Efficacy of Bare foot Exercise Versus Common Footwear Exercise in Subjects with Plantar Fasciitis

 

Kamalakannan. M1*, Earnest Philemon Dass. D 2

1Assistant Professor, Saveetha College of Physiotherapy, SIMATS, Chennai

2Student, Saveetha College of Physiotherapy, SIMATS, Chennai

*Corresponding Author E-mail: kamal1712@gmail.com

 

ABSTRACT:

The aim of the study is to determine the efficacy of barefoot exercise vs. common footwear exercise in subjects with plantar fasciitis. An objective of the study is to find the efficacy of barefoot exercise versus common footwear exercise on pain with numerical pain rating scale among subjects with plantar fasciitis and to find the efficacy of barefoot exercise versus common footwear exercise on balance outcome measure for elder rehabilitation (BOOMER) among subjects with plantar fasciitis. Methodology: 20 patients with plantar fasciitis were selected based on the inclusion and exclusion criteria. The collected data were tabulated and analyzed using descriptive and inferential statistics. To all parameters mean and standard deviation (SD) was used. Paired t-test was used to analyze significant changes within the groups. Unpaired t-test was used to analyze significant changes between the two groups. It has been concluded that barefoot exercise (GROUP A) is more effective than common footwear exercise (GROUP B) in decreasing pain, and increasing balance in subjects with plantar fasciitis.

 

KEYWORDS: Bare Foot Exercise, Common Footwear, Plantar Fasciitis, BOOMER, Intrinsic muscles of the foot.

 

 


INTRODUCTION:

The human foot is a strong and complex mechanical structure containing 26 bones, 33 joints, along with 19 muscles and 107 ligaments. It is the terminal portion of the limb which bears weight and allows locomotion. The plantar fascia is a thick band of tissue that runs across the bottom of your feet and connects the heel bone to the toes. Its primary purpose is to absorb the majority of the stresses we put on our feet, but it has a limit: too much pressure or strain can go on to damage the tissue and lead to inflammation in that area. This inflammation results in the most typical symptom of plantar fasciitis, a stabbing pain in the bottom of the foot near the heel that's usually worse with the first few steps of the day in the morning or after standing for a while1,2,3,4.

 

Plantar fasciitis is defined as inflammation of the plantar fascia and the surrounding perifascial structures.

 

 

It is also referred to as "heel pain syndrome". It is estimated as that 1 in 10 individuals will experience plantar fasciitis during their lifetime. There are three major risk factors for developing plantar fasciitis. It includes anatomical, biomechanical, environmental risk factors. Anatomical risk factor includes pes planus, obesity, leg length discrepancy, etc. Biomechanical risk factor includes weak plantar muscles, excessive subtalar joint Pronation etc. Environmental risk factor includes prolonged standing, walking barefoot, prolonged weight bearing etc5,6,7.

 

Plantar fasciitis is particularly common in people performing any weight-bearing activities or being on your feet for too many hours in a day. People who are overweight, over the age of 40 or who have high arches or flat feet are also at an increased risk of developing plantar fasciitis. Physiotherapy for treating plantar fasciitis is a multi-faced approach. It includes exercises, shoe modification, massage etc. While these treatments may help provide some relief, they are usually ignoring the unsupportive muscles in the foot itself. There are many factors associated with plantar heel pain, deficits in foot plantar flexor muscle performance is an important factor related to failed or incomplete response to treatment. Strengthening of intrinsic foot muscles is important in plantar fasciitis8,9,10.

 

Foot intrinsic muscles are like the ‘core’ muscles of the foot. Just as the core muscles around the spine are essential to stabilize and protect the spine, the foot intrinsic muscles must do the same for the many bones and joints of the foot. When the foot intrinsic muscles are weak and unable to support the foot properly they must be strengthened11,12.

