Tarsal tunnel syndrome

ABSTRACT

Introduction: The purpose of this study was to evaluate adjusting of the foot with stretching vs. orthotics to determine the effectiveness of each in subjects with chronic plantar fasciitis.

Methods:

Design: A prospective, randomized, blinded, controlled clinical trial.

Setting: University of Surrey Chiropractic Clinic, Guildford, Surrey.

Participants: 20 subjects between 18 and 60 years old presented with chronic plantar fasciitis. They were randomly allocated to 2 groups of 10.

Interventions: All 10 subjects (6:M and 4:F with mean age 44.1) in Group 1 received chiropractic adjustments (manipulation) of the foot and ankle and stretching exercises twice a week for 4 weeks and at 1-month follow-up. All 10 subjects (7:M and 3:F with mean age 40.6) in Group 2 received a pair of orthotics and were required to keep them in their shoes for a total of 8 weeks.

Main outcome measurements: The subjective measurements included Numerical Pain Rating Scale 101, the first-step pain form, and the effect of heel pain on 3 types of activities form (leisure, work, and sport). The objective measurements included algometer readings. The measurements for all 20 subjects were taken at baseline, after interventions 5 and 9, and at 1 month after intervention 9.

Results: Homogeneity was found for intra-group comparison (improvement) with both Group 1 (manipulation and stretch) and Group 2 (orthotics) with significant differences observed on pain scale worst (G1 p-0.000 and G2 P=0.026), first-step pain (G1 p=0.000 and G2 P=0.000), heel pain during leisure (G1 p=0.008 and G2 p=0.16), and algometer readings (G1 P=0.004 and G2 p=0.000). For the inter-group measurements, the only reading that revealed significant difference was the pain scale worst measurement on 15, with Group 1 (manipulation and stretching) being superior (earlier) to Group 2 (orthotics).

Conclusion: With the small sample size and methodological limitations of this trial, no firm conclusions can be drawn; the data regarding effectiveness should be interpreted with caution. Nevertheless, within the limits of this trial, both treatments appeared useful when used individually for treatment of common plantar fasciitis and further research is supported.

Key words: Plantar fasciitis, chiropractic, manipulation, adjusting, stretching, podiatry, orthotics.

INTRODUCTION

The purpose of this study was to evaluate adjusting (manipulation and mobilization) of the foot with stretching vs. orthotics to determine the effectiveness of each in 20 subjects with chronic plantar fasciitis.

The term plantar fasciitis (PF) refers to a condition characterized by inflammation of the plantar fascia of the foot. It is usually seen in athletes as an overuse injury, but it's also found in the non-athletic population.1

The etiology of PF is multi-factorial and, therefore, controversial. The most common etiological factors include poor foot mechanics due to pes planus and pes cavus foot types, obesity, pregnancy, inappropriate footwear, heel fat pad atrophy, single major or minor repeated trauma, fatigue of the plantar fascia due to overuse, training errors, and calcaneal stress fractures.2

The most common symptom of PF is "first-step pain" (believed due to inflammation causing scar tissue with contraction), which diminishes after the first few steps. Pain is primarily felt on the anterior medial tubercle of the calcaneus, but may spread distally along the fascia. First-step pain is felt after prolonged periods of nonweight bearing, such as getting out of bed or prolonged sitting,3 which gradually worsens if untreated.1

Gill4 and Lynch et al.2 report that the condition responds to a number of conservative therapies such as rest, ice, physical therapy modalities, stretching, nonsteroidal anti-inflammatory drugs (NSAIDs), steroid injections, foot padding, taping, shoe modifications, heel lifts, arch supports, custom foot orthotics, splints, and adjustment of foot and ankle malalignments.5

The main aim of this investigation was to determine if an intra-group (i.e., a statistically significant change in the same group with treatment, compared with baseline) or inter-group difference (a statistically significant difference between the treatments in terms of effectiveness or improvement) occurred.

For the purpose of this study, 2 different conservative treatment methods were investigated and compared over a period of 9 weeks. The first method included adjusting the foot with stretching exercises (Group 1), while the second method involved the use of orthotic devices (Group 2).

