Evidence-based Evaluation and Christopher E. Green, PT, DPT Treatment of a Patient with Jyotsna J. Gupta, PT, PhD Plantar Heel Pain: A Case Report Michael T. Gross, PT, PhD, FAPTA

Division of Physical Therapy, Department of Allied Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC

ABSTRACT aspect of the forefoot where it attaches to arch at the and the MTP joints of Background: Plantar heel pain (PHP) the plantar skin, the plantar plate at the base the forefoot. The increased 3-point bending is a common musculoskeletal complaint of the proximal phalanges, and ligaments of the places greater tensile stress on the treated by physical therapists. Though clini- of the metatarsophalangeal (MTP) joints.2 plantar . This mechanism describes why cal practice guidelines exist for evaluation The fascia can be anatomically divided into individuals with a greater BMI experience and treatment of PHP, a dearth of case- 3 bands: the medial, the lateral, and the greater tensile stress within the specific studies describe the clinical applica- central. The central band is considered the during ambulation.7 Prichasuk, in a heel tion of these guidelines. In this case report, most important in terms of function and pad thickness and plantar heel pain correla- the various physical, pathoanatomical, and structure.4 The plantar fascia has a variety of tion study reported, that individuals with a social features of PHP are presented with functions in the foot. The fascia supports the greater BMI were more likely to experience a multimodal, evidence-based treatment medial longitudinal arch of the foot during plantar heel pain compared to those with approach. Description: The patient is a weight bearing. During weight bearing, the lower BMI.8 63-year-old female presenting with a com- tibia internally rotates and the arch length- Individuals with a flattened, elongated plaint of chronic unilateral plantar heel pain. ens and flattens. The plantar fascia resists arch known as pes planus place greater ten- Theinitial onset of symptoms was 6 months this arch motion and helps to maintain sile stress on the plantar fascia.9 Excessive prior to the examination. Using recent clini- arch height. The arch is also supported by subtalar pronation and insufficient talocru- cal practice guidelines, orthopedic physical the windlass mechanism, first described by ral dorsiflexion are also intrinsic factors that therapy management was applied. Outcome: Hicks.6 In short, dorsiflexion of the toes in place greater tensile stress on the plantar After 7 visits, the patient reported signifi- weight bearing causes the plantar fascia to fascia. Studies by Irving et al10 and Cornwall cant improvement in pain and function, wind tighter around the metatarsal heads. and McPoil11 support that individuals with and returned to her baseline activity. These This results in increased tension in the plan- a pronated foot including subtalar pronation improvements were maintained or improved tar fascia that in turn increases the height posture were more likely to develop plantar at 7-month follow-up. Conclusion: A mul- of the arch. The activation of the windlass fasciitis. Solan et al12 reported that shortening timodal approach informed by the best mechanism stabilizes the arch to prepare the and tightness of the plantar flexor muscles, available evidence was successfully used for foot for propulsion during ambulation.4 The such as the gastrocnemius, imposed increased management of PHP. intrinsic muscles of the feet can reduce load- strain on the and the plantar ing of the plantar fascia and are also active fascia. Additionally, Riddle et al13 determined Key Words: clinical reasoning, exercise, during the propulsion phase of gait.4 Extrin- reduced dorsiflexion and obese BMI plantar fasciitis, manual therapy sic muscles of the foot including the flexor levels were each independent risk factors hallucis longus, flexor digitorum longus, for developing plantar fasciitis. For normal BACKGROUND and brevis, and posterior ambulation, 10° of ankle dorsiflexion with Plantar fasciitis is a common musculo- tibialis also have tendons that enter the plan- the knee extended is required. If dorsiflex- skeletal impairment that results in heel and tar arch and provide additional truss support. ion is limited, excessive subtalar pronation arch pain in both the athletic population1 These biomechanical implications highlight and midfoot dorsiflexion may be used as a and the general population.2 Plantar fasciitis potential identifying factors and treatments compensatory mechanism to allow forward involves a degenerative irritation3 of the plan- of plantar fasciitis. progression of the leg, thus increasing the tar fascia that leads to heel and arch pain, pri- Common etiological factors in the devel- stress on the plantar fascia. Additionally, the marily after a period of nonweight bearing.4 opment of plantar fasciitis are those associ- presence of forefoot varus may drive foot pro- Roughly 2 million Americans suffer from ated with mechanical overload of the plantar nation and be a factor in the development of plantar fasciitis, and approximately 10% of fascia, and can be delineated into intrinsic plantar fasciitis. With the distal aspect of the the population will seek treatment for it in and extrinsic variables.4 Intrinsic factors foot inclined towards the midline, the lateral their lifetime.5 An understanding of the con- include decreased height of the medial lon- ground reaction force may cause an ever- tributing factors involved in the pathome- gitudinal arch, increased rate of tissue load- sion moment that increases foot pronation, chanics can aid clinical decision-making for ing, or both.4 Individuals with a greater body thereby increasing the tensile stress imposed conservative intervention. mass index (BMI) transmit a greater tibial on the plantar fascia.14 The plantar fascia is a flat band of dense loading force into the dorsal talus at the The extrinsic factors that contribute to connective tissue with a proximal attachment convex aspect of the medial longitudinal arch the development of plantar fasciitis include on the medial calcaneal tuberosity. The fascia of the foot. Equal and opposite ground reac- improper footwear or a rapid increase in fans out into 5 distinct strands at the mid- tion force is imposed on the plantar aspect the frequency, duration, or intensity of metatarsal level as it extends to the distal of the foot at both ends of the longitudinal weight-bearing activities. Footwear that

