A New Protocol for Plantar Heel Pain
Introduction[edit | edit source]
The previous literature reviews on the risk factors, evaluation and management of plantar heel pain (PHP) identified a lack of support for any of the commonly used assessment and treatment options for this condition. This highlighted that there was a need for appropriate methods to assess and manage PHP and led to the development of a new tool for PHP. This protocol involves:
- an assessment tool
- manual therapy and
Assessment Tools for Plantar Heel Pain[edit | edit source]
A comprehensive physical examination is essential for the effective diagnosis and management of plantar heel pain syndrome (PHPS) and effective assessment tools are required. Assessment tools have, over time, become more sophisticated and technologically advanced, but even these advancements have not enhanced the assessment of PHP. Historically, physical examination tests have been an essential part of clinical assessments as they are more readily available and less expensive than diagnostic imaging methods.
In an attempt to find an accurate means of assessing PHP, two tests were found to reproduce the heel pain experienced by an individual with PHPS during a regular foot and ankle evaluation. These were the:
- Single leg heel raise
- Single leg mini squat (half squat) (Figure 1)
Figure 1. Two clinical tests that reproduce PHP
This raised the question of why these tests would provoke pain in the heel (Figure 2). Considering that PHPS is associated with weight-bearing, could the reproduction of the pain be attributed to an increase in weight-bearing? Yet during these movements, the weight is shifted from the heel to the forefoot, thus reducing weight-bearing on the heel.
If not because of increased weight-bearing, could these tests be causing increased stress in the plantar fascia? But once again, when analysing these motions, this does not seem likely. During the single-leg heel raise, the increased extension of the toes might increase tension in the fascia, but plantarflexion at the heel reduces this tension. Similarly, during the single leg mini squat, dorsiflexion of the ankle increases fascial tension, but this is reduced by flexion of the knee. Thus, if there is an increase in fascial tension, it will be minimal considering how these movements cancel each other out.
Figure 2. Proposed reasons for pain provocation in the heel
Based on these findings, Saban and Masharawi investigated if these tests were able to reproduce heel pain in a larger population, and conducted a clinical trial involving 40 patients with a typical presentation of PHP (Figure 3).
- The appearance of the first painful sensation (P1) assessed with the visual analogue scale (VAS). The performance (i.e. repetitions / seconds) was also recorded
- The functional status of the patient, measured using a computerised version of the Lower Extremity Functional Scale (LEFS)
The aims of this study were to investigate whether:
- These tests were reliable and valid in patients with PHPS
- Combining the three tests would enhance the possibility of a positive test response from each patient
The study procedure was as follows:
- The patient was interviewed and completed the functional status questionnaire
- This was followed by an assessment of the patient by Rater 1 using the three clinical tests
- These same tests were re-assessed 30 minutes later by Rater 2 as a measurement of the interrater reliability of the tests
- The patient was then reassessed by Rater 1 one week later in order to establish the intrarater reliability of the clinical tests (Figure 6)
Moderate to high levels of interrater and intrarater reliability were reported for all the tests and a correlation was reported between the level of pain (VAS) and the functional scale (LEFS) (Figure 7).
Figure 8. Frequency of a positive pain response for the clinical tests
It is important to also mention that some of the patients only experienced pain towards the end of the testing protocol, which indicates that many repetitions might be needed to reproduce the patient’s pain.
In conclusion on the assessment tools, the study by Saban and Masharawi indicates the existence of simple, relevant and reliable clinical tests that are performance-based, easily applied and appropriate for the assessment of PHPS.
Considering the presence of pain in the heel with PHPS, the source of pain has often been assumed to be at the level of the heel. This is a prime example of the thought distortions described by Daniel Kahneman when he posed his quiz question described in Figure 9. If one opens his / her mind and looks further, it becomes clear that the pain experienced in PHPS might not be in the heel after all.
Treatment Protocol for PHP[edit | edit source]
No definite conclusions have been made about the treatment of PHPS due to a lack of high-quality evidence. Hence, following the above discussion on the assessment of PHP, it is necessary to consider how to progress to the treatment of this condition. If the heel pain provoked during testing is not caused by an increase in weight-bearing or fascial stress, could it be due to a contraction of the calf muscle? This should be considered given that the:
- Heel raise test incorporates concentric contraction of the calf muscles
- Half-squat test involves eccentric contraction of the calf muscles
Manual palpation of the plantarflexor muscles in the posterior calf on the affected leg in patients with PHPS revealed stiff, non-compliant and painful soft tissue. Thus, a treatment protocol directed at the posterior calf muscles was proposed by Saban et al. The aim of their study was to compare deep soft tissue massage of the posterior calf to a more common treatment approach directed at the heel (Figure 10).
Figure 10. Aim of the study by Saban et al 
In this study, participants were divided into a study and a control group. The control group received a stretching protocol and ultrasound with commonly used settings while the study group received the same stretching protocol combined with deep tissue massage of the posterior calf muscles and a neural stretch (Figure 11).
Figure 11. Study protocol of the study by Saban et al.
The primary outcome measure in this study was a functional status questionnaire (computerised version of LEFS). The secondary measure was the level of first-step pain in the morning (VAS). A visual representation of the flow of patients through the study can be found in Figure 12.
Figure 12. Flow of patients through the study by Saban et al
The characteristics of the patients at baseline were also compared by groups to look for similarities between groups at baseline. No statistically significant differences were found between groups at baseline (i.e. similar age, chronicity of heel pain and similar scores on the functional scale and VAS scale at intake) (Figures 13 and 14).
The results on the primary outcome of the study indicated that even though both groups improved on the functional scale, the deep massage group (DMS) improved by 15 points compared to the 6 point improvement in the ultrasound / control (USS) group (Figure 16). Wang et al. indicated that a change of 8 points is needed for any change to be clinically significant. Thus, even though the USS group improved statistically, there was no real clinical change whereas the DMS group improved both statistically and clinically (Figure 16).
The level of first-step pain in the morning (VAS) decreased similarly in both groups with no significant difference (Figure 17). This could indicate that the complaint of first-step pain in the morning might only be one part of PHPS and that patients have other functional limitations that were picked up by the functional scale score (LEFS).
In the study by Saban et al., deep massage therapy to the posterior calf muscles and neural mobilisation combined with stretching exercises had superior short-term functional scale outcomes compared to ultrasound treatment with stretching exercises. This treatment protocol is easy to use and effective for PHP and could therefore be recommended for individuals with PHPS.
There are, however, some limitations to this study, including:
- No record of daily self-exercise compliance
- Short-term results only
- DMS group performed one additional exercise (SLR with dorsiflexion) thereby introducing an additional variable into the trial
This treatment approach is also supported by two other studies performed by Renan-Ordine et al. (Figure 18) and Ajimsha et al. (Figure 19). Renan-Ordine et al. suggested myofascial trigger point therapy of the calf for PHP, but the results of the study are not that clear and the clinical effect is unknown (Figure 18). Amjisha et al. investigated the effect of myofascial release of the calf in PHP and found a clear difference between groups with the myofascial release group performing much better compared to the control sham ultrasound group (Figure 19).
Conclusion[edit | edit source]
This new protocol for the assessment and treatment of PHP is showing promising results for the management of PHPS. The next course in this series will investigate the anatomical features behind this protocol followed by details on how to apply this technique and manage a treatment session with a patient.
References[edit | edit source]
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