Document 6479888

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
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http://dx.doi.org/10.1136/bjsm.2005.021758
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individual patients: a report of patient specific measure. Physiother Can. 1995;47:258-263.
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