 

Barefoot is the most common term for the state of not wearing any footwear.Wearing footwear is an exclusively human character. There are health benefits and some risks associated with going barefoot. Footwear provides protection from cuts, abrasions, bruises, and impacts from objects on the ground or the ground texture itself. Shoes can limit the flexibility, strength, and mobility of the foot and can lead to higher incidences of a flexible flat foot, bunions, and hammer toe13,14. Plantar heel pain is one of the most common foot and ankle conditions are seen in clinical practice and many individuals continue to have persisting or recurrent pain after treatment. Impaired foot plantar flexor muscle performance is a factor that may contribute to limited treatment success16,17.

 

Walking barefoot was all the rage a few tens of thousands of years ago and back before we had shoes. The reason for this barefoot revival is quite simply that going barefoot has been shown to have various benefits for our health and fitness which make the slight discomfort more than worth it. When we evolved though, we didn't have shoes and so our body is actually designed to walk on bare feet. And unfortunately the difference between footwear and going barefoot is more than just cosmetic, and if you walk in shoes this is an entirely different process to walking barefoot. If you walk in footwear you have support on your ankle and your bridge and you have a huge heal that pads the bottom of your foot, changes your stride and alters the angle that you walk – and none of this is what we're designed18,19.

 

Choosing proper footwear can help to protect you against common injuries associated with your type of workout. Good shoes can lessen the impact of your step and cushion the foot from heavy landings. In addition, sport or exercise specific shoes can improve your performance, enabling, for example, quick direction changes. Remember 25% of the bones in your body are in your feet20. If any of these bones are misaligned, your entire body could be affected. This may manifest itself in

the knee, hip or lower back problems. So although it may be tempting to choose less expensive footwear from any old store, you could be doing yourself more harm than good. So, this study was undertaken with an attempt to determine the efficacy of barefoot exercise versus common footwear exercises in subjects with plantar fasciitis.

 

MATERIAL AND METHODS:

Study design: Randomized controlled trial, Study setting: Saveetha Medical College and Hospital, Sampling method: simple random sampling Sample size: 20 patients. Each group 10 patients. Group A   received UST and barefoot exercise and group B received UST and common footwear exercise. Inclusion criteria: Age group - 20 to 40 years, unilateral plantar fasciitis and Windlass test –positive. Exclusion criteria: joint swelling or any infectious pathology, history of a significant lower extremity injury or recent surgery, recent fractures/injuries in feet, deformity, recent ligament injury. Material required: Exercise room, Couch, Chair, Inch tape and timer

 

PROCEDURE:

Twenty patients with plantar fasciitis were selected according to the inclusion and exclusion criteria. Detailed procedure was explained to the patients in colloquial terms about the safety and simplicity of the procedure and the informed consent was given to those were interested. The selected patients were randomly assigned into two groups 10 in each group by using the lottery method. The Group A and B have patients with plantar fasciitis who were treated with barefoot exercise and common footwear exercise respectively. The outcome measures used in the study for pain-Numerical Pain Rating Scale (NPRS), The balance outcome measure for elder rehabilitation (BOOMER) respectively. For all the patient's pre and post-test were measured by a therapist who was blinded to the study. And the study was accepted by the institutional scientific review board.

 

BAREFOOT EXERCISE:

Barefoot exercise consisted of active movement given in the order.

 

·        Short foot exercise:

The subjects are instructed to pull the first metatarsal head towards the heel without toe flexion.

 

·        Gastrocnemius stretch:

The subjects are instructed to stand about three feet from a wall and put their right foot behind them ensuring their toes are facing forward. Keep your heel on the ground and lean forward with your right knee straight.

 

 

·        Soleus stretch:

The subjects are instructed to stand away from a wall and put their foot behind and ensuring their toes are facing forward.  Lean forward at the ankle while bending the right knee and keeping their heel on the ground.

 

·        Toe lifting:

The subjects are instructed to raises the toes and forefoot up off the floor to strengthen the shin muscles keeping their heels on the ground.

 

·        Heel lifting:

The subjects are instructed to raise the heel keeping their toes and forefoot on the ground. 