Null Hypotheses for lntra- and Inter-group Differences

The null hypothesis was that there would be no intra-group (within-group) difference between the results obtained at baseline and after interventions 5, 9, and at 1 month after intervention 9 for Groups 1 and 2. The alternative hypothesis was that there would be a statistically significant difference.

Ho: ul - u2 = u3 = u4

H1: ul [not =] u2 [not =] u3 [not =] u4

The inter-group null hypothesis states that there is no inter-group (between-group) difference between adjusting of the foot with stretching vs. orthotics at baseline after intervention 5 and 9 and at 1 month after intervention 9. The alternative hypothesis states that there will be a significant inter-group difference.

Ho: ul = u5, u2 = u6, u3 = u7, u4 = u8

H1: u1 [not =] u5, u2 [not =] u6, u3 [not =] u7, u4 [not =] u8

MATERIALS AND METHODS

Twenty subjects were obtained by convenience sampling if they met the inclusion criteria: more than 18 and less than 60 years of age, symptoms present for more than 7 weeks, "first-step pain" in the morning or after inactivity, and compliance with the researchers' instructions.

Each subject was supplied with an information letter and written consent form approved by the University of Surrey Ethics Committee. Subjects were included regardless of other physical problems except those who were pregnant, had calcaneal bursitis, tenosynovitis, fatpad syndrome, tarsal tunnel syndrome, calcaneal fracture, and/or connective tissue/autoimmune disorders, etc.

A diagnosis of PF was made if the subject had plantar heel pain of more than 7 weeks with first-step pain when rising from bed or after prolonged sitting, heel pain relieved after a few steps, pain on palpation of the medial tubercle of the calcaneus, a positive plantar fasciitis test (a commonly used test that palpates the anterior medial tubercle of the calcaneus where the fascia inserts and along the arch distally as the big toe, foot, and ankle are dorsiflexed to tighten the fascia),2 pain that deteriorates toward the end of the day, and heel pain relieved by rest.6 This is probably the most common presentation of plantar fasciitis, but may not include all possible types.

All 20 subjects were randomly allocated into 2 groups of 10. A participant who drew a paper slip with "Group 1" printed on it received adjustments (manipulation and mobilization of the foot) with stretching. Subjects who drew "Group 2" received treatment with orthotics only.

Group 1: All 10 subjects in this group were treated with chiropractic adjustments of all foot and ankle subluxations (joint dysfunction) twice a week for 4 weeks and at the 1-month follow-up. One of the researchers performed the adjustments on each visit after motion palpation and identification of any foot and ankle subluxations (in this case, subluxation means hypomobility or fixation). Various foot and ankle adjustments as described in Brantingham et al.5 were delivered, but "mortice separation" (to increase ankle elongation), subtalar adjustment (to increase inversion or eversion), and forefoot figure-8 mobilization (to increase flexibility in the forefoot) were used most frequently.5,6 The subjects were prescribed Achilles tendon stretching exercises, both with the knee straight for the gastrocnemius (subjects were to lean against a wall with the un-involved knee forward and flexed while the involved leg was behind with the knee in extension and the heel on the ground) and flexed for the soleus (subjects were to lean against a wall with the un-involved knee forward and flexed while the involved leg was behind with the knee in slight flexion and the heel on the ground). These were to be held statically with a comfortable sense of stretch for 20 seconds and performed 10 times each, morning, afternoon, and evening, on a daily basis for the whole 8 weeks.

Group 2: The subjects in this group were supplied with a pair of functional orthotics from nonweight-bearing subtalar and mid-tarsal neutral casts. One of the researchers, a qualified podiatrist, manufactured custom-length functional shock-absorbing orthotics with an outer layer of high-density ethyl vinyl acetate (EVA), and an inner layer of low-density EVA.7 These were supplied to the subjects 1 week after the initial consultation and remained fitted in their shoes for the whole 8-week period. The subjects were carefully advised as to how they should slowly "break in," or accommodate to, the orthotics (i.e., 2 hours the first 2 days, 3 hours the next 2 days, and so forth).

