. How does this clinical fact square with the 'plantar fascia stretching' in the study?

Re: encouraging stretching study results

Ed Davis, DPM on 7/10/03 at 17:53 (123996)


It is interesting to note, in the study, that patient numbers were not mentioned. Additionally, a plantar fascial 'stretching' technique is compared to an achilles stretch BUT not the right kind of achilles stretch.


Re: encouraging stretching study results

Scott R on 7/10/03 at 22:28 (124030)

i didn't see anything wrong with their method of stretching the achilles...leg straight works good for me, but i would have preferred it to be on a step. it did seem to be an aggressive regiimen which could have increased the pain. even if the fascia itself does not stretch, it could be sort of a warming up or massaging for the connection point to the heel and forefoot. They had 82% follow-up (82 out of 101 people)...i wonder what percent of those not following up were achilles stretchers who got better. the 82 people who did follow-up....that's not a very large number as Dr Ed suspected....it's hard to get any statistical significance in this type of study from two populations of only 40 people...the sample is just too small unless it was a huge difference in the results..which i doubt. for example, image the fascia stretching group had 90% recovery and the achilles group had 60% recovery. The difference should not have been much larger unless the authors would like to admit the other treatments that were being applied to both groups did not have any effect. Any way, that would mean 36 of the 40 fascia stretchers and only 24 of the 40 achilles stretchers got better. OK, statistics can probably can show that is significant, but given that the authors were looking for the outcome they got and that the study was not double-blind....i have to look at the article with skepticism. but that they acheived much less pain with first steps in the morning by using this technique is very important. but i would like to make sure the patients with the achilles stretch were reported 'pain with first steps in the morning' were refering to AFTER they had stretched.

here's the abstract:

BACKGROUND: Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. We hypothesized that patients with chronic plantar fasciitis who are managed with the structure-specific plantar fascia-stretching program for eight weeks have a better functional outcome than do patients managed with a standard Achilles tendon-stretching protocol. METHODS: One hundred and one patients who had chronic proximal plantar fasciitis for a duration of at least ten months were randomized into one of two treatment groups. The mean age was forty-six years. All patients received prefabricated soft insoles and a three-week course of celecoxib, and they also viewed an educational video on plantar fasciitis. The patients received instructions for either a plantar fascia tissue-stretching program (Group A) or an Achilles tendon-stretching program (Group B). All patients completed the pain subscale of the Foot Function Index and a subject-relevant outcome survey that incorporated generic and condition-specific outcome measures related to pain, function, and satisfaction with treatment outcome. The patients were reevaluated after eight weeks. RESULTS: Eighty-two patients returned for follow-up evaluation. With the exception of the duration of symptoms (p < 0.01), covariates for baseline measures revealed no significant differences between the groups. The pain subscale scores of the Foot Function Index showed significantly better results for the patients managed with the plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and item 2 (first steps in the morning; p = 0.006). Analysis of the response rates to the outcome measures also revealed significant differences with respect to pain, activity limitations, and patient satisfaction, with greater improvement seen in the group managed with the plantar fascia-stretching program. CONCLUSIONS: A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. These findings provide an alternative option to the present standard of care in the nonoperative treatment of patients with chronic, disabling plantar heel pain. Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.


Re: encouraging stretching study results

Ed Davis, DPM on 7/11/03 at 00:11 (124044)


You must have read the paper itself since I did not note the numbers listed in the absract.

Many patients with PF do very poorly with weight bearing stretches. I would not categorize the wall stretch as consistently incorrect but have to wonder if it was the only stretch used for comparison.


Re: encouraging stretching study results

Dr. Z on 7/11/03 at 14:57 (124130)

Does anyone know the pf stretching technique that they are using. Is it just massaging and or pulling the toes and fascia non-weight bearing????

Re: encouraging stretching study results

Bill S on 7/11/03 at 15:57 (124139)

Here's an extract from the posting:

'Dr. DiGiovanni and his colleagues recommend that patients with heel pain caused by plantar fascitis learn how to perform plantar fascia-stretching exercises. Patients are instructed to perform these exercises before getting out of bed in the morning by sitting on the side of the bed and crossing the affected leg over the other leg, resting the ankle on top of the thigh. Using the hand on the affected side, the patient places the fingers across the base of the toes on the bottom of the foot and pulls the toes toward the shin until he or she feels a stretch in the arch of the foot. The patient places the other hand on the sole of the foot to feel the tension and confirm that it is being stretched. Patients are also instructed to perform the stretch prior to standing after prolonged sitting or inactivity, such as after sitting for a meal.'

Re: encouraging stretching study results

john h on 7/12/03 at 10:13 (124202)

Dr. Z it sounds to me like the crux of this is to manually hold the fascia in a stretched position by dorsiflexing the foot for 10 seconds a few times anytime you sit for a long period of time or sleep. If you have hallux limitus this becomes difficult if not painful.

Re: encouraging stretching study results

Ed Davis, DPM on 7/12/03 at 12:29 (124223)


Interesting point about hallux limitus. Hallux limitus places more than one limitation on treatment of PF. When it comes to orthotics, it is difficult to get good midtarsal joint control when a patient has hallux limitus.

Re: encouraging stretching study results

john h on 7/12/03 at 18:02 (124262)

Ed: I had a cheilcectomy on my left toe about three years ago and it worked great. I am considering my other toe now. The surgery really was not all that bad.

Re: encouraging stretching study results

Judi B. on 9/26/03 at 05:12 (131110)

Well, I'm glad to hear of this study. I wear a nite splint - 8 moonths now - I'm stretched - through the leg! If I don't keep it stretched I need a cane to walk. However, I just can't get the arch stretched well enough, long enough to heal completely. I haven't had the arch pain for a long time now (not sure if that's good or bad?) The variation on the wall-leg stretch from my physiotherapist, intended to hit the arch is hard on the foot itself. I'll have a go at stretching it by hand... The study said 'exercises' plural. I only read of one exercise?! How do I find more?