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Letter to the Editor

We read with great interest the article “The Practical Application of Multimedia Technology to Facilitate the Education and Treatment of Patients With Plantar Fasciitis: A Pilot Study” by Beischer et al published in the February 2008 issue. The authors presented an initial treatment of plantar fasciitis that consisted of an Achilles tendon and plantar fascia stretching exercise program combined with a Viscopot heel cushion. We believe that the results of the studies referenced by Beischer et al were not statistically significant and therefore should not be recommended as initial treatments. However, we do not agree with the authors’ observations listed in Table 2 (taping and podiatric rigid orthosis as nonvalidated treatments) and believe these are more effective initial treatments for plantar fasciitis. In the article, the authors refer to a study by Pfeffer et al comparing the results of nonoperative treatments using different shoe inserts and a program of Achilles tendon stretching exercises. In this study, although the stretching and silicone insert group experienced a greater reduction in plantar pain in comparison to a stretching-only group, the differences in pain were not statistically significant. Furthermore, the trial had no control group, so the program’s effectiveness cannot be assessed. A clinical trial by DiGiovanni et al showed that patients who had been treated with plantar fascia stretching presented better (statistically significant) results with regard to pain compared with the Achilles tendon stretching group. But because there was no group control, it cannot be known if the improvement in the Achilles group was due to orthoses and nonsteroidal anti-inflammatory drugs or from the condition’s being self-limited. A recent randomized sham-controlled trial found no statistically significant improvements in first-step pain, foot pain, foot function, and general foot health between the group receiving treatment with Achilles tendon stretching and placebo after 2 weeks of an intervention. There are several limitations of this trial, including the technique of stretching used and the short period of the intervention. Regarding the authors’ recommendation of the Viscopot heel cushion, Pfeffer et al showed no statistically significant differences in pain reduction between the groups on the Pain Subscale of the Foot Function Index. Lynch et al compared an antiinflammatory therapy, accommodative therapy (viscoelastic heel cup), and mechanical therapy, and a statistically significant difference in visual analogue scale (VAS) score change was found in the mechanical therapy group compared with the accommodative therapy group, indicating that biomechanical studies do not support the use of heel cups in the treatment of plantar fasciitis. The authors of the article also list podiatric rigid orthosis as a nonvalidated treatment; we believe that relates to customized orthosis, which has been considered a “nonvalidated treatment,” according to the article by Pfeffer et al; however, in this study, the differences in pain reduction were not statistically significant between the treatment groups, and the results could have been achieved at random. In relation to the casting technique, Kirby criticized the Pfeffer study, pointing out that if the laboratory that conducted the custom foot orthoses provided an instructional video on casting technique, it assumes that the professionals who performed the casting did not have prior knowledge of the proper foot orthoses negative casting technique and may not have attained the expertise gained from a learning curve through repetition of a task. Kirby also alluded to body weight, or body mass index (BMI), which was 29.3 kg/m in the custom orthosis group (between 1.2 and 2.2 kg/m higher than in the other groups), yet the authors show that this distribution was at random. The available evidence suggests that an increase in BMI is associated with chronic plantar heel pain. Another nonvalidated treatment mentioned was taping. There was a study done by Hyland et al in which 41 subjects were randomly assigned to 4 groups: stretching-alone group, calcaneal taping–only group, control group, and sham taping group. This study found a statistically significant difference in VAS score change posttreatment in the calcaneal taping group over the control group and in the calcaneal taping group over the sham taping group. On the other hand, Radford et al performed a participant-blinded randomized trial to assess the effectiveness of low-dye taping compared with sham ultrasound, and their results demonstrated that low-dye taping produced a small but statistically significant beneficial effect on firststep pain compared with sham ultrasound. In conclusion, even though Beischer et al recommends Achilles tendon stretching as an initial treatment of plantar fasciitis, neither Pfeffer et al nor Radford et al found a statistically significant difference between the studied groups in favor of Achilles tendon stretching. Biomechanical studies do not support the effectiveness of treatments such as Achilles tendon stretching and Viscopot heel cushion. However, a statistically significant beneficial effect has been shown with the use of calcaneal taping and low-dye taping. In addition, the article by Landorf et al justified the custom orthosis with the same principle that Pfeffer et al used to justify the silicone insert or Viscopot heel cushion. Furthermore, if we also take into consideration the results of the article by Lynch et al, the use of podiatric rigid orthosis and taping seems to be a better form of initial treatment than the Achilles tendon stretching and Viscopot heel cushion.