Journal of Geriatric Physical Therapy:
The Clinical Reasoning Process for the Intervention of Chronic Plantar Fasciitis
Peplinski, Stephanie L. DPT1; Irwin, Kent E. PT, MS, GCS2
1 Department of Physical Therapy, Park Nicollet Health Services—Methodist Hospital, St Louis Park, Minnesota.
2 Midwestern University, Downers Grove, Illinois.
Address correspondence to: Kent E. Irwin, PT, MS, GCS, Midwestern University, Alumni Hall Room 340A, 555 31st St, Downers Grove, IL 60515 (email@example.com).
Background and Purpose: Of the many foot and ankle conditions affecting older adults, plantar fasciitis (PF) can be especially debilitating when present for many months or years. Chronic PF is an inflammatory condition of the foot that can be detrimental to an individual's functional abilities. Chronic PF significantly impacts older adults since pain associated with PF can cause gait disturbances, difficulty with activities of daily living, and balance impairments and increase the risk of falling. This case report describes the physical therapy examination and subsequent interventions using iontophoresis with dexamethasone and traditional physical therapy in an older adult with chronic PF.
Case Description: The patient was a 61-year-old woman with a 10-year history of chronic PF in the left foot. Physical therapy interventions focused on pain control, flexibility, bilateral and single leg stance tasks, and a progressive home exercise program. The main intervention for pain control was iontophoresis with 4 mg/mL of dexamethasone.
Outcomes: After 8 sessions of physical therapy that included 7 interventions using iontophoresis with dexamethasone, the patient demonstrated consistent improvement despite the chronicity of her condition. She reported an overall decrease in pain from 6-7 of 10 to 3 of 10 and no longer required night splints. She demonstrated increased ankle active range of motion in all planes. Her weight-bearing tolerance improved as evidenced by the ability to comfortably walk for up to 2 hours, chase after her grandson, and negotiate the grocery store without increased left foot symptoms.
Conclusion: Iontophoresis with dexamethasone combined with individualized traditional physical therapy may have contributed to decreased plantar foot pain, increased ankle active range of motion, and improved functional mobility in this older adult with chronic PF
Pain associated with foot and ankle conditions cause gait disturbances and balance difficulties and also put older adults at a higher risk for falling during activities of daily living (ADLs).1,2 Older adults are more at risk of falling if they are female, have plantar fasciitis (PF), pes planus, and knee osteoarthritis.3 Of the many foot and ankle conditions affecting older adults, PF can be especially debilitating when present for many months or years. In older adults, PF is usually due to biomechanical factors such as decreased plantar fascia elasticity, reduced intrinsic muscle strength, overpronation, and the body's decreased capacity for healing.4,5 In a study investigating community-dwelling adults, 65 years and older, Badlissi et al6 reported that 6.9% of older adults have painful PF causing limitations with work, daily activities, walking, and climbing stairs.
Plantar fasciitis is one of the most common causes of inferior heel pain in the adult population.7–9 This condition is also called painful heel syndrome, chronic plantar heel pain, runner's heel, and subcalcaneal pain.4,10 Plantar fasciitis is described as an inflammatory condition of the plantar fascia in the foot that results from repeated stress to its origin on the distal plantar calcaneus, causing microtears within the fascia.10–13 Hallmark signs of PF are palpation tenderness at the medial tubercle of the calcaneus, pain upon walking the first few steps in the morning, and/or pain with prolonged weight bearing.14,15 Approximately 2 million people in the United States receive treatment for PF annually.11 With aging, many changes occur on the cellular level that can decrease the tensile strength, elasticity, and regenerative capacity of ligaments and tendons including the plantar fascia.16 Fibroblasts, which are responsible for the growth and regeneration of the connective tissue that mostly composes ligaments and tendons, decrease in proliferative capacity and activity with aging. As a result, tendons and ligaments are at higher risk for rupture and have longer healing times.16 Although all ages are affected, the incidence increases between the ages of 40 and 60.17 Of adult patients with PF, the following age ranges with corresponding percentages have been reported in the literature: 30 to 40 years (22%), 41 to 50 years (36%), 51 to 60 years (32%), 61 to 70 years (2%), and older than 70 years (8%).14