Measurements and Observations

The study for each individual subject was conducted over a period of 9 weeks, including the 1-month follow-up period. For both groups, each subject's baseline was established on day 1 (initial consultation), progressed on days 15 and 29 (interventions 5 and 9), and at a 1-month followup after intervention 9, using I objective and 3 subjective measurements. A blinded observer obtained both subjective and the objective measurements on the pre-arranged dates.

The first subjective measurement was Numeric Pain Rating Scale 101 (NRS - 101).2 The second subjective measurement was the first-step pain scale, and the third subjective measurement was the "effect of heel pain on 3 different activities form"; the 3 activities were leisure, work, and exercise. The reliability and validity of the first measurement have been documented widely, but is used generally for pain, and is not particular to plantar fasciitis.8,9 The last 2 subjective measurements were used in the Lynch et al.2 trial and appear most appropriate, though apparently also not yet documented for reliability and validity.

Algometry pressure pain threshold, reliable and valid, was performed on the area of maximum tenderness, usually the medial tubercle of the calcaneus (tenderness at or near this site being the most common objective finding), but is not particular to plantar fasciitis.8,9,11

Statistical Analysis

According to Pallant,12 when small sample sizes are used and the same sample of subjects is measured at 3 or more points in time, the nonparametric Friedman test is the most appropriate test. In this particular trial, each group consisted of 10 subjects and for each group, the measurements were obtained on day 1 (baseline), day 15, day 29, and 1 month after intervention 9 using the 1 objective and 3 subjective measurements. Therefore, the non-parametric Friedman 2-way ANOVA by ranks for repeated measurements was used. The scores were ranked within each subject's scores for repeated measures only. Then, the sum of ranks for each group was determined using the Chi-square r value (X^sup 2^r), which was then compared against the critical Chi-square tables. X^sup 2^r must be equal to or greater than the critical X^sup 2^ value to be significant, with the alpha significance level set at 0.05.

Furthermore, the Wilcoxon signed rank test will be used since it converts scores to ranks and compares them at "time 1" and "time 2." In this study, all subjects in each group will be measured on 2 different occasions (i.e., baseline to day 15, or baseline to day 29, or day 15 to 1 month later, or day 29 to 1 month later). Therefore, the intra-group Wilcoxon test is the most appropriate to use.12 Again, alpha was set at 0.05.

To test the differences between 2 small equal or unequal independent groups on a continuous measure, the (inter-group) Mann Whitney U-test should be used.12 In this trial, the 2 groups involved were tested on day 1, day 15, day 29, and at 1-month follow-up using the 1 objective and all 3 subjective measurements.12 As before, alpha was set at 0.05.

RESULTS

Descriptive Statistics

For the purpose of this trial, 20 participants of both sexes were selected. Group 1 (n=10) consisted of 6 males and 4 females between the ages of 27 and 59 years (mean age=44.1). Group 2 (n=10) consisted of 7 males and 3 females between the ages of 23 and 59 years (mean age=40.6). In summary, no statistically significant difference was noted between the 2 treatment groups with respect to demographic variables.

All 20 subjects who signed up completed the trial, and the blinded observer recorded all measurements on the prearranged dates. None of the subjects reported any adverse reactions, and the overall compliance was very good. The data for all subjects, in terms of age, gender, occupation, chronicity of condition, previous treatments with outcomes, hobbies, and other relevant information are represented in Table 1, p. 37.

Intra-group Comparison - Friedman Test a Wilcoxon Test

A) Subjective intra-group measurements

1. Pain scale results - worst and least:

1.1 Pain scale form - worst (mean summary) (PSW): Group 1 p=0.000 and Group 2 p=0.026. These values are smaller than the critical p value from the statistical tables (p

1.2 Pain scale form - least (mean summary) (PSL): These values (Group 1 p=0.105 and Group 2 p=0.068) were not statistically significant, as shown in Graph 1.