28 Orthopaedic Practice volume 32 / number 1 / 2020

8378_OP_Jan_1218.indd 30 12/18/19 12:10 PM lacks ample cushioning and arch support can and conservative treatment for a patient with SELF-REPORTED OUTCOME cause increased stress to the plantar fascia.15 plantar fasciitis. MEASURES Females may be at even greater risk given the The patient completed the Lower popularity of women’s footwear that does not CASE DESCRIPTION Extremity Functional Index (LEFS) to mea- provide cushioning or arch support.16 Finally, The patient was a 63-year-old female who sure her perception of heel pain’s influence a drastic increase in the frequency, duration, worked as a housing program coordinator on her ability to perform activities of daily or intensity of an activity that requires repeti- and was required to wear dress shoes while at living (ADLs). The LEFS is a 1-page ques- tive loading of the foot can lead to fatigue work. She was diagnosed with plantar fasciitis tionnaire that consists of 20 questions, with of the muscles that support the arch, thereby of the left foot by her primary care physician lesser scores demonstrating greater disability. overstraining the plantar fascia.13 and was prescribed stretches for ankle dorsi- A recent systematic review established the Conservative treatment is the first step flexion, intrinsic foot muscle strengthening, LEFS as having excellent psychometric prop- for treating plantar fasciitis and generally and advice to roll her foot on a frozen water erties, including test-retest reliability (ICC = includes multiple interventions such as plan- bottle. At her 6-month follow-up appoint- 0.85 – 0.99) and responsiveness (effect sizes tar fascia and triceps surae stretching,17 ankle ment, her symptoms had not resolved and > 0.8).29 The minimal clinically important dorsiflexion night splints,18 anti-pronation she was referred to outpatient physical ther- difference (MCID) for the LEFS has been taping,19 improved footwear,20 use of foot apy. At the physical therapy evaluation, the reported as 9 points in patients with lower orthoses,21 and manual physical therapy to patient described symptoms as a sharp left extremity musculoskeletal conditions.29 The increase ankle dorsiflexion.5 Wolgin et al22 heel pain when taking the first steps in the patient completed the LEFS with a score of reported 82 of 100 patients treated conser- morning or after long periods of nonweight 41/80 on initial examination. vatively for plantar fasciitis had good long- bearing. The patient was morbidly obese, Additionally, the patient completed the term results. In this study, the conservative with a BMI of 41.16 kg/m2. She had not Foot and Ankle Ability Measure (FAAM) to treatments included triceps surae and plantar experienced any foot pain previously and did assess physical performance affected by her fascia stretching, custom orthoses, nonste- not report any sudden increase in her activ- foot pain. The FAAM consists of an ADL roidal anti-inflammatories (NSAIDs), injec- ity level when her symptoms began. Aggra- Subscale with 21 items and a Sports Subscale tions, heat, ice, and night splints.22 Similarly, vating factors included walking or standing with 8 items that are each scored on a Likert Davis et al reported favorable outcomes fol- for longer than 30 minutes and participat- system. Greater scores represent an increased lowing conservative treatment that consisted ing in Zumba exercise classes. At the time of level of physical ability. Each subscale asks of relative rest, NSAIDs, heel cushions, evaluation, she was not able to participate in the patient to rate their current level of func- Achilles tendon stretching, and injections in exercise classes and was limited with walking tion subjectively from 0 to 100%, with 100% 89.5% of patients at an average follow-up of longer distances throughout her work day representing their level of function prior to 29 months.23 In the majority of cases, conser- due to her heel pain. The patient noted that their foot or ankle problem. The FAAM has vative treatment leads to resolution of symp- wearing tennis shoes seemed to help decrease excellent test-retest reliability for the ADL toms in less than 12 months.24 her heel pain but using simple store bought (ICC = 0.87) and the Sports (ICC = 0.89) If conservative treatment fails, additional plantar fasciitis insoles had no effect on her subscales.30 The MCID for the FAAM has treatment options include corticosteroid heel pain. She rated her current pain as 2/10 been reported as 8 points for the ADL Sub- injection and surgery. Corticosteroid injec- on the 11-point Numerical Pain Rating scale and 9 points for the Sports Subscale.30 tion for the plantar fascia remains contro- System (NPRS). She reported her worst pain The patient completed the FAAM with an versial, with numerous reported instances of as 8/10 in the mornings and her least pain ADL score of 76.2% and self-rated ability of plantar fascia rupture and additional long- was 0/10. No diagnostic medical imaging 80%. Her sports score was 31.3% with a self- term side effects that can be difficult to treat.25 had been performed on the patient’s left foot. rated ability of 50%. The Sports Subscale of Surgical intervention involves partial to com- The patient’s goals for physical therapy were the FAAM was administered due to her goal plete resection of the plantar fascia and the to decrease her left heel pain, improve her of returning to Zumba exercise classes. removal of any existing heel spurs.26 Com- standing and walking tolerance, and partici- plete resections lead to more pronounced pate in her Zumba exercise class. PHYSICAL EXAMINATION biomechanical consequences, such as loss of The patient’s review of systems to identify A body weight squat was used as a func- medial longitudinal arch height, decreased red flag symptomology that might suggest tional movement assessment, which revealed arch stiffness, the possibility of developing cancer or systemic infection was negative. bilateral genu valgus and bilateral subtalar midfoot osteoarthritis in the future, and She denied recent bowel or bladder changes, joint pronation that was greater on the left increase in pes planus foot position. There- history of cancer, night pain, saddle anesthe- foot compared to the right. The patient was fore, individuals with pronounced pes planus sia, recent weight loss, nausea, vomiting, or unable to balance for more than one second may not benefit from surgical resection. Oth- fever.28 Following the subjective interview, a on her left foot due to pain. Gait analysis erwise, positive outcomes have been reported physical examination was performed. Dif- revealed an antalgic gait favoring her right in both short- and long-term follow-up.27 A ferential diagnoses included plantar fasciitis, side and overt pronation of her left foot. She recent update of Clinical Practice Guidelines calcaneal stress fracture, tarsal tunnel syn- was positioned in prone to test for triceps (CPGs) provides evidence based examina- drome, proximal plantar fibroma, and fat surae extensibility by passively dorsiflexing tion procedures and interventions for the pad atrophy throughout the examination her ankle. Substantial soft tissue restriction conservative treatment of plantar fasciitis.5 procedure. limited dorsiflexion of the left ankle. Signifi- The purpose of this case report is to describe cant forefoot varus of the left foot was visual- the application of evidence from the CPGs ized in this position. She exhibited decreased to examination findings, clinical reasoning, active ankle dorsiflexion range of motion