Since PF is an inflammatory condition, its stages correspond to the following 3 stages of inflammation: acute (0-2 weeks), subacute (2-6 weeks), and chronic (>6 weeks). During the acute stage of PF, inflammation of the plantar fascia results in exquisite heel pain at the medial tubercle of the calcaneus.10 The pain is localized and feels sharp upon standing but can improve within a few steps.11 Over time, if complete healing does not occur, there is an accumulation of microscopic injuries and tears to the fascia, causing chronic inflammation.4,5 In the later (chronic) stages of PF, there is a response of collagen degeneration with fiber disorientation and the possibility of calcification.4 Patients commonly complain of a constant dull or achy foot pain that has gradually occurred and worsened after periods of rest throughout the day.11
Although the etiology of PF remains unclear, several risk factors are believed to contribute to its development—poor or improper shoe wear, overuse secondary to prolonged standing, recent weight gain, a sudden increase in walking/ running, limited ankle dorsiflexion, pes planus, overpronation during ambulation, weak intrinsic musculature, and inadequate flexibility of the lower extremity (LE).10,11,18,19 PF is seen in various populations, including individuals who spend the majority of the day on their feet, athletes/runners, those with a body mass index of more than 30 kg/m2, individuals with diabetes mellitus, and older adults.4,10,14,19 Common changes in body functions and structures associated with PF include postural deviations, pain with palpation to the medial arch, restricted ankle dorsiflexion, weak plantar flexor muscles, weak intrinsic ankle musculature, and excessive subtalar joint pronation.11 Functional limitations and participation restrictions due to PF may include difficulties ambulating, negotiating stairs, sleeping through the night, performing ADLs that require weight bearing, and performing occupations that require long periods of standing.10,11,19
There is no single intervention for the treatment of PF. Symptoms of PF and patient responses vary widely.10,11,20 More than 80% of patients with PF have symptom resolution in less than a year with conservative intervention.21–23 In severe cases, surgical intervention is performed when conservative care has been exhausted.10,24 The most common surgical procedure performed is the partial plantar fasciotomy, where the plantar aponeurosis is partially released from the calcaneus.24 Multiple conservative interventions have been reported to improve symptoms and function in patients with PF—stretching,25,26 orthoses and night splints,8,27 taping,28 extracorporeal shock wave therapy,29 soft tissue mobilization,30 and iontophoresis.30–32 Although the literature does not support one universal intervention for PF, clinical practice guidelines for PF have been published by the Orthopedic Section of the American Physical Therapy Association.33 These guidelines recommend iontophoresis (moderate evidence), manual therapy (theoretical evidence), stretching (moderate evidence), taping (weak evidence), orthotic devices (strong evidence), and night splints (moderate evidence).33
In a prospective, randomized study, Digiovanni et al25 compared a tissue-specific plantar fascia stretching protocol (group A) with a standard standing Achilles stretching protocol (group B) in patients with chronic PF (duration ≥10 months). Patients performed each stretch 3 times per day for 10 seconds and 10 repetitions. At the end of the 8-week stretching program, positive responses in pain, activity limitations, and patient satisfaction were greater in group A than in group B. In a 2-year follow-up, 94% of patients who performed the tissue-specific plantar fascia stretch protocol reported decreased pain and 77% patients reported no limitation in recreational activities or ADLs.26 In a prospective, participant-blinded randomized study, Landorf et al8 divided patients with PF (duration ≥4 weeks) into 3 groups: prefabricated foot orthoses, customized foot orthoses, and sham foot orthoses. After 2 months of intervention, participants in the prefabricated and the customized foot orthoses groups showed benefits in pain and function (Foot Health Status Questionnaire) compared with the sham orthoses group; however, only the effects on function were significant. At the 12-month follow-up, there were no differences in pain and function among the 3 groups.8 In a prospective, randomized trial, Roos et al27 divided patients with PF (duration ≥1 month) into 3 treatment groups: custom orthoses, anterior night splints, and orthoses/night splint combination. After 12 weeks of intervention, participants in all groups showed decreased pain and improved function (Foot and Ankle Outcome Score). At 1-year follow-up, a 62% pain reduction was noted in the combination and custom orthoses groups, whereas a 48% reduction was reported in the night splint group. Because of the ease of use and tolerance of the device, the authors recommended custom orthoses compared with night splints.27
