Elsevier

Manual Therapy

Volume 23, June 2016, Pages 76-82
Manual Therapy

Original article
Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomized controlled single-blind clinical trial

https://doi.org/10.1016/j.math.2015.10.006Get rights and content

Highlights

  • Daily stretching exercises are effective at improving pain and function.

  • Stretching with strengthening did not achieve better results than stretching alone.

  • The three treatment groups had high drop-out rate.

  • Natural progression cannot be inferred because of the lack of non-treatment group.

Abstract

Objective

To compare the effect of stretching with and without muscle strengthening of the foot alone or foot and hip on pain and function in patients with plantar fasciitis.

Design

Single blind randomized controlled trial.

Method

Eighty-three patients with plantar fasciitis were allocated to one of three treatment options for an eight-week period: Foot Exercise Group (FEG – extrinsic and intrinsic foot muscles), Foot and Hip Exercise Group (FHEG – abductor and lateral rotator muscles) and Stretching Alone Exercise Group (SAEG). Main measures: A visual analog scale for pain, the Foot and Ankle Outcome Score and the Star Excursion Balance Test. All evaluations were performed before treatment and after the last treatment session.

Results

Improvements were found in all groups regarding the visual analog scale, the pain, activities of daily living, sports and recreation, quality of life (p < 0.001) and other symptoms (p < 0.01) subscales of the Foot and Ankle Outcome Score as well as posterolateral movement, posteromedial movement and composite score (p < 0.001) on the Star Excursion Balance Test. No time-group interactions were found for any of the variables (p > 0.05).

Conclusions

All three exercise protocols analyzed led to improvements at eight-week follow-up in pain, function and dynamic lower limb stability in patients with plantar fasciitis.

Introduction

Plantar fasciitis (PF) is one of the most common conditions of the lower limbs. It is estimated that 10% of the population is affected at some time in life and two million Americans are treated for PF every year (McPoil et al., 2008). The multifactor etiology of this condition is not yet fully understood. Reduced strength of the plantar flexors, toe flexors and abductor hallucis muscles as well as a reduction in muscle volume in the forefoot are reported to contribute to PF (Kibler et al., 1991, Allen and Gross, 2003, Jung et al., 2011, Chang et al., 2012). Intrinsic and extrinsic muscles of the feet assist in supporting the medial longitudinal arch, absorption of impact during gait and lower limb function. However, studies on the effects of strengthening exercises for these muscles in patients with PF have reached inconclusive results (Soysa et al., 2012).

A low risk factor for PF is the reduction in strength of the abductor and lateral rotator muscles of the hips (McPoil et al., 2008, Martin et al., 2014). These muscles are important to the dynamic alignment of the lower limbs. A reduction in the strength of these muscles can lead to adduction and medial rotation of the hip and dynamic knee valgus, which is related to pronation of the foot (Khamis and Yizhar, 2007, Powers, 2010, Barton et al., 2012). Thus, strengthening the abductor and lateral rotator muscles of the hips may improve the dynamic alignment of the lower limbs and alleviate pain related to dynamic valgus (Snyder et al., 2009, Fukuda et al., 2010, Dolak et al., 2011). However, the effects of such exercises on PF are not yet understood.

Stretching of the plantar fascia and triceps surae muscle is often employed in the conservative treatment of PF. Sweeting et al. (2011) performed a systematic review on the effects of stretching and concluded that this method can assist in reducing pain symptoms. However, there is no consensus on the ideal number of repetitions and frequency. Moreover, there is no evidence of the benefits of combining stretching and strengthening exercises.

The purpose of the present study was to compare the effect of stretching and strengthening of foot and hip with stretching alone on pain and function in patients with plantar fasciitis. We hypothesized that patients who received foot and hip strengthening would demonstrate greater improvements in pain and function than those who received just stretching.

Section snippets

Patients

Eighty-three male and female patients participated in a randomized controlled clinical trial and were allocated into one of the three treatment options for an eight-week period: Foot Exercise Group (FEG), Foot and Hip Exercise Group (FHEG) and Stretching Alone Exercise Group (SAEG). The participants were 20–60 years old, had a medical diagnosis of PF with symptoms for more than 30 days and were recruited through printed and digital media. The diagnosis was performed by physicians from Santa

Results

Among the 365 patients originally recruited, 282 were excluded based on the eligibility criteria: 171 were not within the stipulated age range; 17 had symptoms for less than 30 days; 20 refused to participate; six had a BMI higher than 35 kg/m2; seven were taking pain medications; and 61 had an associated disease that could predispose the individual to heel pain, altered alignment, alter sensitivity or impair the healing process. Thus, 83 patients were randomly allocated to the groups. Four

Discussion

In the present study, the three different exercise protocols achieved similar improvements in pain, function and dynamic stability of the lower limbs in patients with PF. Thus, eight weeks of strengthening exercises of the intrinsic and extrinsic muscles of the feet and the abductors and lateral rotators of the hips combined with stretching exercises did not achieve better results in comparison to stretching alone.

Previous studies also reported the benefits of stretching in the PF treatment (

Conclusion

All three exercise protocols analyzed led to improvements at the eighth-week follow-up in pain, function and dynamic lower limb stability in patients with plantar fasciitis. The non-significant differences among the groups suggest that daily stretching is effective and protocols that combine stretching with strengthening do not achieve better results than stretching alone expressed by the outcomes analyzed in this population.

Acknowledgments

We gratefully acknowledge the financial support from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and Felipe Granado de Souza for statistical support.

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  • Cited by (0)

    Clinical Trial Number: 05439012.0.0000.5505.

    1

    Present address: Health Sciences Institute, Universidade Paulista, Sorocaba, SP, Brazil.

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