Plantar Heel Pain CPG

Welcome to OCS Field Guide, the podcast that helps you study smarter for the OCS exam. Hello and welcome back to the OCS Field Guide podcast. Today we will be discussing the 2014 Heal Pain Planner Fashiiidus Clinical Practice Guideline. Although this is an important CPG, the focus is narrow to this diagnostic group, so this should be short, sweet, and to the point. We'll work through the CPG and then give a sample practice question and call it a day. It's important to note that this CPG will use the term "heal pain" referring specifically to plantar heel pain per ICF lingo and plantar fasciitis to use the ICD-10 lingo interchangeably. So when it says heel pain, it's talking specifically about plantar fasciitis, not insertional achilles to denopathy or tarsal tunnel or other things like that. Those are diagnoses that we will want to be able to differentiate from plantar fasciitis. We'll work through the CPG in order, beginning with diagnosis. Plantar fasciitis is the most common foot condition treated by healthcare professionals across the board. It will affect 10% of the population at some point in their life and accounts for 15% of all foot conditions treated by healthcare professionals. It occurs across athletic and non-athletic populations and across the lifespan relatively evenly. Among athletes, it is especially prevalent in high school, competitive, and recreational distance runners. There are a couple of pathoenatomic features that are associated with plantar fasciitis. Increased plantar fasciitis thickness and altered compressive properties of the heel pad are associated with increased symptoms in people with heel pain. However, across individuals with general foot and ankle-related disability, pain-related fear of avoidance is the strongest single contributor to disability. This seems like a good thing to remember for the OCS. Pain-fear avoidance is the greatest contributor to disability in people with foot and ankle problems. Jumping ahead to the imaging section, imaging is not typically necessary to diagnose plantar fasciitis, but increased plantar fascia thickness and fat pad abnormalities noted on radiographs are the two best factors for differentiation of plantar fasciitis. Increased plantar fascia thickness on diagnostic ultrasound is also correlated with more pain while a decrease in pain is seen with a reduction in plantar fascia thickness. Now here this. The presence of calcaneal bone spurs is not related to the presence of plantar heel pain or the diagnosis of plantar fasciitis, but try convincing your patients or doctors of that. Clinically, plantar fasciitis most commonly presents chronically. Evidence by the time the 2014 revision was published showed that on average people waited over a year to seek treatment. Pognosis however is actually positive with 80% of patients reporting resolution of symptoms within a 12 month period. Risk factors for developing plantar fasciitis include limited ankle door selection range of motion, high body mass index specifically in non-ethletic populations, participation in running, and work related weight bearing activity especially in poor shock absorption conditions. So look out for runners, overweight people, and people who work on their feet on concrete all day. Now on to diagnosis. Physical therapists can use the following findings to include a patient in the plantar fasciitis or heel pain category. Presence of plantar medial heel pain most noticeable with initial steps after a period of inactivity, but also worse following prolonged weight bearing. Pain precipitated by a recent increase in weight bearing activity, pain with palpation of the proximal insertion of the plantar fascia, positive win-last test, negative tarsal tunnel tests, limited active and passive telocural joint door selection range of motion, abnormal foot posture index or FPI 6 score, and finally high body mass index in non-ethletic individuals. Let's dive in on a couple of these factors. The win-last test should be performed in weight bearing as this has a higher sensitivity and specificity. The examiner passively dorsiflexes the toes while the patient is standing, heel pain reproduced or increased is considered a positive test. The best test for tarsal tunnel syndrome, which must be ruled out in somebody with heel pain, is the dorsiflexion eversion test. The examiner maximally dorsiflexes and everts the foot while fully extending the toes and holds this position for 5-10 seconds while tapping over the area of the tarsal tunnel, like a tinell's test. The test would be considered positive with reproduction of the patient's heel pain, significant tenderness at the tarsal tunnel or numbness into the foot. The foot posture index is an assessment tool consisting of six criteria of foot posture where each criterion is rated between negative two and positive two. Higher positive numbers indicate a more pronated foot while lower negative numbers indicate a more supernatory foot posture, so-called neutral would lie closer to zero then. I'll link the tool in the notes just so you know what it looks like. Do not waste your time memorizing it. The most you would need to know is that positive means a more pronated foot while negative numbers indicate a more supernatated foot. The study that got abnormal FBI included as a diagnostic criteria found an average FBI score of 2.4 in the chronic heel pain group while an average of 1.1 in the control group. This seems to say that people with a more pronated foot are more likely to have chronic heel pain, but it's important to note that some of the source research that they list found correlation both with a more caveous or supernatory foot and with a more pronated plainist foot, so extremes in either direction are likely important, but we don't have a specific cut off. Just to recap, patients are included