Orthopaedic Practice volume 32 / number 1 / 2020 29

8378_OP_Jan_1218.indd 31 12/18/19 12:10 PM (ROM) of 0° bilaterally and passive dorsiflex- itis of the left foot was established as a work- zation and cross friction massage were per- ion range at 2° bilaterally. Ankle dorsiflexion ing diagnosis. Subjective reports consisting of formed to areas of soft tissue restriction at was measured with the knees extended to heel pain with the first step in the morning, the left medial head of the gastrocnemius mimic the functional position during gait. after a period of inactivity, and after pro- muscle and directly to the plantar fascia.37 Her ankle plantar flexion, inversion, and longed weight bearing supported this diagno- Both Looney et al37 and Cleland et al38 dem- eversion ROM measurements were within sis.5 Objective findings including tenderness onstrated the benefits of soft tissue work in normal limits for each ankle. to palpation of the insertion of the plantar these areas to decrease pain and improve Plantar fibroma was included in the dif- fascia at the medial calcaneal tubercle, a posi- function in individuals with plantar fas- ferential diagnoses based on the location of tive Windlass Test, limited active and passive ciitis. To improve the patient’s talocrural pain. Palpation of the plantar aspect of the ankle dorsiflexion OM,R a greater FPI score, dorsiflexion estriction,r a grade IV anterior- calcaneus to the mid-tarsal region of the and a greater BMI, further supported this to-posterior talocrural joint mobilization foot was performed to identify any thick- clinical working diagnosis.5 The absence of was performed during the first 4 visits. The ened nodules.31 No nodules were present. a dense nodule at the mid-tarsal level of the patient was positioned in supine as the thera- Palpation revealed tenderness of the medial plantar aspect of the foot suggested that plan- pist used one hand to stabilize the lower leg plantar aspect of her calcaneus. Calcaneal tar fibroma could be ruled out.31 A negative and grasped the anterior, medial, and lateral fracture was a differential diagnosis and was tarsal tunnel test suggested that tarsal tunnel talus with the other hand to apply an ante- screened using the Ottawa Ankle Rules. The syndrome could likely be ruled out.34 Fat pad rior-to-posterior force to the talus as the ther- patient was not tender to bony palpation atrophy was ruled out due to the absence of apist passively dorsiflexed the ankle with his at the base of the fifth metatarsal or at the complaints of pain at rest, pain at night, and (Figure 9).38 Additionally, a joint mobi- navicular. She could bear weight on her left bilateral foot pain.36 lization with the patient in half kneeling was foot while ambulating in the clinic. There- used to improve her left ankle dorsiflexion. fore, a calcaneal fracture was ruled out.32 Her INTERVENTIONS The patient knelt with her right knee on a lower extremities and were tested for Based on the working diagnosis and the pillow and assumed a lunge position with her muscle strength using manual muscle testing lack of formal conservative treatment to date, left hip and knee flexed to 90° with her left procedures. She scored 5/5 globally with this physical therapy intervention was deemed foot flat on the ground. The therapist applied testing. appropriate. To address the identified soft a stabilizing anterior-to-posterior force over was included in tissue restrictions, the patient was prescribed the anterior talus while the patient shifted the differential diagnosis due to complaints a stretching routine that targeted the pos- her weight forward into painfree ranges of of medial plantar pain and worsening of terior muscles of the leg, Achilles tendon, ankle dorsiflexion and the therapist imposed symptoms during weight-bearing activities.33 and plantar fascia of the left foot. She was an anterior glide of the distal leg (Figure 10). The tarsal tunnel test was performed to rule instructed to face a wall and step forward This was repeated for 3 sets of 10 repetitions. out tarsal tunnel syndrome.34 In sitting, the with her right foot while leaving her left From a mechanistic view, intrinsic plan- patient’s ankle was maximally dorsiflexed knee fully extended to promote more effec- tar muscles decrease the stress placed on the and everted with full extension of all 5 toes. tive stretching of the . plantar fascia during mid-stance and propul- This position was maintained for 10 seconds Importantly, the plantar fascia was stretched sion of the gait cycle by providing dynamic while the tarsal tunnel was percussed repeat- in this position by placing a small towel support to the medial longitudinal arch of edly. Her symptoms were not reproduced, beneath the left toes to activate the windlass the foot.38-40 The FPI, administered with the nor did the patient experience any local ten- mechanism (Figure 7). She was instructed patient in standing, and gait analysis revealed derness. The Windlass Test was performed in to keep both feet facing forward and to lean the patient had a flattened arch. Therefore, weight bearing to rule in plantar fasciitis.35 into the wall with her arms while bending strengthening of the intrinsic plantar muscles She stood on a 4-inch box with the head of her front knee until she felt a gentle stretch of her foot was prescribed to reduce stress on the first left metatarsal head resting on the in her posterior leg and the plantar aspect the plantar fascia.39 A hand towel was placed box with the edge of the box aligned with the of her foot. She was instructed to hold this on the ground beneath the patient’s foot. The first MTP joint line. She was instructed to stretch for 3 sets of 45 seconds, 3 times daily. patient was instructed to repeatedly pull the bear weight equally through each foot as the A second stretch was prescribed as described towel towards her heel using her toes while therapist passively extended the first MTP above, except the back leg was to remain bent keeping her foot on the ground. This was joint. Her heel pain was reproduced during as the patient leaned into the wall to pro- performed for 3 sets of 10 repetitions. At the the Windlass Test on her left foot. Finally, the mote more effective stretching of the soleus second visit, a trial of anti-pronation taping Foot Posture Index (FPI) was used to identify muscle. The patient was also prescribed a using kinesiotape was performed on the left the contribution of pronated foot posture on stretch to be performed in bed before she foot. The skin was cleaned and free of oils or the patient’s chronic heel pain.10 She scored took her first step in the morning. She was lotions. A strip of approximately 5 inches of a +10 on the FPI (Table 1), indicating sig- instructed to assume a long sitting position, kinesiotape was cut with the ends rounded nificant pronation of the left foot that could wrap a towel around the ball of her foot, and off to increase wear time.41 The tape was exacerbate plantar fasciitis.10 Figures 1-6 pull her forefoot towards her while keeping placed beginning on the dorsum of the left depict the patient’s specific postural elements her knee straight. This stretch was to be held foot, wrapped and circled laterally around that were scored on the 6 criteria for the FPI. for 3 sets of 30 seconds each morning. Addi- the left foot to resist subtalar pronation using tionally, the patient was prescribed a plantar 75% tension. The tape was anchored by fin- CLINICAL WORKING DIAGNOSIS fasciitis night splint to be worn every night ishing the wrap around the ankle at the level Following the subjective history and the (Figure 8). of the medial malleoli. The patient wore the objective physical examination, plantar fasci- Instrument assisted soft tissue mobili- tape for approximately 5 days and reported

