Plantar Fasciitis: What's an Evidence-Informed Consumer to Do?

In the Spring 2005 issue of Physiotherapy Canada, I wrote an editorial about the “dilemma” of evidence-based practice (EBP)¹ that subsequently generated a number of thought-provoking responses from our readers in the form of letters to the editor. Those letters certainly heightened my awareness of the many difficulties involved in trying to be an evidence-based practitioner when working in typical clinical settings.^2–6 In several of those letters, the authors commented on the difficulty and/or expense of accessing and securing relevant articles if one is not affiliated with a university.^2,3,5

As a university-based physiotherapist, I cannot disagree that my access to research and review articles is certainly far easier and cheaper than that of my clinician colleagues who are not university-affiliated clinical instructors, faculty members, or graduate students. Nonetheless, there is a widely increasing array of no-cost options available to any physiotherapist who wishes to practice in an evidence-based manner. To exemplify my point, let me use an example from my current perspective as a person who is experiencing acute plantar fasciitis.

My clinical expertise as a long-time paediatric physiotherapist has certainly not included musculoskeletal conditions typically found in middle-aged adults. But as a lifelong jogger (now brisk walker), I needed to get to the bottom (or sole) of this inflammatory condition! I would like to share with you what I did to access the evidence about this condition in the hope that you can replicate these steps when treating patients with any type of disease or disorder.

STEPS IN SEARCHING THE LITERATURE

Step 1: Google

Google is a very easy-to-use search engine for anyone who owns a computer: www.google.ca. The down side of using Google is that you will find not only some credible evidence but also a lot of advertisements from companies that provide products to deal with the disorder in question, in this case plantar fasciitis. On the first page of my Google search, after typing in “plantar fasciitis,” I was able to refine my search to the following topics that appeared on the screen: “causes/risk factors,” “symptoms,” “tests/diagnosis,” “treatment,” and “for patients” or “for health professionals.”

I chose to look first at “symptoms” and “tests/diagnosis” to confirm my own diagnosis. One of many options available to me was the Mayo Clinic website, which seemed like a first-rate place to start: www.mayoclinic.com/health. Based on the symptom information at that site (including sharp pain on the inside of the bottom of the heel, heel pain that is worse after awakening, and heel pain that is worse after long periods of walking or jogging), I was reasonably sure of my diagnosis.

I scrolled down the first page a bit further to find a patient-oriented article from the highly respected Journal of the American Medical Association (JAMA), and the PDF was available to me immediately (at no cost) with a click of my mouse.⁷ Next I clicked on “treatment” and found a very informative 11-page e-Medicine article on plantar fasciitis, last updated in April 2006, authored by two physicians⁸: http://www.emedicine.com/emerg/topic429.htm. From this article I learned that the peak incidence for plantar fasciitis is in women aged 40 to 60 years, adding further confirmation to my diagnosis.

Not being certain whether or not e-Medicine is peer reviewed, I decided to examine the reference list from that article. Seven relatively recent research or review articles (1999–2005) were referenced, several from very prestigious medical journals (e.g., Journal of Bone & Joint Surgery, New England Journal of Medicine). Each article in the reference list had a MEDLINE icon following it; consequently, I was able to access abstracts for all seven articles and the full text for three—at no cost, and without using my university Internet connection.

One article was a randomized controlled trial (RCT) comparing calf/Achilles stretches to tissue-specific plantar fascia stretching;⁹ another was an evidence-based review of diagnosis and therapy for plantar fasciitis,¹⁰ and the third was a review article on diagnosis and therapeutic considerations.¹¹ Two of the articles were published in 2005 and the third in 2003, so I was reasonably confident that I had up-to-date information.

Step 2: Google Scholar

Google Scholar is a no-cost search engine available to anyone who owns a computer. All you need to do is enter Google and then type in Google Scholar—or you can access it directly via http://scholar.google.com/. Surprisingly, I found Google Scholar less helpful than Google had been (i.e., the articles I found on plantar fasciitis were older than those I had uncovered through my Google search). Consequently, I decided to go “right to the source” and see what was available on PubMed.

Step 3: PubMed

PubMed is a free search engine from the National Library of Medicine of the US National Institutes of Health: http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed.