in this heel pain planar fasciitis group who present with plantar medial heel pain most noticeable with initial steps after a period of inactivity, but also worse following prolonged weight bearing. heel pain precipitated by a recent increase in weight bearing activity, pain with palpation of the proximal insertion of the planar fascia, positive win-last test, negative tarsal tunnel tests, limited active and passive telocrural joint dorsiflexion range of motion, abnormal FBI score, and a high body mass index and non-ethletic individuals. Now for the most exciting section, outcome measures. I'll keep this brief. There is a level recommendation that clinicians should use the foot and ankle ability measure or FAM, the foot health status questionnaire or FHSQ, or the foot function index or FFI. There is also recommendation that clinicians may use the computer adapted version of the LEFS. How simple fire studying for you? The FAM and the LEFS are the only ones that aren't so complicated that you couldn't actually write an OCS question about them, and for both of them, higher scores equal higher function. The FHSQ is laughably complicated and has many sub-scales that actually go back and forth on whether a higher or lower score indicates more or less function. Don't bother looking it up. The FFI is less complicated, but has way too many items, and even though it is a function index, higher scores actually mean higher disability. The only MCID worth knowing is that of the LEFS, for which the most commonly cited score is 9 for the MCID. For the other measures, they have multiple different MCIDs for the different sub-scales, so really this would be too complicated to ask an OCS question about. So don't look them up or memorize them. The physical impairment measures section is really not any new info. It pretty much says, take a baseline measure for each of your diagnostic criteria and monitor those for change over the course of care. Specifically, pain level with initial steps, pain with palpation of proximal, plenary fascia attachment, active impassive dorsiflexion range of motion, and body mass index for non-ethylic individuals. Now for the real fun, interventions. We'll start with the 5A-level treatment recommendations that are listed in this CPG. Number one, manual therapy. There is A-level recommendation that clinicians should use manual therapy consisting of joint and soft tissue mobilization. to treat relevant lower-extremity joint mobility and calf flexibility deficits, and to decrease pain and improve function. The studies described did show good evidence for greater faster improvement in groups, including manual therapy and self-stretching compared to stretching or manual therapy alone. So as pretty much always, it's understood that the manual therapy recommendation is in combination with exercise. Number two, stretching. There is A level recommendation that clinicians should use planter fascia-specific and gastroch and soleus stretching to provide short-term as in one week to four months, pain relief, and that heel pads may be added to increase the benefits of stretching. The 2008 guideline did recommend a stretching dosage be something like two to three times a day, utilizing either sustained, such as three minute holds, or intermittent, such as 20 seconds. Neither seem to have a greater effect. Number three, taping. There is A level recommendation that clinicians should use anti-pronation taping for immediate up to three weeks, pain reduction, and improved function. Additionally, clinicians may use elastic therapeutic tape applied to the gastric nemias and planter fascia for short-term as in one week, pain reduction. Number four, foot orthoses. There is A level recommendation that clinicians should use foot orthoses, either prefabricated or custom, to support the medial longitudinal arch and cushion the heel to reduce pain and improve function for short-term to long-term as in two weeks for even up to one year periods. It is especially effective in individuals who respond positively to anti-pronation taping. Number five, night splints. There is A level recommendation for the prescription of a one to three-month program of night splints, specifically for individuals who consistently have pain with the first step in the morning. Next, there are a few recommendations on physical agents. The first is low-level laser. There is C level recommendation that clinicians may use low-level laser therapy, but later high-quality evidence published after the time frame that they cite here did not support the use of low-level laser. So that's a recommendation that could end up changing in the future. Next is phonophoresis. There is C level recommendation that clinicians may use ketoprofen phonophoresis. However, ultrasound gets a C level recommendation against the use of ultrasound for this condition. So if you're sounding anything, it should be phonophoresis. Now for footwear. There is C level recommendation that clinicians may prescribe a rocker-bottom shoe in conjunction with foot orthoses and shoe rotation during the work week for those who stand for long periods. Next, electotherapy. The 2008 CPG had a B-level recommendation that clinicians can use Ionto-phoresis in the short term. However, the 2014 update changes this and gives a D or conflicting evidence recommendation for the use of manual therapy stretching in foot orthoses instead of electrotherapeutic modalities for immediate and long-term improvements. And then says clinicians may or may not use Ionto-phoresis to provide short term such as two to four weeks pain relief and improve function. In other words, if you really want to use electrotherapy, you can use Ionto, but other forms are not recommended. And really, you should just use manual therapy stretching in orthoses instead, according to this recommendation. Next is education and