Calcaneal taping is believed to improve the biomechanical position of the calcaneus to decrease stress on the plantar fascia.28 In a prospective, randomized study, Hyland et al28 demonstrated that a 1-week trial of calcaneal taping for PF provided a greater improvement in pain than did passive stretching of the ankle plantar flexors, no treatment, or sham taping. Malay et al29 reported that 3 months following 1 session of extracorporeal shock wave therapy (25 minutes, 3800 shockwaves, 150 shocks per minute), participants with chronic proximal PF (duration >6 months) had decreased pain compared with those in a placebo group. Light and deep myofascial therapy (soft tissue mobilization) to the plantar fascia and ankle plantar/dorsiflexors, as well as transverse (cross) friction to the plantar fascia insertion site, has been described to improve soft tissue mobility in PF.4,10,30
Iontophoresis is a physical therapy intervention used to administer anti-inflammatory medications for decreasing pain and inflammation in conditions of the musculoskeletal system.34–39 Iontophoresis is a noninvasive drug-delivery intervention that uses an electrical current to transdermally deliver aqueous ionic solutions (ie, acetic acid, hydrocortisone, and dexamethasone) via bipolar electrodes. The aqueous ionic solutions are electrically charged mediums that migrate through the skin to promote healing and decrease inflammation in superficial localized areas.38 Although several authors have described inconclusive results or no effects with the use of iontophoresis for musculoskeletal conditions,37,40,41 others have demonstrated positive effects in pain and function in carpal tunnel syndrome,34 acute medial and lateral epicondylitis,36 osteochondritis dissecans,42 acute Achilles tendon pain,35 and acute or recalcitrant heel pain.43
Unfortunately, minimal research has been published on the use of iontophoresis as a treatment option for the various stages of PF.30–32 Gudeman et al31 examined whether iontophoresis with 0.4% dexamethasone combined with traditional modalities—ice, plantar fascia and gastrocnemius-soleus muscle stretching, strengthening of the extrinsic muscles, and a viscoelastic heel cup—provides more immediate PF symptom relief than do traditional modalities alone. They did not report the average time that the subjects experienced symptoms. The authors randomly divided 40 affected feet (36 subjects, mean age 42.1 [13.6]) into 2 groups, with each group receiving 6 treatments over 2 weeks. Both groups received traditional modalities while group 1 received a placebo iontophoresis and group 2 received iontophoresis with 0.4% dexamethasone. Patient sensitivity determined the iontophoresis current amplitude (up to 4.0 mA). In communication with the authors, the dosage for this protocol was indicated as 40.0 mA·min. Outcomes were measured using the Maryland Foot Score (MFS) prior to intervention, immediately after intervention, and 1 month after intervention. The MFS assesses pain and function in the following categories on a 100-point scale: pain, gait, stability, support, limp, shoes, stairs, terrain, cosmesis, and ankle motion.44 Immediately following the 6 treatments, improvements in the MFS were greater in group 2 (6.8 [5.6]) than in group 1 (3.1 [4.1]). However, 1 month after the 6 treatments there was no significant difference in the MFS between groups. The authors concluded that iontophoresis with dexamethasone might be effective for immediate, short-term results in treating PF.31
Osborne and Allison32 studied the efficacy of iontophoresis using either acetic acid or dexamethasone combined with low-dye taping in the treatment of PF. The authors randomly divided 42 affected feet (31 subjects, mean age 51.1 [10.6]) into 3 groups. On average, subjects experienced symptoms for approximately 12 months prior to the study. Each group received low-dye taping, calf stretches, and 6 treatments of iontophoresis with 0.4% dexamethasone, 0.9% sodium chloride (placebo), or 5.0% acetic acid. The iontophoresis was delivered over a period of 2 weeks using a current of up to 4.0 mA, depending on the patient's sensitivity, and a total dose of 40.0 mA·min. The outcomes of pain and stiffness were measured using a 10-cm visual analog scale at baseline, immediately after intervention, and 2 weeks after intervention. Immediately following treatment, all 3 groups had improvements in morning pain, average pain, and morning stiffness; however, the group receiving acetic acid showed the greatest improvements in morning pain and in residual stiffness. Furthermore, the only group that had a continual decrease in pain during the 2-week follow-up was the group that received dexamethasone iontophoresis.32
