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Hey everyone – Casey and I would like to keep the discussion going from last weekend’s material, first starting with plantar fascia pain. Here’s the first article by Drake (the rapper) et al, “The Short-Term Effects of Treating Plantar Fasciitis with a Temporary Custom Foot Orthosis and Stretching.”
What is your biggest clinical takeaway form this article? Feel free to use patient case examples.
Does anyone use orthotics for plantar fascia pain at their clinic? If so, what type of orthotic / posting do you use?
Do you think foot type (planus / cavus) would change how you use orthotics for plantar fascia pain?
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My biggest takeaway from the article is the importance of acutely off-loading the plantar fascia in order to decrease symptoms. I think my PT-brain would want to immediately turn to stretching or exercise to help decrease symptoms, but its important to give the fascia time to heal. I don’t see my clinic implementing their TCFO technique, however the basic principle is still helpful. I could try taping techniques, or patient-education about foot postures to decrease stress until the fascia has time to heal.
I don’t use orthotics at my clinic but that is mostly because I have had minimal exposure to them. We have them available to give to our patients. Also, in my September lit review, my systematic review was about orthotics in the treatment of posterior heel pain. Overall, there were only short-term positive effects with some of the orthotics (vs. conservative management, which was loosely defined) and these effects weren’t found usually after two weeks. My personal bias would be to promote education, and if the patient wants to buy an orthotic (thinks it will help), to recommend a general prefab, because in the systematic review, there were no differences between custom-made and prefab. The only exception to this would be if the patient demonstrated a very noticeable and likely pain-provoking foot posture, then I may recommend a specific orthotic to help their specific foot type. I’ve attached the article at the bottom.
Going off my last point, yes I think that the patient’s foot type should dictate if, and what type of orthotic I would use, if I truly think an orthotic would help. In Dhinu’s presentation, he mentioned that a pes cavus foot usually results in a shortening of the plantar fasicia, and a pes planus foot is an overstretch of the plantar fascia (someone correct me if I heard this incorrectly). To me, this would make my treatment for these two things very different, and this is one of my difficulties with the article. The article protocol was two weeks of the TCFO, then a bunch of weeks of stretching. However if the patient’s plantar fascia is already overstretched due to their foot type (pronated foot resulting in pes planus), continuing to stretch it may add to the problem. I would be interested in what others think about this.
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My biggest takeaway from this study the significant changes seen in NPRS and FAAM after the initial two weeks of constant TCFO usage. As Jeff had mentioned being a young eager clinician I want to get my hands on patients decrease their symptoms with manual techniques and stretching. After reading this article I think a lot of treating this pathology like any other pathology comes to educating our patients. Finding ways to decrease aggravating factors to allow our tissues proper healing time before implementing stretching, manual or stretching interventions is key for positive long-term outcomes.
I personally do not make any custom orthotics or make many recommendations for orthotics in my practice. I will however discuss with patients choice of footwear and ask them about how they feel in their different pairs (i.e. dress shoes, tennis shoes, heels, etc.) of shoes and approach the conversation in that manner. I have yet to consider taping either but I could see how that could have a similar effect to the TCFO as the article had mentioned providing support to the plantar fascia and reducing the pull with each step. It may be something I try to implement if I come across the case of PF that is not progressing as expected.
I too believe that resting foot type (pes planus, cavus, neutral) will determine orthotic recommendation or use for plantar fascia pain. As Dhinu had previously mentioned and Jeff stated with pes plaus or cavus we are dealing with two separate issues, (overstretching, over shortened). I believe the role of an orthotic in these particular cases would not be to correct the actual “deformity”, but to redistribute forces along the foot to decrease the stresses placed on the plantar fascia.
Jeff to your question I agree with your questioning of the protocol to stretch a foot that may already be irritated due to overstretching (pes planus) of the plantar fascia. Maybe these patients would benefit from a strengthening protocol ie short arch springs, towel scrunches, or SLS? I wonder what everyone else thinks as well.
