Evidence Based Protocols for Therapeutic Intervention Plantar Fasciitis Description: Pain located in plantar medial heel region; most noticeable with initial steps after a period of inactivity but also worse after prolonged weightbearing or a recent increase in weightbearing activities. Risk factors are limited ankle dorsiflexion and a high body mass index in nonathletic populations. Differential diagnosis includes tarsal tunnel syndrome, fat pad atrophy, and posterior tibialis tendinosis. Stages of Plantar Fasciitis: Stage 1: Acute reversible inflammation. Minor achy pain after heavy activity or with first initial steps after period of inactivity. Symptoms are not constant and may resolve after basic anti-inflammatory measures followed by stretching exercises. Stage II: Intense pain with activity and symptoms also at rest. Usually can still perform routine activities. Decreased inflammatory cells and increased angiofibroblastic invasion. May have developed calcaneal spur. Stage III: Intense pain with activity and at rest. Significant functional limitations because of pain and cannot perform routine activities. May have partial or full rupture of plantar fascia. Extensive angiofibroblastic invasion. Overview: Numerous interventions have been described for the treatment of plantar fasciitis, but few high quality randomized, controlled trials have been conducted to support these therapies. Anti-inflammatory agents such as steroid injections may provide short term relief. Both tenderness and pain scale scores were significantly improved when reassessed 2 weeks after an injection. A major concern is the risk of subsequent rupture of the plantar fascia after an injection. Dexmethasone .4% or acetic acid 5% delivered via iontophoresis provides short term relief (2-4 weeks) and improved function. Manual therapy and nerve mobilization procedures can provide short term pain relief (1-3 mos) and improved function. Manual therapy techniques help to improve ankle dorsiflexion, 1st MTP extension, and mobility along the course of the median nerve. Calf and plantar fascia stretching can be used to provide short term pain relief (2-4 mos) and improvement of calf flexibility. Calcaneal and low Dye taping can be used to provide short term (7-10 days) pain relief. Studies indicate that taping does cause improvements in function. Orthotic devices either pre-fab or custom can be used to provide short term pain relief (3 mos) and improvement in function. There is no difference between pre-fab or custom. No evidence supports the use of orthotics for long term pain management or functional improvement. Night splints are considered when symptoms are greater than 6 months in duration. Levels of Evidence All studies are categorized using the Oxford Centre for Evidence-based Medicine Levels of Evidence as summarized below. {If you are unfamiliar with the Oxford criteria, please contact the Ortho or Sports lead for relevant information, websites, and/or references.} Levels of Evidence Level I (*L1*) Evidence obtained from high-quality randomized controlled trials, prospective studies, or diagnostic studies Level II (*L2*) Evidence obtained from lesser-quality randomized controlled trials, prospective studies, or diagnostic studies (improper randomization, no blinding >80% follow-up) Level III (*L3*) Case controlled studies or retrospective studies Level IV (*L4*) Case series Level V (*L5*) Expert Opinion Phases / Stages of healing: Evidence-based Protocol for progression of activities Acute Stage 0-4 weeks Phase I Goals Decrease inflammation Decrease pain Improve function Iontophoresis (Osborne & Allison 2006) *L2* .4% Dexmethasone or 5% acetic acid 6 treatment sessions over 2 week period Good short term pain relief and improved function for 2-4 weeks Taping (Hyland et al 2006) *L3* Calcaneal or low dye taping Provides short term pain relief No evidence to show improved function Phase II Activity Limitations (Expert opinion) *L5* Use reproducible measure of activity restrictions secondary to heel pain to determine if interventions are effective. • ie: Patient unable to stand longer than 5 minutes without heel pain and now can stand for 15 minutes without heel pain or use numeric pain scale. Helps demonstrate to clinician and patient whether interventions are working. Subacute Stage 4 