I entered “plantar fasciitis” and was somewhat surprised to find only 459 entries. Because PubMed citations generally appear in chronological order, starting with the most recent publications, I decided to search for any articles published since 2005. Of the 70 English-language citations from 2006 and 2007, 8 were available in full text at no cost (and without a university affiliation), and free abstracts were available for all of them. Two of those, both RCTs, sounded interesting and relevant, so I downloaded the PDFs and printed the articles.^12,13

DESIGNING AN EVIDENCE-BASED TREATMENT PLAN

Although physiotherapist colleagues who work in orthopaedics had recommended calf-stretching exercises to me, two of the articles I accessed suggested that tissue-specific plantar fascia stretches were superior to calf stretches.^9,13 My colleagues had also recommended shoe inserts/orthoses to correct “over-pronation.” I was delighted to find that pre-fabricated (off-the-shelf) orthoses were similarly effective to customized orthoses in one study¹⁴ and even more effective than customized orthoses, when each was combined with stretching, in another study.¹⁵ A recent RCT supported the use of non-steroidal anti-inflammatory medication (NSAID) as part of a conservative treatment approach for plantar fasciitis.¹⁶

Although I was unable to locate any studies that examined the effects of decreasing the extent of upright ambulatory activities, especially jogging and recreational walking, on the resolution of symptoms, most experts who have published on this topic believe that these are triggers for initiating or exacerbating plantar fasciitis, and my personal history of jogging/brisk walking for 20 to 25 miles per week appeared to corroborate that.

Treatments for Which There Is Limited Research Support

A 2003 Cochrane systematic review of interventions for plantar fasciitis found either limited or conflicting evidence for the use of the following treatments: topical corticosteroids administered by iontophoresis; low-energy extracorporeal shock-wave therapy; corticosteroid injections; and dorsiflexion night splints.¹⁷ There was no evidence to support the use of ultrasound, low-intensity laser therapy, or magnetic shoe insoles. To date, there have been no controlled trials to examine the effects of surgery in the management of plantar fasciitis.

Evidence-Based Treatment Plan

Based on the evidence available to me from reading and printing a number of abstracts of peer-reviewed research and half a dozen full-text articles available at no cost, I developed the following treatment plan: (1) purchase and use pre-fabricated shoe inserts/orthoses combined with new running shoes; (2) conduct tissue-specific plantar fascia stretching three times daily for sessions of 10 10-second stretches; (3) take extra-strength ibuprofen every four waking hours; (4) discontinue jogging until pain has resolved; and (5) decrease brisk walking from 20–25 miles per week to 10–15 miles/week.

Ideally, I should switch from recreational walking to other low-impact or no-impact sports, such as bike riding or swimming, until the pain has resolved. However, given that one of the three components of evidence-based medicine is the incorporation of patient values,¹⁸ I chose to stick with those activities that I most value.

SUMMARY AND RECOMMENDATIONS

The primary purpose of this editorial is to demonstrate how one can become an evidence-based practitioner despite having no access to a university library search system. Although my searches took a bit of time to conduct, as well as some reading and digesting of the available research, I am reasonably confident that I could now become an evidence-based physiotherapist in treating persons with plantar fasciitis. The tissue-specific plantar fascia–stretching techniques are well described in at least two of the articles to which I had free access, with accompanying photos demonstrating the stretching technique.^10,13

According to the Oxford University Centre for Evidence-Based Medicine,¹⁸ evidence-based medicine (or evidence-based practice, EBP) involves melding the best research evidence available with clinical expertise and patient values (which must be integrated into clinical decisions). Although I am far from a “clinical expert” when it comes to the management of adult musculoskeletal disorders, such as plantar fasciitis, I had the good fortune of being able to consult with clinical musculoskeletal experts and to combine those opinions with the best research evidence and my own values to continue recreational walking as opposed to other types of recreational activities.

Plantar fasciitis is a relatively common clinical condition, especially for physiotherapists who treat persons with musculoskeletal impairments. My goal here is not to educate readers about plantar fasciitis diagnosis and treatment (though I hope I have succeeded in that, to some extent) but to demonstrate how easy it is to become an evidence-based practitioner, even without access to university search capabilities.

For common (or rare) clinical conditions encountered in everyday practice, I would encourage practitioner readers to take the following steps in conducting literature searches for the best available research evidence: (1) access PubMed first and type in the relevant disease or disorder; (2) narrow the search by using key-word combinations such as “plantar fasciitis AND treatment” or “plantar fasciitis AND diagnosis”; and (3) view and print relevant abstracts and available full-text articles (the latter will appear as coloured orange-and-green icons to the left of the article title). Starting your search with PubMed will ensure that most of the articles you find will have been peer reviewed.

As a back-up strategy, use Google (or Google Scholar) to find additional information about the condition; you will find a lot of resources that have not been peer reviewed, but you may also be able to access specific articles that you were unable to access in PubMed.

I would welcome letters to the editor from clinicians who try these strategies and would like to hear also about successes or pitfalls encountered. We owe it to our profession—and, more importantly, to our patients—to lead the health care world in demonstrating our ability to use research evidence in making informed decisions about the care we provide.