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Interesting that you all bring up this idea of stretching versus strengthening when treating plantar fascitis. I was listening to a podcast the other day where they were discussing this exact thing. They were emphasizing the need to meet these patients where they are along the continuum of their pain, treating pragmatically. Obviously managing them in the acute stage, strengthening may not be well tolerated and neither may a firm orthotic that is just prodding away at the irritable tissue. I think exploring less invasive changes to decrease tissue load to the plantar fascia should start with education on shoewear then thinking of adding adjunct treatments like taping, then on to more invasive/expensive orthotic options. I’ve also found that a lot of these patients might already know what has worked and what hasn’t (through their attempt to self treat) so digging into what they have found helps or doesn’t help during the subjective history is very beneficial as a clinician to know where my recommendations might lie on that spectrum.
Going back to strength versus stretching…..Take a look at this study by Rathleff published in the Scandinavian Journal of Medicine and Science in Sports (2014) that compared plantar-specific stretching with a heel cup vs high-load strength training with a heel cup. The results found that the high load strengthening group was associated with a larger improvement in FFI (foot function index) and tendency to be more satisfied with the results of the treatment compared to the stretching group. Interested to see what you guys think about it?
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I agree with you guys. Jeff, you’re right that the treatment should be individualized, but what I like most about this report is how vague the patient demographic was (e.g, ~50% pes planus / ~50% not, sx duration 2-84mos). Given the small sample size n=15, there was still a strong improvement in all 3 primary outcome measures with a strong p value a=0.001. This suggests to me that, while every patient needs an individual approach, I can respect the pathology at hand and recognize the general concept of appreciable early unloading to the anatomy.
I don’t have much experience with TCFOs, but a quick Google search suggests to me that they might run between $100-$300 (maybe you guys can suggest otherwise). I might opt to use leukotape arch support, as the study suggests benefit from artificial support for just 2 weeks… (though they admit a longer duration should be studied). I’ve had anecdotal success with this technique, the primary goal to conceptually unload the tissue along the medial arch.
I’d like to know more about the patients used in the study since 13/15 were female. Does gender specific shoe wear act as a predisposing factor? What were their BMIs?
Casey, I love 2 things about your article: 1) The combined concepts used in the study by placing the PF tissue on stretch while applying a high tensile load through a heel raise. 2) That it all goes back to the anatomy. “The plantar fascia is made up of collagen type 1 fibers (Stecco et al., 2013). It appears that this type of collagen responds to high-load through increased collagen synthesis (Langberg et al., 2007). As patients with plantar fasciitis show degenerative changes at the plantar fasciaenthesis (Jarde et al., 2003; Lemont et al., 2003), increased collagen synthesis may help normalize tendon structure and improve patient outcomes.” If we’re specific with what we’re treating, we can apply concepts to be more effective at tissue modification to reach our goals.
^
My takeaways are only limited to the context of folks with chronic pain, as this was an inclusion criteria for the study. -
My takeaway from the second article is how much time it takes for pain to decrease in this population, no matter what treatment the individual received. This will help me set patients’ expectations. It may also result in me tapering off their frequency so that when their pain is manageable, I’d only see them once a week or every other week to check-in and make adjustments as needed.
I also really liked the exercise the exercise group received. It combined strengthening as well as included a stretch of the plantar fascia via the windlass mechanism. I also was intrigued that it may have combined an ankle DF stretch with it. Was anyone surprised that the stretching group only focused on DF the toes and not working on ankle DF ROM?
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Hi guys, continuing this train on treating plantar heel pain. Here’s the second article: “Effectiveness of Trigger Point Dry Needling for Plantar Heel Pain: A Randomized Controlled Trial.” Have a read. 😊 I’ve listed some questions below to help drive the discussion, however I encourage you to come up with your questions as well!
