Today we transition to the foot and ankle with a review of the 2014 plantar heel pain CPG. Since this CPG is showing its age a little, Austin augments the recommendations with some research updates.
The Foot Posture Index noted in the episode can be found on Physiopedia here.
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Hello and welcome back to the OCS field guide podcast. Today we will be discussing the 2014 heel pain-plantar fasciitis 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 questionand call it a day.
It is important to note that this CPG will use the term heel pain (referring specifically to plantar heel pain per ICF lingo), and plantar fasciitis, to use ICD lingo, interchangeably. So when it says heel pain, its talking specifically about plantar fasciitis, not insertional achilles tendinopathy or tarsal tunnel, etc. Those are diagnoses we 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 and 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 pathoanatomic features that are associated with plantar fasciitis. Increased plantar fascia 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 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 correlated with more pain, while a decrease in pain is seen with a reduction in plantar fascia thickness. Now hear this, presence of calcaneal bone spurs is not related to presence of plantar heel pain or 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. Prognosis 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 dorsiflexion range of motion, high body mass index in nonathletic populations, 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 use the following findings to include a patient in the plantar fasciitis/heel pain category:
• 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 weightbearing activity
• Pain with palpation of the proximal insertion of the plantar fascia
• Positive windlass test
• Negative tarsal tunnel tests
• Limited active and passive talocrural joint dorsiflexion
range of motion
• Abnormal Foot Posture Index, or FPI, score
• High body mass index in nonathletic individuals
The windlass test should be performed in weight bearing, as this has a higher sensitivity and specificity. The examiner passively dorsiflexes the toes while a 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, is the dorsiflexion-eversion test. The examiner maximally dorsiflexes and everts the foot while fully extending the toes and holds this for 5-10 seconds while tapping over area of the tarsal tunnel, like a Tinel’s test. A positive test is reproduction of the patients heel pain or significant tenderness at the tarsal tunnel.
The foot posture index is an assessment tool consisting of 6 criteria of foot posture where each criterion is rated between -2 and +2. Higher, positive numbers indicate a more pronated foot, while lower, negative numbers indicate a more supinatory foot posture. So called “neutral” would lie closer to zero. 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 more pronated, while negative numbers indicate a more supinated foot. The study that got abnormal FPI included as a diagnostic criteria found average an average FPI score of 2.4 in the chronic heel pain group and 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 its important to note that some of the source research listed found correlation both between the cavus foot, or the very high arched supinatory foot, and the more pronated, planus foot. So extremes in either direction are likely important, but we don’t have a specific cutoff.
Just to recap, patients are included in this heel pain/plantar 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 weightbearing activity, Pain with palpation of the proximal insertion of the plantar fascia, Positive windlass test, Negative tarsal tunnel tests, Limited active and passive talocrural joint dorsiflexion range of motion, Abnormal FPI score, and High body mass index in nonathletic 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 FAAM, the Foot Health Status Questionnaire or FHSQ, or the Foot Function Index or FFI. Also that clinicians may use the computer adapted version of the LEFS. I’ll simplify your studying for you. The FAAM and LEFS are the only ones that aren’t far too complicated to actually write an OCS question about, 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 higher or lower scores are better. 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 are actually higher disability. Don’t go looking for or memorizing MCIDs on any of these, if they happened to get you on that for these measures, it would only be one question and still would not have been worth your time to memorize.
The physical impairment measures section is really not any new info, it just pretty much says to take a baseline measure for your diagnostic criteria and monitor those for change over the course of care. Specifically, pain level with initial steps, pain with palpation of proximal plantar fascia attachment, active and passive dorsiflexion range of motion, and body mass index for nonathletic individuals.
Now for the fun: interventions. We’ll work our way from the stronger, A-level recommendations toward the weak recommendations.
1. 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 alone, so as pretty much always, its understood that the manual therapy recommendation is in combination with exercise.
2. Stretching. There is A-level recommendation that clinicians should use plantar fascia-specific and gastroc and soleus stretching to provide short-term (1 week to 4 months) pain relief, and that heel pads may be added to increase the benefits of stretching. The 2008 guideline did recommend stretching dosage be 2-3 times/day, utilizing either sustained such as 3 min holds, or intermittent such as 20 seconds. Neither seems to have a greater effect.
3. Taping. There is A-level recommendation that clinicians should use anti pronation taping for immediate (up to 3 weeks) pain reduction and improved function. Additionally clinicians may use elastic therapeutic tape applied to the gastrocnemius and plantar fascia for short-term (1 week) pain reduction.
