Plantar fasciitis loading programs – overhyped evidence

I have managed to get myself into a few spats in social media lately over the results of the Rathleff et al (2014) study on loading programs for plantar fasciitis mainly because I think the study is way overhyped and blindly and widely shared by too many devoid of critical thinking skills. I blogged about this study at the time on my other blog, so thought I would re-litigate the main issues here, so I can refer those in my social media spats to have a read of.

Firstly, I do clinically use the loading/strengthening program that is advocated in this study, have been using it and teaching it in my Clinical Biomechanics Boot Camps since before the study was published, so I like it and think it is important to do. I use it as it makes sense to do so. The approach I have long advocated for plantar fasciitis is to deal with that initial ‘hot’ phase (ice, NSAIDs; strapping); then reduce loads (activity modification; foot orthotics with the right design features (getting that right is important); stretching); then loading and strengthening; then return to full activity plan; if that does not go according to desired outcomes, then do things to facilitate healing (eg shockwave, injection therapy, etc). Above all, plantar fasciitis is a mechanical problem and needs mechanical solutions (initially reduce loads, then increase loads).

So what is the problem I have with the Rathlef et al study? The problem I have, is the hype and importance that is given to it. It is way over hyped. It still gets widely promoted in social media. The strength of evidence that the study gives to the use of a loading program is really low, if at all. It should not make it into a meta-analysis or any sort of consensus document because of that weakness (unless, of course, those writing the consensus document want to use it to confirm their preconceived biases).

The study randomized participants with plantar fasciitis into two groups. One group got the strengthening/loading program and the other a stretching program. Both groups got better, but at 3 months the loading program group did better. On the surface that looks like a good outcome for loading programs.

However, both groups were also given silicone heel pads which we know from the Pfeffer et al (1999) study that they work in plantar fasciitis. Both groups were probably going to get better because of that. It could easily have been that both the stretching and loading/strengthening actually delayed healing but they still got better because of the silicone heel pads. The claimed results that the loading group did better could easily be explained by the loading/strengthening not delaying healing as much as the stretching group. The study did not have a ‘no treatment’ group or control group. Now, in all honesty, I very much doubt that is what happened, but because it remains a possibility to explain the results, you can see why I think the results of the study are way over-hyped and given too much weight. This is also why the strength of the design of the study is so weak, as we do not know how a placebo or no treatment group would have gone (or preferably, a group just given the silicone inserts). If there was a third group that just had the silicone insert, then presumably this group would have improved (as the Pfeffer study showed), so how much better than that would have the stretching and strengthening/loading groups have been, if at all? We just do not know.

Another issue, and I on shaky grounds saying this, is look at the graph in the paper of the results. Look at the reduction in the Foot Function Index at say 3 months and at 6 months. How well do you think you would be doing in clinical practice if that was all you were getting in your patients? Like I said, I on shaky grounds saying this as this is the artificial environment of a clinical trial, but if you are not getting those levels of pain reduction at 1 month, then you probably need to take a serious look at your clinical practice as to why.

…nuff said. Critical thinking please. Next.

Please sign up for my newsletter when a new content is posted:




Advertisement:

SaleBestseller No. 1
2024 Coding Companion for Podiatry (Spiral)
  • Optum (Author)
  • English (Publication Language)
SaleBestseller No. 2
Pocket Foot and Ankle Medicine and Surgery (Pocket Notebook Series)
  • English (Publication Language)
  • 400 Pages - 07/18/2018 (Publication Date) - LWW (Publisher)
SaleBestseller No. 3
Minimally Invasive Foot and Ankle Surgery: A Percutaneous Approach
  • Hardcover Book
  • Vulcano MD, Dr. Ettore (Author)
SaleBestseller No. 4
QYUVK Retractable Podiatry Badge Reel with Alligator Clip, Funny Black Glitter Foot Badge Holder Gift for Doctors Nurses Podiatrist Podiatry Squad Podiatric or Foot Doctor, DPM Graduation Gift
  • 【PRODUCT SIZE】: The width of The retractable badge reel is 1.8 inch, length is 4.1 inch, retracts to extend 24 inch (60cm) nylon cord, weight about 0.60 oz.
  • 【HIGH QUALITY】: The Glitter badge holder is made of high quality Acrylic, ABS and metal, and the rope is mainly made of quality nylon material, which is sturdy and strong, safe and reliable, not easy to break, fade or tear, you can use for a long time with confidence.
Bestseller No. 5
Jaws Podiatry No B.S. Callus Cream 40% Urea Callus Remover For Feet - Soften Exfoliates Hydrates and Renews Skin - Podiatrist-Recommended
  • 40% Urea Acid - Our Callus Cream is enriched with an impressive 40% concentration of Urea Acid, a powerful ingredient known for its exfoliating and moisturizing properties. This high level of Urea Acid effectively softens and breaks down calluses, promoting the gentle removal of dead skin cells.
  • Intensive Moisturization - Beyond callus removal, our cream deeply nourishes and hydrates the skin. The rich and emollient formula penetrates deep into the skin, providing long-lasting moisture that helps prevent the recurrence of calluses. Enjoy the luxury of velvety-smooth feet with each application.
Bestseller No. 6
Podiatry Student Handbook: (Second Edition)
  • Shi, Eric (Author)
  • English (Publication Language)
Bestseller No. 7
Large Surgical-Grade Nail Clippers - Podiatrist-Recommended Stainless Steel Toenail Clippers - Pedicure Tools for Thick Toenails - Jaws Podiatry
  • Surgical-Grade Stainless Steel - Experience the pinnacle of quality with our toenail clipper, meticulously crafted from surgical-grade stainless steel. This premium material ensures longevity, corrosion resistance, and a sharp cutting edge that effortlessly trims even the toughest toenails.
  • Double Action Mycotic Nail Nipper - A specialized nail care tool designed to cut through thick, fungal-infected toenails and fingernails with ease and precision. Features a double-action mechanism to provide extra leverage, reducing hand strain and ensuring a clean, smooth cut. Ideal for both professional podiatrists and individuals managing mycotic nail conditions at home. Made from high-quality stainless steel for durability and easy sterilization.
SaleBestseller No. 8
Bestseller No. 9
Podiatry Medical Assistant Podiatrist Funny Podiatry Nurse T-Shirt
  • A funny podiatry graphic for medical assistants, nurses, foot doctors, specialists and physicians working in podiatric medicine in hospitals and medical clinics.
  • A podiatry medical assistant design for men and women.
SaleBestseller No. 10

I get commissions for purchases made through links on this website. As an Amazon Associate I earn from qualifying purchases