-Has anyone had exposure to this treatment for plantar fascitis? Have you seen success with it? If not, what clinical application do you take away from this article?
-What clinical and biopsychosocial factors would drive your reasoning process on choosing dry needling as a treatment technique?
-Do the limitations of this study, both discussed in the article and flaws you may have identified yourself effect your opinion on the conclusion of this study?
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I am not DN certified either, however would like to become certified within the next couple years. I asked the PT at the clinic who is DN certified if she has used DN for PHP, she stated she rarely used it.
In practice, I think I would consider DN if a patient had PNP with a trigger point distal to the knee, especially if referred pain with compression. The article stated the NNT was only 4, so I would ensure to use other treatments in addition to the DN. I agree with Cameron, DN would be a good tool to use if a patient stated decreased pain following manual compression of a trigger point, or if a patient was immobilized for a long time.
Overall I thought that the article’s methods were well done and appropriate. I don’t think that the limitations of the study significantly altered the findings of the study.
Cameron, I agree with your last comment. It seems that PHP generally takes a very long time to heal, and therefore these patients are more likely to be seen less frequently but for longer overall treatment lengths. With this in mind, I would emphasize the importance of HEP adherence and provide education about the length of time PHP takes to improve. However if a patient has acute-sub-acute pain, I wonder if the prognosis for these patients is any better?
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After reading these few articles posted for discussion I feel more comfortable with educating patients on their prognosis for treatment and setting patient expectations from day 1. As previously mentioned each patients individual symptoms will drive decision making for each intervention to provide them the best outcome. These combination of articles have highlighted many different approaches to treatment that could be implemented into a patient’s POC. Like Jeff mentioned however, this pathology takes time to heal no matter what interventions are performed.
I really liked how the second article implemented their strength training protocol, implementing maximal dorsiflexion of the toes to place maximal stress through the plantar fascia. This is something that I will definitely explore especially early on in treatment based on the results of the study.
I too am not dry needling certified so I have never considered it as an intervention for plantar fasciitis symptoms. With that being said dry needling is never the first intervention that comes to mind when treating any of my patients. If patients are improving with less invasive techniques, ie, manual techniques, stretching/ strengthening exercises, orthotics, taping etc.. then those would be my first options. I believe providing them education, and self management techniques will promote more long term independence as compared to providing them relief with dry needling and them feeling dependent on it for improved symptoms.
The findings of the article and their conclusions are definitely appropriate based on their findings. One part of their conclusion that really stuck out to me was, “real dry needling produced medium reductions in foot pain beneath the heel, its value also must be considered in the inconvenience of the intervention.” does not have me convinced that dry needling is the intervention for plantar fasciitis. It will be interesting to see what conclusions future research will have regarding dry needling for heel pain. -
My opinion has some serious personal bias since I was the pin-cushion for someone practicing for their DN certification levels 1 and 2.
With a PEDro score of 9/10 I can appreciate the results of this review – and it’s not enough for me to use this as a first or second line of treatment for most PHP folks. I can tell you that the foot is serious in the amount of pain DN provoked, and I can’t imagine how intense that might get if I’d had an irritable pathology lurking down there. I might consider it for low-irritable, low severity folks who’ve had chronic pain, but it’d be after I’d demonstrated marginal<>no gains from less invasive techniques that are also research supported.
I appreciate that this review demonstrates improvement in first-step pain compared to sham treatment, but there have been studies that demonstrated positive benefit from alternative strategies including the study posted just before that demonstrates the improvement in foot function with a simple, progressive exercise protocol.
It’s in my toolbox… but I’m leaving it there for the tough jobs.
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Cam,
Great article. I was reading bits of it since Monday, but had to let some parts simmer in my mind to try and let it all come together with my current knowledge.
I really appreciate the continuum model for how it lays out the known stages tendinopathy, which are both unique, overlapping, and ambiguous. Effective treatment relies on my interpretation of where the patient is presenting on the continuum. The model presents at least a map of what to expect so that I can tailor my treatment appropriately.