4. 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 (2 weeks) to long-term (1 year) periods. It is especially effective in individuals who respond positively to anti pronation taping.
5. Night Splints. There is A-level recommendation for the prescription of a 1-3 month program of night splints, specifically for individuals who consistently have pain with the first step in the morning.
The next few are physical agents:
• Low-level laser: There is C-level recommendation that clinicians may use low-level laser therapy, but later higher quality evidence published after the time frame did not support the use of low level laser.
• Phonophoresis: there is C-level recommendation that clinicians may use ketoprophen phonophoresis.
• However, ultrasound gets a C-level recommendation again the use to ultrasound for this condition.
• Footwear: there is C-level recommendation that clinicians may prescribe a rocker-bottom shoe in conjunction with foot orthosis and shoe rotation during the work week for those who stand for long periods.
• Electrotherapy: The 2008 CPG had a B-level recommendation that clinicians can iontophoresis in the short term. However the 2014 update changes this and gives a D, or “conflicting” evidence, recommendation for the use to manual therapy, stretching, and foot orthoses instead of electrotherapeutic modalities for immediate and long term improvements, and then says clinicians may or may not use iontophoresis to provide short term (2-4 weeks) pain relief and improved 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 use manual therapy, stretching, and orthoses instead.
• Education and counseling for weight loss. There is E-level recommendation, remember this means 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 refer individuals to an appropriate health care practitioner to address nutritional issues.
• Therapeutic exercise and neuromuscular re-education. This is a rare one to have such little evidence, but this receives an F-level, or expert opinion, recommendation. This recommendation for prescribing strength exercises 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 rotator strengthening, balance, etc. Having done some quick research, it does seem that there have been a couple studies done since this was published supporting heavy-slow resistance training. I’d expect a stronger recommendation in the next update.
• Dry needling: There is F-level recommendation, or expert opinion, that trigger point dry needling cannot be recommended, and then a note that a later randomized clinical trial compared trigger point dry needling and sham needling to assessed lower extremity myofascial trigger points. They found greater improvement in VAS and FHSQ, but only a significant difference at 6 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 approach was. There has however been more support of dry needling since this was published, such as Dunning et al 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, and ultrasound than the group that received only manual therapy, stretching, and ultrasound. There are a couple other studies giving more support to dry needling for this population, so I expect this recommendation to change as well.
Finally there is a quick note on extracorporeal shockwave therapy and corticosteroid injections. For extracorporeal shockwave therapy, they cite a systematic review that felt the better-quality studies did not favor extracorporeal shockwave therapy. However, without doing a bunch of extra research, this seems to be shifting as well. For corticosteroid injections however there seems to be more reason to avoid as improvement appears to be short term, with a lot of potential for harm including subcutaneous fat pad atrophy, plantar fascia rupture, peripheral nerve injury and muscle damage.
Just to recap, 5 interventions get an A-level recommendation: Manual therapy, stretching, taping, foot orthoses (prefab or custom), and night splints. There is C-level recommendation for other things like phono, low level laser, and footwear changes; and a C recommendation against ultrasound. Electrotherapy gets a D, conflicting recommendation saying probably do the things that work instead but maybe you can do ionto. 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 with a quick practice question:
A 55 year-old male presents to physical therapy with chief complaint of left heel pain that began about 8 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, up to 5/10 on the NPRS, later in the day and when he has been walking longer, but generally does not have pain in the morning. Objective examination reveals the following:
- Left dorsiflexion range of motion of 5 degrees with knee at 90, and 2 degrees with knee at 0
- Left ankle dorsiflexion, inversion, and eversion manual muscle testing 4-/5
- L hip abduction manual muscle test 3+/5
- Foot posture index score of 6
- Concordant pain reproduced with palpation at the left medial calcaneal tubercle
You decide to go ahead with treatment consisting of manual therapy including talocrural mobilization and soft tissue mobilization to the gastrocnemius and soleus; and gastroc, soleus, and plantar fascia stretching. Which of the following would be the best additional treatment to improve his pain and function for work in the short term?
A. Night splints
B. Antipronation taping
D. Weight loss counseling
The correct answer here is B. Antipronation taping. Although night splints also receive an A-level recommendation, this individual does not have the more typical first-step pain, which would lead use to recommend night splints. Although iontophoresis may be an acceptable treatment, it gets a C level recommendation, and also 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 has just has theoretical or foundational support. Also, though 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.