1.3 First-step pain results (mean summary) (FSP): Both groups have p=0.000, which is smaller than the critical p value (p

2. Effect of heel pain on 3 types of activities leisure, work, and sports.

2.1 Leisure (mean summary) (HPL): Both groups showed a significant difference with p=0.008 for Group 1 and p=0.016 for Group 2, both of which are smaller than the critical p value (p

2.2 Work (mean summary) (HPW): The measurement for heel pain at work reveals that for Group 1 p=0.552 and for Group 2 p=0.179, both values are greater than the critical p value (p>0.05), so there is no significant difference when comparing day 1 (baseline), day 15, day 29, and the 1-month follow-up.

Graph 4 - Group 1: The bars representing all four interventions are within 0.2 on the activity scale. For Group 2, however, there seems to be a significant difference between interventions 3 and 4. This variance can be attributed to the small graph scale (Graph 4).

2.3 Sports (mean summary) (HPS): For Group 1 p=0.080 and for Group 2 p=0.234, which are greater than the critical p value (p>0.05); therefore, there is no significant difference when comparing day 1 (baseline), day 15, day 29, and 1-month follow- up. Graph 5 shows the relatively smooth ascending flow toward point 2, which indicates improvement, but no significant difference.

B) Objective intra-group measurements

1. Algometry (mean summary) (AR): The algometry readings showed that for Group 1 (p=0.004) and for Group 2 (p=0.000), the p value of both groups is smaller than the critical p value (p

In summary, the intra-group results illustrated basic homogeneity between groups 1 and 2. However, to determine if this is a valid comparison, both groups need to be tested against each other (inter-group comparison) by repeating and comparing the measurements, using the MannWhitney U-test.

Inter-group Comparison - Mann-Whitney U-test

A) Subjective inter-group measurements

1. Pain scale results - worst:

1.1 Day 1 or baseline (PSW1): p=0.818, which is greater than the critical p value (p>0.05). This suggests that, at baseline, there was no significant difference between the two groups (Graph 1 - psw1).

1.2 Day 15 (PSW2): p=0.03. This value is smaller than the critical p value (p

1.3 Day 29 (PSW3): p=0.235. This is greater than the critical p value (p>0.05). It is therefore concluded that there is no significant difference between the 2 groups (Graph 1 - psw3).

1.4 One month later (PSW4): p=0.442. This is greater than the critical p value (p>0.05); therefore, at 1-month follow-up, there is no significant difference between the 2 groups (Graph 1 - psw4). In summary, these results appear to demonstrate that adjusting with stretching is more effective in the short term (day 15), while there is no significant difference between the 2 groups at baseline or in the long term.

2. Pain scale results - least (PSL): For all 4 periods, it is revealed that the p values (p>0.05) were not statistically significant (Graph 1).

3. First-step pain results (FSP): For all 4 measurements, it was found that the p values (p>0.05) were not statistically significant (Graph 2).

4. Effect on heel pain of 3 types of activities leisure, work, and sports.

4.1 For all heel pain/leisure (HPL), heel pain/work (HPW), and heel pain/sports (HPS), statistically (p>0.05), there was no significant difference (Graphs 3, 4, and 5).

B) Objective inter-group measurements

1. Algometer reading results: Statistically, (p>0.05) for all 4 measurements, there is no significant difference (Graph 6). It looks as if there might be some difference between the 2 groups, but participants in Group 1 began with a higher baseline (arl) and ended with a higher final measurement (ar4) than Group 2.

Power Analysis

Inter-group power analysis:

Power analysis was low in the overall majority of cases for all subjective and objective readings since it was smaller than 0.80, the critical power value. This indicates that the "no significant difference between the 2 groups" may be due to a type 2 error.

DISCUSSION

Demographics

The demographic statistics reveal that 13 of the subjects who participated were male and 7 were female (Group 1, 6:M - 4:F and Group 2, 7:M 3:F). Ambrosius and Kondrackill have stated males are more at risk, as in Lapidus and Guidotti's13 study of 127 subjects, which showed 74.2% male and 25.8% female. In contrast, Pfeffer et al.14 claim the majority of subjects are female, since in their trial of 236 subjects, 160 were female and 76 were male.

