Joint Mobilization and Stretching Exercise vs Steroid Injection in the Treatment of Plantar Fasciitis: A Randomized Controlled Study – Duke Center of Excellence in Manual and Manipulative Therapy

Author Names

Celik, D., Kuş, G., & Sırma, S. Ö.

Reviewer Name

Abby Bergeron, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: This study compared the effectiveness of joint mobilization combined with stretching exercises (JM&Str) vs steroid injection (SI) in the treatment of plantar fasciitis (PF).

Methods: A total of 43 patients (mean age, 45.5 ± 8.5 years; range, 30-60 years; 23 females) with PF were randomly assigned to receive either JM&Str (n = 22) or SIs (n = 21). JM&Str was applied 3 times per week for 3 weeks for a total of 9 visits. The SI group received 1 injection at baseline. The patients’ functional scores were assessed using the Foot and Ankle Ability Measure (FAAM), and pain was evaluated using the Visual Analog Scale (VAS). Outcomes of interest were captured at baseline and at 3-week, 6-week, 12-week, and 1-year follow-ups. The primary aim was examined using a mixed-model analysis of variance (ANOVA). Pairwise comparisons were performed to examine differences between the baseline and follow-up periods using Bonferroni equality at an alpha level of 0.05.

Results: Age, sex, body mass index, and dorsiflexion range of motion did not significantly impact pain relief or functional outcome (P > .05) at the 3-, 6- or 12-week follow-ups compared to baseline. Planned pairwise comparisons demonstrated significant improvements in pain relief and functional outcomes in both groups (P < .05) at the 3-, 6-, and 12-week follow-ups compared to baseline. However, at the 12-week and 1-year follow-ups, pain and functional outcomes were significantly improved in only the JM&Str group (P = .002). The overall group-by-time interaction was statistically significant for both FAAM (P = .001; F = 7.0) and VAS (P = .001; F = 8.3) scores. Between-group differences favored the SI group at the 3-week (P = .001, P = .001), 6-week (P = .002, P = .001), and 12-week (P = .008, P = .001) follow-ups for pain relief and functional outcomes. However, no significant differences (P = .62, P = .57) were detected in the measured outcomes at the 1-year follow-up.

Conclusion: Our study demonstrated that while both groups achieved significant improvements at the 3-, 6-, and 12-week follow-ups, the SI group exhibited better outcomes at all 3 time points. The noted improvements continued in only the JM&Str group for a period of time ranging from 12 weeks to 1 year.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Cannot Determine, Not Reported, or Not Applicable

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

When compared to baseline, both steroid injections and joint mobilization/stretching interventions significantly improved pain and function in patients with plantar fasciitis at 3-, 6-, and 12-week follow-ups.

Key Finding #2

The group that received steroid injections experienced greater improvements in pain and function than did the joint mobilization/stretching group throughout the 3 to 12-week time frame.

Key Finding #3

Only the joint mobilization/stretching group demonstrated improvements in pain and function for the period of 12 weeks to 1 year (though not statistically significant).

Please provide your summary of the paper

This 2016 randomized controlled study examined and compared the effectiveness of joint mobilization combined with stretching exercises to that of a steroid injection in reducing pain and improving function in patients with plantar fasciitis. Forty-three patients were randomly assigned to receive either joint mobilization with stretching interventions or the steroid injection, though four participants (two from each group) dropped out of the study by the time it was completed. The joint mobilization/stretching group received Grade I and Grade II rhythmic oscillations to control pain. The same physical therapist applied subtalar traction, talocrural dorsal glides, subtalar lateral glides, and first tarsometatarsal joint dorsal glides at each session. Stretching exercises (gastrocnemius stretching and plantar fascia-specific stretching) were completed over 9 visits to the clinic and twice at home. For participants who were allocated to the steroid injection group, the injection was administered once at baseline at the point of maximal tenderness of palpation.

At multiple time points (3-week, 6-week, 12-week, and 1-year follow-ups) the Foot and Ankle Ability Measure (FAAM) (both the ADL and sports subscales) was used to measure function and the Visual Analog Scale (VAS) was used to monitor pain intensity. When compared to baseline, both steroid injections and joint mobilization/stretching interventions significantly improved pain and function in patients with plantar fasciitis at 3-, 6-, and 12-week follow-ups, though the group that received steroid injections experienced greater improvements. Of note, only the joint mobilization/stretching group demonstrated improvements in pain and function for the period of 12 weeks to 1 year (though not significant).

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This randomized controlled study demonstrates the effectiveness of commonly implemented treatments for plantar fasciitis: steroid injections and joint mobilizations combined with stretching. However, these appear to provide significant improvements in pain and function only in the short term (up to 12 weeks). It is therefore important to consider patient goals when recommending a treatment approach for plantar fasciitis. That is, it is essential to determine if your patient needs shorter-term pain relief versus a longer-term solution. Though steroid injections can provide significant short term pain relief and improved function, results from this study may indicate that manual therapy may be a more appropriate treatment approach to achieve longer-term improvements in these outcomes when compared to steroid injections.