In a recent case report, Costa and Dyson30 described the use of acetic acid iontophoresis in managing chronic heel pain. The subject described was a 15-year-old female soccer athlete with complaints of bilateral heel pain for approximately 1 year. She demonstrated limited passive ankle dorsiflexion range of motion, severe tenderness, muscle hypertonicity of the gastroc/soleus complex, and gait abnormalities. The patient received acetic acid iontophoresis 3 times per week for 2 weeks and then 2 times per week for 2 weeks. The iontophoresis treatments were administered with an 80.0-90.0 mA·min dosage of 4.0 mL of 5.0% acetic acid solution. The treatments were performed in combination with physical therapy modalities—athletic taping, soft tissue mobilization, joint mobilization and manipulation, stretching/strengthening exercises, proprioceptive facilitation, and orthotics. The authors reported that these interventions might have helped this patient return to her athletic activities within a period of 6 weeks.30
Adults through the fourth, fifth, and sixth decades of life are more likely to develop PF and therefore experience a reduction in ADLs, functional mobility, and societal participation due to the unrelenting discomfort. Because of training in biomechanics, exercise, balance and posture, mobility, and pain control,45 physical therapists are in a prime position for intervening in patients with PF. The literature suggests that iontophoresis with dexamethasone may be an effective component of a comprehensive physical therapy program to provide short-term pain relief31,32 in older adults with chronic PF with the ultimate goal of improving function and mobility. The purpose of this case report was to describe the use of iontophoresis with dexamethasone combined with traditional physical therapy management in an older adult with chronic PF.
The patient, ER, was a 61-year-old woman with a 10-year history of left inferior heel pain. ER was 1.57 m (62 in) tall and weighed 63.5 kg (140 lb) (body mass index = 25.6 kg/m2). Her job as a caregiver for her 2½-year-old grandson 2 times per week required constant standing and frequent mobility on various surfaces throughout the day. On the medical history intake form, she indicated that she had osteoporosis in the left hip and osteoarthritis. Her medications included Celebrex (celecoxib), Evista (raloxifene), Tylenol (acetaminophen), calcium, glucosamine, Juice Plus, Xalatan (latanoprost ophthalmic) eye drops, aspirin, folic acid, COQ10 (ubiquinone), and Allegra (fexofenadine).
ER complained of left ankle stiffness and left heel pain when taking her first steps in the morning. The pain decreased intermittently and then gradually increased throughout each day. She described an aching and stabbing pain in the lateral plantar side of her left foot that increased with squatting and ascending/descending stairs. The pain bothered her most when she played with her grandson, walked less than a half mile, and stood and walked through the grocery store for less than 1 hour. ER indicated that her symptoms began 10 years back following a left foot stress fracture. Prior care had been largely unsuccessful including a trial of custom-made arch supports and night splints, both directed by a podiatrist. At the time of this evaluation, ER stated that she wore the night splints 2 to 3 times per week. She had not received physical therapy for her PF. She reported that a recent x-ray film of her left foot revealed a bone spur near the proximal end of the plantar aponeurosis on the calcaneus. Although the presence of a heel spur is not required for PF diagnosis, it is sometimes an incidental finding on x-ray film.9,46 ER's goals for physical therapy were to walk comfortably for long distances up to 2 hours, wear “fun” shoes, and play with her grandson without left foot discomfort.
ER's inferior heel pain caused difficulties with ambulating, squatting, standing, and taking care of her grandson. There are a number of conditions that can cause inferior heel pain, including PF, Achilles tendonitis, fat pad atrophy, heel contusion, plantar fascia rupture, posterior tibialis tendonitis, retrocalcaneal bursitis, neuralgias, and referred pain due to S1 radiculopathy.21,24 On the basis of ER's report and description of functional limitations, we hypothesized that her left inferior heel pain was due to PF, Achilles tendonitis, or posterior tibialis tendonitis.
ER provided clear responses to questions and appropriately processed commands. She was oriented to time, place, person, and location. Both of her feet were examined for asymmetries. Palpation of the plantar surface of both feet revealed tightness in the left plantar aponeurosis and that pain and tenderness were specifically along the medial and lateral plantar surfaces of the left foot. A visual posture analysis with ER in the standing position was performed to determine whether alignment deviations at other joints contributed to her left foot symptoms. She demonstrated left genu valgum and bilateral pes planus. Her feet were also observed in a non–weight-bearing, seated position. In this position, the bilateral pes planus was not apparent.