weeks to 3 months Goals Improve function Decrease pain Improve joint mobility Improve neural mobility Improve soft tissue mobility Provide stability during weight-bearing activities Manual Therapy (Young et al 2004) *L4* Talocrural joint posterior glides Subtalar joint lateral glides Ant/Post glides of 1st TMT joint Subtalar joint distraction manipulations Provides short term pain relief (1 to 3 mos) and improved function Phase II Subacute Stage 4 weeks to 3 months Passive neural mobilization (Meyer et al 2002) *L4* Increased pain noted with SLR test with passive dorsiflexion and eversion to put increased stress on tibial nerve Passive and active mobilization of soft tissue aimed at restoring pain free mobility along the course of the median nerve Perform procedures in a slumped sitting position 10 treatment sessions over a 1 month period of time May provide short term pain relief (1-3 mos) and improvement in function Calf and Plantar fascia stretching (Porter et al 2002) *L2* Calf muscle or plantar fascia specific stretching can be performed either 3 times per day or 2 times per day utilizing either a sustained 3 minute stretch or intermittent 20 second stretching time. Neither dosage produced a better effect. Can be used to provide short term (2-4 mos) pain relief and improvement in calf flexibility Phase III Orthotic Devices (Landorf et al 2006) *L1* Prefabricated and custom orthotics are favored over sham orthotics No differences in effectiveness noted between prefabricated and custom orthotics Provides short term (3 months) reduction in pain and improvement in function. No evidence to support the effectiveness of long term (1 year) pain management and improved function Chronic 3 months to 1 year Goals Improve function Work toward return to sport/recreational activity Continue to improve joint and soft tissue mobility Continue to improve neural mobility if appropriate Make referral to appropriate medical professionals if necessary Night Splints (Crawford/Thomson 2003) *L2* Should be considered as an intervention in patients with symptoms greater than 6 month duration Desired length of time for wearing the device is 1-3 months The type of night splint used (posterior/anterior/sock-type) does not appear to affect the outcome Continue with interventions cited in Phase II if proven effective with functional outcome questionnaires Examination components History Pain in plantar medial heel which is increased with first few steps out of bed in the morning or after a period of inactivity. Pain also worsens after prolonged weight bearing activity. May be precipitated after a recent increase in weight-bearing activity such as walking or running or after an increase in weight gain. Risk factors include limited ankle dorsiflexion and high body mass index in non-athletic populations Systems review Rule out the following differential diagnoses: • Calcaneal stress fracture • Bone bruise • Fat Pad Atrophy • Tarsal Tunnel Syndrome • Soft tissue, primary, or metastatic bone tumor • Paget disease of bone • Reiter’s Syndrome • Sever’s disease • Referred pain as a result of an S1 radiculopathy Tests / Measures Outcome Measures- Use validated self report questionnaires (Martin et al 2005) *L1* • Foot Function Index (FFI) • Foot and Ankle Health Status Questionnaire (FHSQ) • Foot and Ankle Ability Measurement (FAAM) • Only FAAM has been validated in a physical therapy practice setting. Consists of 21 item activities of daily living (ADL) and an 8 items sports subscale. • Test and re-test reliability of FAAM .89 and .87 for the ADL and sports subscales respectively. • MCID (minimally clinically important difference) for FAAM were 8 points for ADL subscale and 9 points for sports subscale • Activity Limitations Measures- no activity limitations measures specifically reported in the literature. Suggestions are as follows: (Stratford et al 1995) *L5* o Percent of time experiencing ankle, foot, or heel pain over the previous 24 hours o Pain level with initial steps after sitting or lying o Pain level with single leg stance o Pain level with standing for a specified period of time, such as 30 minutes o Pain level after walking a specific distance, such as 1000 m • • Patient Specific Functional Questionnaire o Questionnaire that can be utilized to quantify changes in activity