counseling for weight loss. There is E level recommendation. Remember, this means that there is theoretical or foundational support that clinicians may provide education and counseling on exercise strategies to gain or maintain optimal lean body mass or to refer individuals to an appropriate healthcare practitioner to address nutritional issues. Next is therapeutic exercise and neuromuscular re-education. This is a rare one to have such level evidence in the positive, but this receives an F level recommendation or expert opinion recommendation. This recommendation is for prescribing strength exercise and movement training to control pronation and attenuate forces during weight-bearing activities. Interventions would include things like foot intrinsic strengthening, hip abductor, and external rotation strengthening, balance, etc. Having done some quick research, it does seem that there have been a couple of studies done since this was published supporting heavy slow resistance training for planar fasciitis. I'd expect a stronger recommendation for this in the next update. Next is dry needling. There is F level recommendation or expert opinion that trigger point dry needling cannot be recommended. And then there's a note that a later randomized controlled trial that compared trigger point dry needling and sham needling to lower extremity trigger points was performed. They found greater improvements in VAS and FHSQ, but only a significant difference at six weeks, but still not meeting the MCID. However, they found a fairly high risk of transient adverse effects, which seems to be telling on how aggressive the needling approach was. There has, however, been more support of dry needling since this was published, such as Dunning et al in 2018, which showed significantly greater improvements in pain at three months in the group that received electrical dry needling in addition to manual therapy stretching in ultrasound, than the group that received only the manual therapy stretching in ultrasound. There are a couple of other studies giving more support to dry needling for this population, so I'd also expect this recommendation to change. Finally, there is a quick note on extra corporeal shockwave therapy and on corticosteroid injections. For extra corporeal shockwave therapy, they cite a systematic review that felt the better quality evidence did not favor extra corporeal shockwave therapy. However, without doing a bunch of extra research, I think this may be shifting as well. For corticosteroid injections, however, there seems to be more reason to avoid them as improvement appears to be short term with a lot of potential for harm, including subcutaneous fat pat atrophy, planar fascia rupture, peripheral nerve injury, and muscle damage. So generally, they're saying, "Council patients away from them." Just to recap real quick, five interventions get A-level recommendation. Manual therapy stretching, taping, foot orthoses, prefabricated or custom, and night splints. There is C-level recommendation for other things like phono, low-level laser, and footwear changes, and a C-level recommendation against ultrasound. Electrotherapy gets a D-conflicting recommendation, saying, "Probably do the things that work instead, but maybe you can do Ionto." There's E-level recommendation for weight loss, and finally, expert opinion recommendation for therapeutic exercise to target muscles that work eccentrically to control loading response, and thus theoretically decrease pronation and attenuate weight bearing forces. Let's finish off with a quick practice question. A 55-year-old male presents to physical therapy with a chief complaint of left heel pain that began about eight months ago after he began working a warehouse job where he has to walk on concrete for most of the day. He has a BMI of 31, and his medications include metformin and metoprolol. He reports his pain is at its worst later in the day when he has been working longer up to about a five at a 10 on the NPRS, but generally does not have pain in the morning. Objective examination reveals the following. Left dorsiflexion range of motion of five degrees with knee at 90, and two degrees with knee at zero degrees. Left ankle dorsiflexion, inversion, and e-version manual muscle testing are four minus out of five. Left hip abduction manual muscle test is three plus out of five. The foot posture index score is six. He has concordant pain reproduced with palpation at the left medial calcaneal tubercle. You decide to go ahead with treatment consisting of manual therapy targeting tailocural mobilization and soft tissue mobilization to the gastric nemias and solias, and gastrox solias and planar fascia stretching. Which of the following would be the best additional treatment to improve his pain and function for work in the short term? Would it be A) night splints, B) anti-pronation taping, C) Iontoferesis, or D) weight loss counseling. The correct answer here is B, anti-pronation taping. Although night splints also receive an A level recommendation, this individual does not have the more typical first step pain which would lead us to recommend night splints. Although Ionto Faresis may be an acceptable treatment, it gets a C level recommendation. And also this would not likely impact what he is feeling late in the day at work. Finally, although this individual could certainly benefit from weight loss counseling, this just has theoretical or foundational support. Also, the weight loss would likely help this person long term it does not address his pain and function at work in the short term. That wraps up this episode of OCS Field Guide. For more resources, check out our Patreon page where you can get access to various study aids, exclusive podcasts and lectures, and participate in our live study sessions which will restart as we get closer to the next exam.