Bilateral knee active range of motion (AROM) was grossly assessed, and all motions were without limitation. Although not formally tested, there were no observable limitations of gross bilateral hip and lumbar AROM. Ankle AROM measurements were made with a standard goniometer and compared with documented normal values47 (Table 1). For these measurements, ER was in the long-sitting position with her feet hanging off the treatment table.48 A limitation in dorsiflexion has been shown to be associated with the etiology of PF because this restriction can result in excessive pronation during stance that increases the stress to the plantar aponeurosis and fascia.14 The position for the inversion and eversion measurements was supported by Menadue and colleagues.49 The authors reported the reliability of ankle inversion and eversion AROM to be relatively high (intraclass correlation = 0.82-0.96) by the same observer within sessions.49 Therefore, the same examiner took goniometric measurements on ER throughout the plan of care. To assess muscle performance, both ankles were examined and scored according to the manual muscle testing (MMT) grades of 0-5 of 5.50,51 A literature review by Cuthbert and Goodheart50 reported that interexaminer reliability for MMT ranges from 82% to 97% and from 96% to 98% for test-retest reliability. This review also demonstrated that in order to be confident that change in muscle performance occurs, MMT scores need to improve more than 1 full grade. To minimize ER's discomfort, the plantar flexors were tested with manual resistance52 in the long-sitting position in contrast to the accepted testing technique of single leg heel raises for multiple repetitions.51,53 The MMT grades for ER's bilateral ankle dorsiflexors, plantar flexors, invertors, and evertors were equal bilaterally and strong (5/5) and painless, indicating a noncontractile source of her pain.54
ER's intermittent left inferior foot pain was at its worst in the morning when weight bearing for the first time and bothered her most while standing. The majority of her pain was aching and stabbing along the medial and lateral side of the arch on her left foot. Using the numeric rating scale (NRS) of 0 to 10 (0 = no pain, 10 = emergency department pain), she rated the pain as a 6-7 of 10 at its worst and 0 of 10 at its best. The NRS is valid, reliable, and appropriate for use in clinical practice.55 ER ambulated 25 ft independently with shoes (arch support included) and without shoes. During gait with shoes, ER demonstrated decreased stance time on the left LE and decreased toe off from her left foot. No other deviations were noted during gait while wearing shoes. During gait without shoes, she demonstrated excessive left foot pronation during the stance phase. ER continued to display decreased stance time on the left LE and decreased left toe off. The decreased left LE stance time and decreased left toe off observed with and without shoes may have been due to tightness of the ankle plantar flexors, pain in the left plantar aponeurosis, left hip osteoporosis, or osteoarthritis. The excessive left foot pronation observed only when the arch supports were removed suggests the possibility of a mechanical deformity in the left medial arch. In addition, ER displayed no limitations or deviations in her base of support width during gait. This finding was encouraging because an increased base of support during gait (>4.0 in) may be related to gait instability.56
To screen for standing balance deficits, ER stood unsupported with feet together for 30 seconds, implicating an ankle synergy. She stood easily for 30 seconds. ER described an inability to walk for more than a half mile, stand and walk for more than 1 hour, or stand on uneven surfaces. When negotiating stairs and squatting in the clinic, she reported an increase in left foot pain. Performing these activities safely and with minimal pain were important to ER because she frequently squatted to pick up her grandson and made numerous trips up and down the stairs from her grandson's bedroom to the main floor.
On the basis of ER's history and tests/measures, changes in body functions and structures, activity limitations, and participation restrictions were categorized according to the World Health Organization's International Classification of Functioning, Disability, and Health model (Table 2).33,57 The activity limitations and participation restrictions included an inability for ER to play with her grandson or walk through the grocery store without experiencing an increase in symptoms, having pain in her left foot while squatting and negotiating stairs, and an inability to wear “fun” shoes because of the severity of the left foot pain. These limitations most likely resulted from significant pain in the arch and heel of her left foot, limited ankle AROM, perceived ankle stiffness, left genu valgum, and pes planus.