 

Table 1: Exercise protocol for Bare Foot Exercise

Session

2 session / day

Repetitions

5 repetitions / day

Rest time

3 seconds

Hold time

6 seconds

Frequency

5 days/week

Duration

3 weeks

COMMON FOOTWEAR EXERCISE:

·      The common footwear exercise consisted of active movement given in the order.

·      Forefoot press: Place the back of your foot on a sturdy object, such as a book, and the front half of your foot on a weight scale, ensuring your foot is horizontal. Press down on the scale with your forefoot so you can measure the strength.

·      Gastronomies stretch: The subjects were instructed to stand about three feet from a wall and put their right foot behind them ensuring their toes are facing forward. Keep your heel on the ground and lean forward with your right knee straight.

·      Soleus stretch: The subjects were instructed to stand away from a wall and put their foot behind and ensuring their toes are facing forward.  Lean forward at the ankle while bending the right knee and keeping their heel on the ground.

·      Toe lifting: The subjects are instructed to raises the toes and forefoot up off the floor to strengthen the shin muscles.

·      Heel lifting: The subjects are instructed to raise the heel keeping their toes and forefoot on the ground.

 

Table 2: Exercise protocol for Common Footwear Exercise

Session

2 session / day

Repetitions

5 repetitions / day

Rest time

3 seconds

Hold time

6 seconds

Frequency

5 days/week

Duration

3 weeks

 

 

OUTCOME MEASURES:

The Numerical Pain Rating Scale (NPRS) is a one-dimensional measure of pain intensity to the patients. The NPRS is a segmented numeric version of the visual analog scale (VAS) in which a respondent selects a whole number (0-10 integers) that best reflects the intensity of his/her pain. The common format is a horizontal bar or line. Similar to the VAS, the NPRS is anchored by terms describing pain severity extremes. The 11-point numeric scale ranges from representing one pain extreme (e.g. no pain) to representing the other pain extreme (e.g. pain as bad as you can imagine or worst pain imaginable).

 

The Balance Outcome Measure for Elder Rehabilitation (BOOMER):

The Balance Outcome Measure for Elder Rehabilitation (BOOMER) was developed to assist in clinical practice to quantify standing balance. The combination of a variety of single-item outcome measures makes the BOOMER a highly feasible and applicable tool that is both time and resource efficient.

 

The BOOMER consists of the following four tests:

·      Timed static stance - Feet together with eyes closed.

·      Functional reach (FR) - Individual reaches as far forward as possible in a standing position without losing balance.

·      Step test - One foot is repeatedly placed on top of a 7.5cm step and returned back down to the ground as many times as able in 15 sec. The average between legs is then calculated for scoring.

·      Timed up and go (TUG) - From a seated position, individual stands, walks 3m, turns 180°, walks 3m back to the chair and sits down with back resting.

 

STATISTICAL ANALYSIS:

The collected data were tabulated and analyzed using descriptive and inferential statistics. To all parameters mean and standard deviation (SD) was used. Paired t-test was used to analyze significant changes between pre-test and post-test measurements. Unpaired t-test was used to analyze significant changes between the two groups.

 

 

Table 3: Comparison between the post-test values for numerical pain rating scale Group A and B.

PARAMETERS

 

Mean

Standard

Deviation (SD)

Mean

Standard

Deviation (SD)

p-value

Group A

Group B

Numerical

rating scale (NPRS)

4.50

0.53

4.70

0.82

<0.0001

The post-test mean value comparison of NPRS between Group-A and Group-B is 4.50 and 4.70 respectively.


 

 

Table 4: Comparison between the post-test values for BOOMER Group A and B

PARAMETERS

Mean

Standard Deviation (SD)

Mean

Standard deviation (SD)

p- value

BOOMER

12.40

0.92

10.80

0.92

< 0.0001

The post-test mean value comparison of BOOMER between Group-A and Group-B is 12.40 and 10.80 respectively.