The age distribution was in general agreement with the literature, as plantar fasciitis is most commonly seen in people over 40 years of age.5,15,1,2 The Group 1 mean age was 40.6 years, while the mean age for Group 2 was 41.1 years.

Subjective Intra-group Measurements

For pain scale - worst (PSW) in Group 1, significant differences are observed between the baseline and day 15 (p=0.005), day 29 (p=0.005) and 1-month follow-up (p=0.008), but no significant differences are noted between the interventions. In Group 2, significant differences are observed between the baseline and day 15 (p=0.038); day 1 and 1-month follow-up (p=0.021); days 15 and 29 (p=0.035); and day 15 and the 1-month follow-up (p=0.023) (Graph 1).

For pain scale - least (PSL) for Group 1 and Group 2, there was no significant intra-group difference (p>0.05) when comparing day 1 (baseline), day 15, day 29, and the 1-month follow-up. On average, there was very minimal pain, and in some instances, no pain at all (Graph 1).

Considering the pathomechanics of plantar fasciitis and its relationship to the second subjective measurement, first-step pain (FSP), during sleep or prolonged inactivity, the foot adapts to a plantarflexed position. As a result, the Achilles tendon and the plantar fascia shorten, and on awakening, the subjects' first few steps are painful as the tissues are suddenly stretched and micro-tears develop.16 From the intra-group results obtained, it was revealed that both treatments provided significant improvement (p

The results of heel pain on leisure, work, and sports demonstrated slight variation. More specifically, the mean summary (overall) effect of heel pain during leisure revealed that there is significant intragroup difference for both groups (p0.05) demonstrated no significant intra-group difference. In addition, the results of the mean heel pain on sport for Group 1 has a marginal p value (p=0.080), which indicates the increased possibility of a type 2 error.

These results of heel pain on sports might have been affected by the demands that the subjects' occupations place on their bodies, and also by the fact that not all subjects participated in sporting activities; some of those who did had to alter their usual training program due to pain (Table 1). Therefore, the results for the effect of heel pain on leisure, work, and sports should be interpreted with caution since the elements outlined above have influenced the validity and reliability of this study.

Objective Intra-group Measurements

The algometer overall mean readings indicate that for Group 1 p=0.004 and for Group 2 p=0.000, there is a significant intra-group improvement (p

Although there is a general appreciation that intra-group comparison found both investigated treatments beneficial, some particular cases did not agree with the overall intra-group results. For example, subject 3 in the adjusting group, a professional pentathlete until recently, has been suffering from plantar fasciitis for 5 years and has responded poorly to all previous treatments. In the past, he has received various treatments including 2 steroid injections, heel-spur removal, strapping, cushioning insoles, and electroshock therapy twice. Furthermore, this participant's subjective scores did not show improvement throughout the trial, which may be due to his pessimistic attitude considering the negative outcomes of all previous treatment attempts. On the other hand, this subject's algometry readings at baseline were 2.2kg/cm^sup 2^, on day 15 3.5kg/cm^sup 2^, on day 29 5.2kg/cm^sup 2^, and 1 month later 5.8kg/cm^sup 2^. These results offer possible evidence that, despite the chronicity, adjusting of the foot with stretching exercises may have provided some improvement.

Another important case is subject 9 of Group 1, who did not improve with chiropractic adjustment. In fact, her condition deteriorated, but she did complete the trial. When studying the 1 objective and 3 subjective measurements of this subject, it was concluded that they all appeared poorer, compared with other subjects. This is perhaps due to the fact that this particular subject was obese, which agrees with Lynch et al.2 and Lawrence17 who suggest that excessive weight is a precipitating factor and chiropractic manipulation of the foot with stretching may simply have further stressed already overstressed fascia.

Another important element of subject 9's negative treatment response is that the only treatment she previously received was the administration of a steroid injection. According to Leach18 and Brockley,19 corticosteroid injections have no therapeutic effects and can lead to rupture of the plantar fascia. In addition, Acevedo and Beskin,20 in another trial, concluded that plantar fascia rupture following corticosteroid injection for the non-operative treatment of plantar fasciitis might result in long-term sequelae that are difficult to resolve.