30 Orthopaedic Practice volume 32 / number 1 / 2020

8378_OP_Jan_1218.indd 32 12/18/19 12:10 PM Table. Foot Posture Index (FPI).53 Underlined items represent the patient’s left foot score for each item (+10 total).

-2 points (supinated) -1 point 0 points (neutral) +1 points +2 points (pronated) Talar Head Palpation Talar head palpable on Talar head palpable Talar head equally Talar head slightly Talar head not palpable lateral side/but not on on lateral/ palpable on lateral palpable on lateral on lateral side/but medial side slightly palpable on and medial side side/palpable on palpable on medial side medial side medial side

Supra and infra lateral Curve below the Curve below Both infra and supra Curve below the Curve below the malleoli curvature either malleolus concave, malleolar curves malleolus more malleolus markedly straight or convex but flatter/more roughly equal concave than curve more concave than than the curve above above malleolus curve above malleolus malleolus

Calcaneal frontal plane More than an Between vertical Vertical Between vertical More than an estimated position estimated 5° inverted and an estimated 5° and an estimated 5° 5° everted (valgus) (varus) inverted (varus) everted (valgus)

Bulging in the region Area of TNJ Area of TNJ slightly, Area of TNJ flat Area of TNJ bulging Area of TNJ bulging of the TNJ markedly concave but definitely concave slightly markedly

Congruence of medial Arch high and acutely Arch moderately high Arch height normal Arch lowered with Arch very low with longitudinal arch angled towards the and slightly acute and concentrically some flattening in the severe flattening, arch posterior end of the posteriorly curved central position contacts ground medial arch

Abduction/ No lateral toes visible. Medial toes clearly Medial and lateral Lateral toes clearly No medial toes visible. adduction of forefoot Medial toes clearly more visible than toes equally visible more visible than Lateral toes clearly on rear foot visible lateral medial visible

Abbreviation: TNJ, talonavicular joint

no decrease in symptoms. There- fore, anti-pronation taping was not used during the remainder of the treatment sessions. After 5 weeks of treatment, the patient was fitted for custom orthoses by another physical therapist in the same clinic. Sulcus length foot orthoses with increased arch fill were fitted to the patient. Due to the patient’s need to wear dress shoes at work, the orthoses were not full length. Ideally, medial forefoot posting would have been added to the full-length orthoses to address her forefoot varus. Education on wearing supportive footwear that could Figure 2. Observation accommodate the custom ortho- Figure 1. Observation of the supra and Figure 3. Observation ses was provided at this time. of talar head position. infra lateral malleolar of the calcaneal frontal Thepatient’s home exercise Small circle indicative curvature of the involved plane position. More than program throughout treatment of the lateral talar left lower extremity in an estimated 5° everted included the following: head position and the weight bearing. A more (valgus). • triceps surae/plantar fas- larger circle indicates acute curve is visualized cia stretching for 3 sets of the weight-bearing inferior to the lateral 45 seconds, 3 times per position of the talar head malleolus due to the day; medially. abduction of the foot • seated towel stretches and eversion of the before first step in the calcaneus. morning, 3 sets of 30 seconds, every morning;