ER experienced the greatest amount of pain in her left foot when stretching the plantar fascia. We hypothesized that this stretch occurred every time her heel contacted the ground, thus explaining the pain she experienced while walking through the grocery store or chasing her grandson. She demonstrated decreased bilateral ankle AROM in all motions, except plantarflexion, when compared with documented normal values (Table 1).47 Without full-ankle AROM, tasks such as negotiating stairs and squatting to pick up her grandson were difficult to perform. Typically, the uninvolved limb would be used for comparison to establish AROM goals. However, in ER's case, both ankles had limited AROM. It was unclear why the patient did not have PF symptoms in her right foot. Although the patient's symptoms were reported only in the left foot, goals were established for bilateral improvements to prevent PF symptoms from occurring in the right foot since one-third of people with PF have bilateral involvement.21
Achilles tendonitis and posterior tibialis tendonitis were considered as causes of her inferior heel pain and were eventually eliminated through careful examination of the entire foot and surrounding structures. Palpation tenderness of the plantar fascia region only and strong/painless ankle muscle testing aided in ruling out these 2 conditions. ER's left inferior heel pain when first weight bearing in the morning, palpation tenderness at the plantar fascia, standing postural malalignments, decreased ankle mobility, gait deviations, and gradual and intermittent pain over many years led to the diagnosis of chronic PF. According to the Guide to Physical Therapist Practice, her condition was classified under the Preferred Practice Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation with a corresponding ICD-9-CM code of 728.71: “Plantar fascial fibromatosis, plantar fasciitis.”45
ER had a positive attitude and was highly motivated to maximize her gains in physical therapy. However, her rehabilitation potential may have been reduced because of the chronicity of the condition. The following short-term goals were established for the first 2 weeks of physical therapy: (1) Patient will be independent with her initial home exercise program (HEP); (2) Patient will report pain/symptoms of 4 of 10 or less in her left foot; and (3) Patient will demonstrate increased AROM in both ankles to within documented normal ranges (Table 1). The long-term goals were set based on the patient's ability to perform tasks as related to her previous level of function. ER was expected to achieve the following long-term goals within 4 weeks: (1) Patient will be independent with her final HEP; (2) Patient will report pain/symptoms of 2 of 10 or less in left foot; (3) Patient will stand and walk through the grocery store up to 1 hour and walk up to a half mile without an increase in symptoms; and (4) Patient will report the ability to keep up with her grandson without an increase in symptoms.
The Guide to Physical Therapist Practice states that 80% of patients classified into Practice Pattern 4E will achieve optimal improvement in 6 to 24 visits over 2 to 4 months of physical therapy.45 The initial physical therapy plan of care included patient participation in 30-minute sessions, 2 times per week for 4 weeks. Physical therapy interventions focused on pain control, flexibility, bilateral and single leg stance tasks, and a progressive HEP (Appendix). The first session focused on determining the severity of the chronic PF and instituting an appropriate physical therapy program. The second session ensured that ER performed the prescribed exercises safely and correctly. The following 3 weeks of physical therapy consisted of stretching and AROM exercises, strengthening exercises, higher-level balance activities, and iontophoresis with dexamethasone to manage the chronic condition. At the end of week 2, ER's goals were reviewed and measurements were taken to document progress. At the end of week 4, final ankle AROM measurements were taken for comparison with the initial measurements (Table 1).
