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.

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