Pain is big in the model, and it’s essentially one of 2 items we’re really interested in (pain + function) in terms of rehab strategies. It’s my job to determine the patient’s presentation and give an appropriate treatment: reactive (address loading tolerance, aka function) <<or>> reactive-on-degenerative (address pain).
I had a 56yo active male who was having Achilles pain when he walks in flip flops (this was LA, so he wore these 100% of the time) and when he rows a boat for recreational sport (5x/week). His pain began 4mos ago insidiously, worsening to this point with additional apparent girth increase to the entire tendon. He’s noticed that while he can no longer tolerate rowing the boat d/t pain, and he can no longer walk normally or perform a SL heel raise on that side. He landed on the reactive-on-degenerative region, and we had to be really particular with his treatment to get him back to such a high level. We included…
– SLS with uniplanar >> multiplanar reaches
– SL RDL
– Standing BAPS
– DL tilt board balance and slow taps >> SL balance
– side step-downs (for eccentric DF)My treatment was prescribed with his pain severity and irritability in mind and originally emphasized improvement of proprioceptive and mechanoreceptor response with the gradual progression to load tolerance and compound movements. (Great success!)
I can say that I had a much more superficial understanding of the proposed continuum wherein it made sense to me that a patient with this pathology will teeter between full function<>pain<>pain and functional loss. This article improved my depth of understanding, which can aide in my education to a patient, and it reminded me the other half of the spectrum leading to reactive-on-degenerative stages. Cam, this has been a big help and will aide in my identification of where a patient is presenting on the spectrum and which direction they are headed.
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I like the idea of the tendon continuum model. It helps guide treatment as well as set expectations for how much achievement can be made. What I found very helpful was that the continuum states that you can only improve so much if you are only treating an individual’s pain. I think so many people (non-PTs) have the thought that rest is the best treatment for tendinopathy, but this article really explains why that is not the case. I think this also explains why so much individuals suffer from recurrent bouts of tendinopathy – they are not address the function and load capacity of the tendon itself.
What I did not like about this article is that it didn’t seem to assist the reader in knowing where to place their patient on the continuum. I wish it would’ve given examples or common S/S of individuals in different stages of the continuum. Obviously some of this is common sense, but more emphasis on this would’ve been helpful.
My patient was a 14 yo male who played basketball. He had recently undergone a growth spurt, and had b/l achilles pain that was worst after he played basketball. I would place him on the reactive tendinopathy continuum (btn yellow and red). This was his first bout of pain, but it had been going on for several months before starting PT, and he was not taking breaks or doing anything to address his pain before beginning PT. He had fairly high pain levels.
I began him with isometrics of about 5-10 seconds at a time (going back in time I would’ve had him hold these for 20-30 sec). I had him do these about 2x/day for the first couple of weeks. I also videotaped his running, jumping, and landing mechanics – so while he was performing mild-intensity activities, I was also working on proprioception, gait mechanics, and hip strengthening – as I felt these were all impacting his pain. Some examples of these exercises were holding heels off stairs, SLS and balance exercises, double leg squatting with TB around knees.
As his pain became less limiting, I progressed him to concentric and the eccentric exercises, going from double limb to single limb exercises. At this stage he was more-so in the reactive tendinopathy (yellow stage). Eventually I had him jumping and landing and working on his biomechanics with these. I don’t remember the specific dosage for these exercises, but generally began low resistance/high volume –> higher resistance/low volume. Examples of these exercises included PF on leg press machine, jumping/landing on SL, bounding side-to-side, running and landing in SLS on foam pad.In the future, this article will change my patient education about this pathology. Not all of the science jargon, but educating the patient on the importance of more than just their pain-rating in dictating their treatment. I will make more of an effort to discuss and treat their function, looking at how they do their sport/activity that caused the tendinopathy in the first place, and treating the impairments appropriately.
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