In fact, the possibility of partial rupture of the plantar fascia is open, but there was no history of a "popping or snapping sound" reported to confirm such a complication and no further investigation (i.e., MRI) was ordered to follow the case after the completion of the trial.

Subjective and Objective Inter-group Measurements

All subjective and objective measurements appeared to have no significant statistical intergroup differences with values greater than P=0.05, apart from the pain scale worst (psw2) measurement on day 15 (p=0.03), which showed that adjusting with stretching was superior to orthotics in the short term (Graph 1). This finding indicates that adjusting of the foot with stretching for a short period of 2 weeks is more effective, and, according to Harvey et al.,21 muscle stretching increases the extensibility of soft tissues; it is therefore widely administered to improve joint mobility.5 In contrast, during the same period, the subjects who used orthotics did not respond so well; this is supported by Raymond,22 who found that orthotics usually require more time to enable the bones, soft tissues, and muscles of the rear foot and of the whole lower extremity to adapt.

Limitations - Recommendations

It is recommended that a larger sample size be used (i.e., at least 30 per group). Although orthotics have been proven superior to antiinflammatory therapy (NSAIDS) with injections (steroid and lidocaine) and accommodative "offthe-shelf viscoelastic heel cups,2 it might be helpful to have an additional placebo control group.

The number of treatments and the 1-month follow-up period should be extended because plantar fasciitis is a chronic condition that may require more time to show accurate therapeutic effects.

Different subjective measurements should be employed since first-step pain and the effect of heel pain measurements have been used in the Lynch trial only,2 and their validity and reliability have not been evaluated in the literature. Further work in this area could include validity and reliability testing of these 2 subjective indices.

The subjective measurement "effect of heel pain on leisure, work, and sport" should be revised as it provided only 2 options, "effect" and "no effect." Future studies should include the option of "nonapplicable" since numerous subjects reported "no effect" because they altered their activities to minimize pain (swimming, instead of running), not because these activities were pain-free. One school believes parametric tests are generally robust enough to withstand even major violations of central limit theorem assumptions without critically affecting the validity of statistical outcomes. Although we chose to use (because of the small sample size) nonparametric statistical evaluation, parametric and ANCOVA statistical evaluation might have better elucidated the data.25

Literature review of conservative treatments for plantar fasciitis and present study conclusions are outlined in Fig. 1.

In addition, some believe plantar fasciitis and heel spur are the same condition; with heel spur an occasional and possibly more serious complication, especially in athletes. Often heel spur and plantar fasciitis are initially treated with the same protocol and if non-responding, special padding or surgical procedures may later be utilized.13·26 Nevertheless, these may be two separate and distinct disorders not screened for in this study, and perhaps these findings do not apply to heel spur. Additionally, the majority of patients with chronic plantar fasciitis will have their symptoms resolve within 12 months.13 The literature, however, is not in total agreement as to what constitutes "chronicity," so in this regard, Magee's definition of symptoms lasting 7 weeks or longer was utilized.27

Although this trial did not address it, and we have no data to support it, the authors believe that a protocol combining these and other treatment modalities (such as concentric and eccentric arch- [and calf-] strengthening exercises) may be beneficial, although these combined treatments await further clinical trials.

CONCLUSION

With the small sample size and methodological limitations of this trial, no firm conclusions can be drawn; the data regarding effectiveness should be interpreted with caution. Nevertheless, within the limits of this trial, both treatments appeared useful when used individually for treatment of common plantar fasciitis and further research is supported.

References

1. Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis. Etiology, treatment, surgical results, and review of the literature. Clin Orthop Rel Research 1991;266:185-190.

2. Lynch DM, Goforth PW, Martin JE, Odom RD, Preece CK, Kotter MW. Conservative treatment of plantar fasciitis. A prospective study. J Amer Podiatr Med Assoc 1998;88(8):375-380.

