Foot Core Stabilization Exercises vs. Shockwave Therapy for Pain, Strength, and Function in Plantar Fasciitis

Foot Core Stabilization Exercise Group (FCSEG)

Participants in the Foot Core Stabilization Exercise Group (FCSEG) performed a supervised exercise program consisting of seven exercises: short foot exercise, towel curl exercise, big toe press exercise, toe splay exercise, calf raise to big toe press exercise, leg swing exercise, and backward tandem walking. The exercises were performed for 40 minutes per session, three times per week for five consecutive weeks under the supervision of a physiotherapist. Each exercise was performed according to the standardized protocol, with 15 repetitions for the specified exercises. The exercise intensity and difficulty remained unchanged throughout the intervention period.

Extracorporeal Shock Wave Therapy Group (ESWTG)

Participants in the Extracorporeal Shock Wave Therapy Group (ESWTG) received ESWT using the Gymna ShockMaster 500 device with a 12-mm applicator. Treatment was administered in continuous mode at a frequency of 15 Hz and a pressure of 3 bar, delivering a total of 1,800 impulses per session. ESWT was applied to multiple painful points in the heel region, including the central and medial aspects, by a trained physiotherapist. Treatment was administered once weekly for five consecutive weeks.

Heel pain intensity was assessed using the Visual Analog Scale (VAS). Participants indicated their pain intensity on a 10-cm horizontal scale, where 0 represented no pain and 10 represented severe pain. Higher scores indicated greater pain intensity.

The Navicular Drop Test will be used to assess participants' MLA height. Before measurements, the navicular tubercle will be marked while the individual stands barefoot. First, the distance between the navicular tubercle and the ground will be measured in millimeters while seated with the foot unloaded. Then, the individual will stand and bear full weight, and the new distance will be recorded. The difference between these two measurements will be calculated. Results will be classified as increased supination (<5mm), neutral foot (5-9mm), and increased pronation (>9mm).

Ankle dorsiflexor and plantar flexor muscle strength was assessed using a Kinvent K-Force digital dynamometer. Participants were positioned supine during testing. For dorsiflexor strength assessment, the dynamometer was placed over the dorsal metatarsal region, while for plantar flexor strength assessment, it was positioned under the plantar metatarsal region. Participants were instructed to exert maximal force against the device. Three maximal voluntary isometric contractions were performed for each muscle group, and the highest recorded force value was used for statistical analysis. Muscle strength was expressed in kilograms (kg).

The quadriceps (Q) angle was measured using a plastic goniometer to evaluate lower extremity alignment. Participants were positioned supine with their knees fully extended. The pivot point of the goniometer was placed at the center of the patella, the stationary arm was aligned with the tibial tuberosity, and the moving arm was directed toward the anterior superior iliac spine. The angle formed between the two arms was recorded in degrees (°).

Foot posture will be assessed using the Foot Posture Index (FPI). Individuals with PF will stand in a relaxed position, looking forward, with arms at their sides, maintaining body alignment.

FPI includes six clinical criteria:

• Talar head palpation
• Curvatures above and below the lateral malleolus
• Calcaneal inversion/eversion
• Bulging in the talonavicular joint
• MLA structure
• Forefoot abduction/adduction relative to the rearfoot

Each criterion is scored from -2 to +2, and the total score is recorded. A score of 0 indicates a neutral foot, positive values indicate pronation, and negative values indicate supination.

Foot function was assessed using the Foot Function Index (FFI), a 23-item questionnaire consisting of three subscales: pain, disability, and activity limitation. The pain subscale evaluates foot pain experienced in different situations, the disability subscale assesses difficulties in performing functional activities, and the activity limitation subscale evaluates restrictions in daily activities due to foot problems. Participants rated each item based on their foot condition during the preceding week using a Visual Analog Scale (VAS) scoring system. Higher FFI scores indicate greater foot-related pain, disability, and functional limitation.