Application of the New Protocol for Plantar Heel Pain

Original Editor - User Name

Top Contributors - Merinda Rodseth, Wanda van Niekerk, Kim Jackson, Jess Bell, Olajumoke Ogunleye and Ewa Jaraczewska  

Introduction

The application of the “new protocol” for Plantar Heel Pain (PHP) will be discussed in three distinct parts:

1. Assessment of the patient
2. Planning of the initial session
3. Planning of the treatment series

Patient Assessment

“Not only will a thorough subjective exam tell you what the problem(s) are, but also how to treat them”. - Geoff Maitland

Communication plays an essential role in the process of assessment and effective, competent clinical communication skills are key to high-quality healthcare (Iversen 2020). Different communication techniques, such as motivational interviewing, also have positive effects on the outcomes of physiotherapy treatment (Hiller 2018). Following the principles of Motivational Interviewing, communication with the patient should include: (Saban 2021, Norris 2019, ?Pace 2017, Hashim 2017))

• Open questions
• Patient involvement
• Empathy
• Active listening
• Use of reflections
• Explanations during the interview

Assessment is one of the cornerstones of the physiotherapeutic approach (Maitland 2006). While the principles of musculoskeletal assessment are universal, it is important to also focus specifically on the area the patient complains of, which in this instance is the heel.

The typical musculoskeletal assessment includes:(Maitland 2006, Alazzawi 2017)

• Subjective assessment (interview)
• Objective/physical examination

The interview should include: (Saban 2021)

• Personal information
• Analysis of the symptoms to a diagnosis of whether the condition is typical or atypical
• Differential diagnosis of the sources of heel pain, including systemic sources, yellow flags and red flags
• Functional measures including functional limitations
• General health

Typical questions asked in a thorough interview (subjective evaluation) includes: (Figure 1 and 2) (Saban 2021, Killens 2018, Alazzawi 2017)

• Areas of pain
• History of the complaint
• Behaviour of the symptoms (factors that provoke and ease symptoms, 24-hour behaviour)
• Functional difficulties

Figure 1. Heel Pain Specific Examination Form - Location and pain and history

Figure 2. Heel Pain Specific Examination Form - Behaviour of the symptoms

The interview is followed by the physical examination of the patient, which includes (Figure 3 and 4): (Saban 2021)

• Physical measures, which for PHPS includes the 3 heel pain tests previously discussed (Saban 2016)
• Support for the estimated diagnosis and whether the presentation is typical or atypical
• Investigation of other sources of heel pain, including the spine, systemic disease, yellow flags and red flags

Figure 3. Heel Pain Specific Examination Form - Physical examination (Saban 2021)

Figure 4. Heel Pain Specific Examination Form - Physical examination (Saban 2021)

Completion of the examination includes: (Saban 2021) (Figure 5)

• The setting of functional and clinical treatment goals (Stevens 2017)
• Planning of the treatment interventions - manual therapy and exercises
• Explanations to the patients including information about the syndrome, recommendations, advice, answering of questions and the treatment plan

Figure 5. Completion of the examination

Planning of the Initial Sessions

Each treatment session will include 3 main sections:

• Assessment (Ax)
• Manual Therapy (MT)
• Exercise Therapy (ET)

The first treatment session should include:

• The interview and physical examination, including the 3 clinical tests (Saban 2016) and palpation of the calf muscles (Saban 2014, 2016)
• Treatment - deep friction massage of the calf muscles for at least 10 minutes (Saban 2014)
• Reassessment using the 3 clinical tests
• Home exercise - the Lunge exercise (Saban 2014)

For the second treatment session, it is necessary to establish “what has changed” since the previous session with the patient through reassessment. From here on, each treatment should be customised for each patient in order to comprehensively address their needs.

The second treatment will include an assessment of the functional measures as reported by the patient (Figure 6). These generally include the level, frequency and duration of the pain with “first steps in the morning”, followed by other measures previously reported by the patient.

Figure 6. Functional measures (Saban 2021)

Following the reassessment of the functional measures, the clinical measures (3 clinical tests) should also be reassessed based on the (Figure 7):

• Level of pain
• Number of repetitions
• Time standing

Figure 7. Reassessment of the Clinical Measures

Figure 8 provides a summary of the steps to follow during the second treatment session

Figure 8. Second Treatment Session

All follow-up sessions should follow the sequence of the first session while progressing the exercises as necessary (Figure 9).

Figure 9. Approach to Follow-up Visits (Saban 2021)

Planning of the Treatment Series

Management of the treatment series will be mostly determined by the functional and clinical measures (Figure 10). If there is a 90-100% improvement in these measures, the patient can be discharged from therapy  with advise to:

• Continue with the stretch exercises to prevent deterioration of their condition
• Incorporate self-massage of the calf muscles

It is also important to note that the effect of the deep friction massage and the stretch exercises might not be immediate as it takes time for the tissues to change and adapt. Treatments can also be varied as the patient progresses through the treatment series by:

• Including different exercises
• Incorporating different muscles in the massage
• Adapting the advice to the patient

Figure 10. Management of the treatment series

On average, six to eight treatments provided at a frequency of once to twice a week should be sufficient to alleviate symptoms of heel pain in individuals with PHPS (Saban 2014, Saban 2021). Hence, even if no improvement occurred in the functional and clinical measures after 4-5 treatments, treatment should be continued. Change in the calf muscles with palpation (more pliable, less stiff, fewer painful areas) can also be used to measure improvement should there be no change in the functional or clinical measures after six treatments (Figure 10).  Refer to a physician if no improvement occurs and the patient reports worsening of the symptoms which cannot be attributed to treatment soreness (Saban 2021).

Patients should be encouraged to return to function, including walk and gradual return to sports. Research has shown an association between a lack of participation in regular exercise and PHPS, affirming that walking, running and sports are not risk factors for PHPS but rather protective against it (Saban 2014,  Van Leewen 2016).

Patients often arrive at physiotherapy with ideas from friends/family of what is needed to alleviate their symptoms. Figure 11 provides an option for the conversation with the patient demanding specific tretment modalities which might have limited effect on their condition.

Figure 11. Option for conversation

Conclusion

The series on PHPS has provided clinicians with:

• an assessment tool that that provides immediate and useful measures and is cost-free and easy to apply
• a manual therapy intervention which includes deep friction massage and exercise
• a self-exercise programme

providing pain relief and return to function for the patient.

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