3. Ryan J. The use of posterior night splints in the treatment of plantar fasciitis. Amer Fam Phys 1995;52:891-898.

4. Gill LH. Plantar fasciitis: diagnosis and conservative management. J Academ Orthop Surg 1995;5(2):109-117.

5. Brantingham J, Snyder W, Dishman R, Hubka M, Brown R, Brantingham C, Markham D. Plantar fasciitis. Chiropr Techn 1992;4(3):75-78.

6. Morris C. The relative effectiveness of anterior night splints and the combination of anterior night splints and manipulation of the foot and ankle joint complex in the treatment of plantar fasciitis (dissertation). Durban (SA): Technikon Natal; 2000.

7. Merriman LM, Tollafield DR. Assessment of the lower limb. Philadelphia: Churchill Livingstone; 1995. p. 358.

8. Wewers ME, Lowe NK. A critical review of Visual Analogue Scales in the measurement of clinical phenomena. Res Nurs Health 1990;13:227-236.

9. Jensen M, Karol P, Barner F. The measurement of clinical pain intensity: a comparison of six methods. Pain 1986;27:117-126.

10. Fischer AA. Pressure threshold measurement for diagnosis of myofascial pain and evaluation of treatment results. Clin J Pain 1987; 2(4):208-214.

11. Ambrosius H, Kondracki MP. Plantar Fasciitis. Euro J Chiropr 1992;40:29-40.

12. Pallant J. SPSS survival manual. A step-bystep guide to data analysis using SPSS for Windows (versions 10 and 11). Philadelphia: Open University Press; 2001. p.170-175, 260-265.

13. Lapidus PW, Guidotti FP. Painful heel: Report of 323 patients with 364 painful heels. Clin Ortho 1965; 39:178.

14. Pheffer G, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Intern 1999;20(4):214-221.

15. Brown C. A review of sub-calcaneal heel pain and plantar fasciitis. Austral Fam Phys 1996;25(6):875-885.

16. Batt ME, Tanjii JL. Measurement options for plantar fasciitis. Phys Sport Med 1995; 23(6):77-85.

17. Lawrence D. Year book of chiropractic. Williams & Wilkins; 1997. p. 194-196.

18. Leach R, Jones R, Silvia T. Rupture of the plantar fascia in athletes. J Bone Joint Surg 1978;60:537-539.

19. Blockley M. Painful heel: a controlled trial of the value of cortisone. BMJ 1956;1:1277-1278.

20. Acevado JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Intern 1998; 19(2):91-97.

21. Harvey L, Herbert R, Crosbie J. Does stretching induce lasting increases in joint ROM? A systematic review. Physiother Res Intern 2002;7(1):1-13.

22. Raymond JA. The manufacture and use of the functional foot orthosis. NY: Karger; 2001. p. 20-30.

23. Glen SP, Brantingham JW. The relative efficacy of chiropractic adjustment compared to placebo in the treatment of subjects with PF - a pilot study (dissertation). Guildford (UK): University of Surrey - EIHMS; 2000.

24. Wolgin M, Cook C, Graham C, Maudlin D. Conservative treatment of plantar heel pain: Long-term follow-up. Foot Ankle 1994; 15(3):891899.

25. Portney LG, Watkins PW. Foundations of clinical research: applications to practice - 2nd ed. NJ: Prentice-Hall; 2000. p. 409.

26. Reid DC. Sports injury assessment and rehabilitation. NY: Churchill-Livingstone; 1992. p. 192-200.

27. Magee DJ. Orthopedic physical assessment, 2nd ed. Philadelphia: W.B. Saunders; 1992 p. 7.

Acknowledgments

We wish to thank the University of Surrey, Guildford, England, and the European Institute for Health and Medical Sciences for help and support.

Evagelos S. Dimou, BSc (Hons) Podiatry, MChS, SRCh, MSc Chiropractic,* James W. Brantingham, DC, CCFC (U.S.A.), FCC (U.K.),# and Timothy Wood, BSc (HMS), Mtech (Chiropractic)^

* First author: Edessa, Greece

# Second author: associate professor, Cleveland Chiropractic College, Los Angeles, CA

^ Third author: lecturer, (clinical) program of chiropractic, University of Surrey, Guildford, Surrey, U.K.

All correspondence to Dr. Brantingham at:

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