The main intervention for pain control was iontophoresis with 4.0 mg/mL of dexamethasone delivered by an Empi Dupel Iontophoresis System (St Paul, Minnesota). The negatively charged dexamethasone pad was placed on the medial plantar surface near the left calcaneal insertion while the buffering pad was placed on the left posterior calf. ER received iontophoresis at the end of each treatment session with the exception of session 1. The parameters for each treatment session remained relatively constant with the exception of sessions 5 and 7 (Appendix). During these 2 sessions, ER had a higher sensitivity to the iontophoresis; therefore, the amplitude of the current was reduced, leading to slightly longer treatment durations. We hypothesized that iontophoresis with dexamethasone would provide pain relief so that ER could better tolerate activities that required active stretching of the plantar flexors and plantar fascia (ie, squatting and negotiating stairs). As reported earlier, iontophoresis has been shown to decrease PF symptoms.30–32
In addition, soft tissue mobilization to the plantar surface of the left foot was performed during 3 of the 8 sessions. This intervention was initially chosen to decrease the stiffness and pain in the plantar fascia when stretched.4 During treatment session 4, ER experienced an increase in pain and therefore the soft tissue mobilization was not performed. At session 5, her pain had decreased, so soft tissue mobilization was resumed. Following this treatment, the intensity of the symptoms increased again. At this point, the soft tissue mobilization was not effective in managing the pain; therefore, this intervention was discontinued. At discharge, in addition to many functional exercises, ER was educated on performing self–soft-tissue mobilization to her plantar fascia before getting out of bed every morning. This exercise was given to soften and reduce fibrotic scar tissue in the plantar muscles and fascia and also to decrease the amount of discomfort experienced when weight bearing for the first time in the morning.4,26
Tight calf muscles may contribute to the decreased dorsiflexion typically experienced with chronic PF.14,26 The interventions chosen to address ER's flexibility restrictions included a slantboard stretch, long sitting ankle towel stretch, ankle alphabet writing, towel scrunching, and Thera-Band exercises. The slantboard stretch was performed at the beginning of each session to stretch the gastrocnemius and soleus muscles.4 During treatment session 1, ER was educated on how to perform the long sitting ankle towel stretch and was instructed to include this exercise as a part of her HEP. This exercise was also performed at every session through session 5. She was instructed to write each letter of the alphabet with her ankle twice during each session through session 6. Finally, to facilitate improved flexibility, she was instructed to scrunch up a towel with her toes of both feet and perform Thera-Band exercises with her ankle. These exercises were included in the plan of care to maintain ankle strength while improving the ankle AROM in multiple directions.26 To better utilize her treatment time, the Thera-Band exercises were discontinued during in-clinic sessions and were incorporated into her HEP after session 3. The towel scrunching and Thera-Band exercises were also performed in an attempt to increase the strength of the patient's intrinsic foot muscles. Research has demonstrated that these exercises can be effective in increasing strength and proprioception in unstable ankles.58 As a part of ER's HEP, she was instructed to perform a kneeling plantar fascia stretch to improve the AROM of both ankles.
In preparation for the challenging tasks of ultimately chasing her grandson safely and negotiating uneven surfaces, ER participated in the following dynamic weight-bearing interventions: balance board taps, toe/heel walking, ball toss on a foam pad, half foam roll balance, and BAPS board exercises. Since these interventions were functionally based, most were not initiated until ER's ankle AROM improved. The balance board taps were incorporated to regain control of the ankle in the frontal and sagittal planes.59,60 This exercise was performed during sessions 3 through 5 and then progressed to the BAPS board for sessions 6 through 8. The BAPS board required more stability from the ankle and was not integrated until the patient's single leg stance tolerance improved. To further challenge ER, a ball toss while standing on a foam pad was incorporated into sessions 6 through 8. Finally, episodes of standing balance on a half foam roll were incorporated to improve balance in the anterior/posterior and medial/lateral planes. This exercise also provided a prolonged stretch to the plantar fascia. Research has demonstrated that improvements in balance control can be observed in healthy older women following a short-term balance training program utilizing a semicompressible foam roll.61 In addition to these exercises improving weight-bearing tolerance and balance on uneven surfaces, they can strengthen the intrinsic and extrinsic ankle musculature. Strengthening exercises may help correct mechanical deformities in the ankle while also improving a person's gait pattern.62 For ER, changes in muscle performance in such a short time frame were most likely due to neural adaptation rather than muscle hypertrophy.63
At the time of discharge, ER had completed 8 physical therapy sessions (2 times per week for 4 weeks). Despite the chronicity of her condition, she demonstrated consistent progress throughout the physical therapy program. By session 4, ER demonstrated independence in her HEP and reported pain in her left foot with ambulation to be 4 of 10. At discharge, ER discontinued the night splints and reported decreased pain with ambulation; however, it was still perceptible at a tolerable level of 3 of 10. When compared with the initial session, the 3- to 4-point decrease in pain on the NRS exceeded the minimal clinically important difference (2.0-2.5 points) reported in patients with chronic musculoskeletal conditions.64–66 Overall, bilateral inversion and eversion AROM surpassed documented normal ranges; however, even though there were improvements in bilateral dorsiflexion AROM, they did not reach the documented normal range (Table 1). ER's improvements from baseline to discharge in eversion, inversion, and plantarflexion AROM exceeded or nearly exceeded published minimal reliable change (11.3°) in patients with ankle sprains.67
Prior to physical therapy, ER tolerated less than a half mile of continuous walking and less than 1 hour of standing and walking through the grocery store. At the end of 4 weeks of physical therapy, ER reported walking for approximately 2 hours without experiencing any increase in symptoms in her left foot. Although she occasionally experienced minor pain in the lateral left foot when walking, she could chase her grandson and walk through the grocery store without increased symptoms.