limitations related to plantar fasciitis symptoms Physical Examination o Palpation of proximal plantar fascia insertion o Active and passive talocrural dorsiflexion range of motion assessement (Martin et al 2005) Patient prone with feet over edge of treatment table. Patient actively dorsiflexes ankle while ensuring the foot does not invert or evert. Measure with goniometer along shaft of fibula and moving arm along shaft of 5th metatarsal. ICC .64-.99 for active test ICC .74-.98 for passive test o The tarsal tunnel syndrome test (Kinoshita et al 2001) Dorsiflexion of ankle, eversion of ankle, and extension of all toes. Maintain position for 5 to 10 seconds while tapping over the region of the tarsal tunnel to determine if the pt. complains of local nerve tenderness Sn. .81 and Sp. .99 for increased numbness Sn. .92 and Sp. .99 for more pronounced Tinel sign o Windlass Test (DeGarceau et al 2003) Non-weight bearing: With patient sitting examiner stabilizes the ankle joint in neutral with 1 hand placed just behind the first metatarsal. The examiner then extends the first metatarsal while allowing the interphalengeal joint to flex. Passive extension of the 1st MTP is continued until the patient’s pain is reproduced. Sn. .18 and Sp. .99 Weight bearing: The patients stands on top of a step stool with the metatarsal heads positioned on the edge of the step. Peform the same test as above. Sn. .33 and Sp. .99 o Longitudinal Arch Angle (McPoil et al 2005) With patient standing with equal weight on both feet, the midpoint of the medial malleolus, navicular tuberosity and the most medial prominence of the first metatarsal head are identified using palpation and marked with a pen. A goniometer is then used to measure the angle of the three points with the navicular tuberosity acting as the axis point. The LAA is a static foot measure of foot posture. Accurate threshold for developing medial tibial stress syndrome. The LAA provides a measure of foot structure and function that can be related to the development of planar fasciitis. References 1) Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2003; CD000416. http://dx.doi.org/10.1002/14651858.CD000416 2) De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int. 2003;24:251-255. 3) Hyland MR, Webber-Gaffney A, Cohen L, Lichtman PT. Randomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the short term management of plantar heel pain. J Orthop Sports Phys Ther. 2006; 36: 364-371. http://dx.doi.org/10.2519/jospt.2006.2078 4) Kinoshita M, Okuda R, Morikawa J, Jotoku T, Abe M. The dorsiflexion test for diagnosis of tarsal tunnel syndrome. J Bone Joint Surg Am. 2001;83-A:1835-1839. 5) Landorf KB, Keenan AM, Herbert RD. Effectiveness of foot orthoses to treat plantar fasciitis: an randomized trial. Arch Intern Med. 2006:166:1305-1310. http://dx.doi.org/10.1001/archinte.166.12.1305 6) Martin RL, Irragang JJ, Burdett jRg, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM), Foot Ankle Int. 2005; 26: 968-983. 7) Martin RL, McPoil Tg. Reliability of ankle goiniometric measurements: a literature review. J Am Podiatr Med Assoc. 2005;95:564-572.95/6/564 [pii] 8) McPoil TG, Cornwall MW. Use of longitudinal arch angle to predict dynamic foot posture in walking. J Am Podiatr Med Assoc.2005;95:117-120. 9) Meyer J, Kulig K, Landel R. Differential diagnosis and treatment of subcalcaneal heel pain: a case report. J Orthop Sports Phys Ther. 2002;32:114-122; discussion 122-114. 10) Osborne HR, Allison GT. Treatment of plantar fasciitis by LowDye taping and iontophoresis: short term results of double blinded, randomised, placebo controlled clinical trial of dexamethasone and acetic acid. Br J Sports Med. 2006;40:545-549; discussion 549. http://dx.doi.org/10.1136/bjsm.2005.021758 11) Porter D, Barrill E, Oneacre K, May BD. The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study. Foot Ankle Int. 2002;23:619-624. 12) Stratford PW, Gill C, Westaway MD, Binkley JM. Assessing disability and change on individual patients: a report of patient specific measure. Physiother Can. 1995;47:258-263. 13) Young B, Walker MJ, Strunce J, Boyles R. A combined treatment approach emphasizing impairment-based manual physical therapy for plantar heel pain: a case series. J Orthop Sports Phys Ther. 2004;34:725-733. http://dx.doi.org/10.2519/jospt.2004.1506