 


RESULT:

From the statistical analysis made with the quantitative data revealed that there is a statistically significant difference between pre-test and post-test values of Group-A and Group-B. The post-test mean value comparison of NPRS between Group-A and Group-B is 4.50 and 4.70 respectively which has a statistically significant difference showing the intervention of Group-A is effective. The post-test mean value of pain shows more reduction in Group-A. The post-test mean value comparison of BOOMER between Group-A and Group-B is 12.40 and 10.80 respectively which has a statistically significant difference showing the intervention for Group-A to be more effective.

 

DISCUSSION:

Plantar heel pain is a repetitive strain injury of the medial arch and heel it is one of the most common causes of foot pain. Plantar fasciitis is usually a repetitive microtrauma overloaded injury of the attachment of the plantar fascia at the inferior aspect of the calcaneus. It is common, often disabling complaint and is estimated to account for up to 15% of all foot symptoms in adults. It has been estimated that it affects as much as 10% of the general population over the course of a lifetime.

 

The plantar fascia is a dense, fibrous connective tissue structure originating from the medial tuberosity of the calcaneus. It has three portions-medial, lateral and central portions. The central portion of the fascia originates from the medial process of the calcaneal tuberosity superficial to the origin of flexor digitorium brevis, quadrates planate, and abductor hallucis muscle.

 

The fascia extends through the medial longitudinal arch into individual bundles and inserts into each proximal phalanx. The plantar fascia blends with the Para tendon of the Achilles tendon, the intrinsic foot musculature, and even the skin and subcutaneous tissue. The plantar fascia is an important static support for the longitudinal arch of the foot. A strain on the longitudinal arch exerts its maximal pull on the plantar fascia, especially its origin on the medial process of the calcaneal tuberosity. The plantar fascia elongates with increased loads to act as a shock absorber, but its ability to elongate is limited (especially with decreasing elasticity common with age).

 

The classical presentation of plantar fasciitis includes a gradual, insidious onset of inferring medial heel pain at the insertion of the plantar fascia. Pain and stiffness are worse with rising in the morning or after prolonged ambulation and May exacerbated by climbing stairs or doing toe raises and also impairs the activities of daily living. It is rare for patients with plantar fasciitis not to have pain or stiffness with first few steps in the morning or after a prolonged rest.

 

Non-surgical management for the treatment of the symptoms and discomfort associated with plantar fasciitis can be classified into broad categories: reducing pain and inflammation, reducing tissue stress, restoring muscle strength and improving flexibility. To reduce pain ultrasound, Cryotherapy and medical treatment like corticosteroids are used and to reduce tissue stress footwear modification, foot orthotic, foot strapping and taping are used. To improve flexibility stretching are given. But they are not concentrating on muscle strength. Impaired foot plantar flexor muscle performance is a factor that may contribute to limited treatment success, but the reason for impairment is unclear. It is possible that pain inhibits muscle performance, or that atrophy has occurred due to disuse or prolonged accommodation. So, strengthening of intrinsic foot muscle is important in plantar fasciitis.

 

Barefoot exercise is the norm for many sports. In addition, many people perform modern dance, Pilates and yoga in bare feet. Wearing shoes all day weakens the feet and arches, but barefoot exercises strengthen the muscles and improve the arches. Barefoot runners have fewer shin splints and less plantar fasciitis, an inflammation under the heel. Barefoot exercise and common footwear exercise strengthens the intrinsic foot muscle, mainly abductor hallucis. It is a dynamic stabilizer of foot and elevator of an arch. Strengthening the muscle that supports the arch which in turn reduces the stress on the plantar fascia. Strengthening the muscle which may reduce or eliminate the collapsing the arch. The present study showed that the reduction of pain and improvement in balance in subjects with plantar fasciitis.

 

CONCLUSION:

From the result, it has been concluded that Barefoot exercise is more effective than Common footwear exercise in reducing pain and improving the balance.

 

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

 

 

 

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Received on 05.10.2018         Modified on 19.11.2018

Accepted on 16.12.2018      © RJPT All right reserved

Research J. Pharm. and Tech. 2019; 12(3):1039-1043.

DOI: 10.5958/0974-360X.2019.00171.9