The purpose of this case report was to describe the use of iontophoresis with dexamethasone when combined with traditional physical therapy management in a 61-year-old woman with chronic PF—a common overuse syndrome that can respond well to conservative therapy.20 The subject of this case report responded well to the 4-week physical therapy intervention, achieving her goals of walking long distances and caring for her grandson, despite the 10-year history of left foot pain.
Findings in this case report support previous literature that iontophoresis with dexamethasone may improve outcomes in treating chronic PF when used in combination with traditional physical therapy interventions. The 7 sessions of iontophoresis used in this case report were within the 6 to 10 range previously reported in the literature.30–32 Although she did not achieve the goal of pain reduction of 2 of 10 or less, she did reach 3 of 10 from a 6-7 of 10, achieving the minimal clinically important difference of 2.064,66 and was able to show functional gains. Because of the chronicity of the condition, achieving a 4- to 5-point reduction in pain in 8 physical therapy sessions over 4 weeks may have been unrealistic. If she received additional physical therapy sessions with iontophoresis, she may have reached the long-term goal regarding pain.
Currently, there is a lack of high-quality studies examining the effectiveness of treating chronic PF with iontophoresis with dexamethasone. Although Osborne and Allison concluded that acetic acid iontophoresis is a more effective treatment than iontophoresis with dexamethasone, both treatments demonstrated improvements in pain and function in patients with PF of 12 months average duration.32 It is impossible to determine the contribution of the iontophoresis with dexamethasone in the pain relief and functional improvements experienced by ER since the physical therapy program consisted of multiple interventions (ie, exercises, stretching, and single leg stance). Further research should isolate the interventions and use a therapeutic dose of iontophoresis with dexamethasone.
Limitations of this case report include the use of impairment-based outcome measures rather than function-based measures, necessitating the reliance on patient's self-report. This case report would have benefited from using an effective functional examination for measuring mobility and balance in the older adult population such as the Berg Balance Scale, single leg standing test, tandem walking test, or the 6-minute walk test.2,68,69 During ER's examination, MMT resulted in ankle muscle performance scores of 5/5 for all muscle groups, achieving a ceiling effect. Bohannon and Corrigan70 have reported significant differences in force measurements (in Newtons) when comparing 5/5 MMT grades of the knee extensors. The authors stated that the ceiling effect of MMT compromises its discriminant validity and responsiveness. For this case report, the handheld dynamometer would have been a more appropriate measurement tool to assess ankle muscle performance because it has been reported to be objective and responsive in measuring muscle strength changes in community-dwelling older adults and patients with foot deformities.71,72 Based on the initial manual resistance assessment of the ankle muscles, weakness did not appear to play a role in this case report. However, testing and reevaluation using a dynamometer or single leg heel raises may have identified plantar flexor muscle performance deficits. Finally, it may have been beneficial to measure leg lengths to determine whether a discrepancy contributed to the irregular gait pattern and the patient's symptoms.
When interpreting the outcomes from this case report, it cannot be assumed that iontophoresis with dexamethasone, if used in isolation, would produce the same pain-reduction results in a different patient with chronic PF. Further research with an adequate number of subjects, randomized controlled, and/or different iontophoresis parameters studied would be required to support such assumptions. Research comparing iontophoresis with dexamethasone with traditional physical therapy modalities as well as determining the optimal number of iontophoresis treatments would also be useful in helping guide clinical decisions for older adults with chronic PF.
Chronic PF is a common inflammatory condition of the foot that can be detrimental to an individual's functional abilities. This significantly impacts older adults since pain and deformities of the foot and ankle can cause gait disturbances and balance impairments and increase the risk of falling. This case report described the physical therapy management for a 61-year-old woman with a 10-year history of chronic PF consisting of iontophoresis with dexamethasone combined with traditional physical therapy interventions. Following 8 physical therapy sessions over 4 weeks, this individual showed improvements in pain, flexibility, walking distance/duration, single leg standing tolerance, and functional mobility.
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chronic plantar fasciitis; dexamethasone; geriatric physical therapy; ICF model; iontophoresis; older adult
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