Orthopaedic Practice volume 32 / number 1 / 2020 31

8378_OP_Jan_1218.indd 33 12/18/19 12:10 PM to posterior ankle mobilizations, as well as soft tissue mobilizations of the plantar fascia and triceps surae, had better functional out- comes at 4-week and 6-month follow-up.38 Gastrocnemius muscle tightness can affect ankle dorsiflexion ROM because it crosses the knee and the ankle joint. The gastrocne- mius muscle is at its longest length and thus at its maximal tension with the knee in full extension just prior to heel-off. Knee flexion Figure 4. Observation indicating Figure 5. Observation of the height reduces the influence of the gastrocnemius bulging in the region of the and congruence of the medial muscle on ankle dorsiflexion as the length talonavicular joint represented by longitudinal arch of the involved of the muscle is shortened. Baumbach et the circled area. Rearfoot pronation lower extremity. A low arch is al42 reported gastrocnemius muscle tightness demonstrated by adduction of the observed with severe flattening. does not affect ankle dorsiflexion at 20º of head of the talus. knee flexion. The patient’s ankle dorsiflex- ion was only measured with the knee in full extension. A comparison of ankle dorsiflex- • towel scrunches for 3 sets of 10 repeti- performing her stretches. Her LEFS score ion ROM with the knee extended versus tions, 1 time per day; improved from 73/80 to 75/80 and her flexed to 20º may have provided a more spe- • wearing the night splint every night; FAAM ADL and Sports Subscales improved cific choice for intervention targeting joint and to 97.6% and 84.4%, respectively. Her self- mobilizations versus soft tissue mobiliza- • wearing the custom foot orthoses rated ability on the ADL and Sports Subscales tions. Future research should seek to distin- with supportive footwear during any also improved to 95% and 90%, respectively. guish the difference between soft tissue- and weight bearing. The patient had been able to continue prac- joint-related ankle ROM restrictions. ticing yoga without heel pain. It should be The CPG cites numerous studies that OUTCOMES noted the patient was not participating in suggest stretching of the triceps surae and The patient was seen for a total of 7 visits activities that required running or jumping. the plantar fascia are beneficial. Rompe et over the course of 7 weeks. At 2 weeks follow- She completed the outcome measures based al demonstrated that plantar fascia-specific stretching improved foot function at 2- and up, she described her morning foot pain as on her perceived ability to complete the 17 greatly reduced after wearing the night splint activity items listed. 4-month follow up. Sweeting et al deter- consistently. At discharge from physical mined that plantar fascia-specific stretching DISCUSSION may be more beneficial than Achilles tendon therapy, the patient showed improvements 43 on the NPRS, the LEFS, the FAAM, and This case study describes the examina- stretching only. Digiovanni et al described subjective performance of daily activities. tion, clinical reasoning, and conservative a distinct improvement in pain and func- Specifically, the patient reported use of the treatment approach for a patient with heel tion of patients who performed both Achilles custom orthoses decreased pain with walking pain caused by plantar fasciitis. Secondary to tendon and plantar fascia-specific stretching versus only plantar fascia stretching over their from 8/10 to 0/10 on the NPRS. Her LEFS the complexity of multiple contributing fac- 44 score improved from 41/80 to 73/80 at dis- tors to the diagnosis of heel pain, a thorough 16-week course of care. Often, these com- charge from physical therapy. Her FAAM subjective interview and objective physical ponents are stretched using different exer- score improved from 76.2% to 87.5% for examination are needed to differentiate plan- cises. In this case, a novel stretching approach the ADL Subscale and from 31.3% to 50% tar fasciitis.36 Conservative treatment should simultaneously addressed tightness of the for Sports Subscale and her self-rated ability be the first line treatment in managing plan- triceps surae, the Achilles tendon, and the on the FAAM also improved from 80% to tar fasciitis. Wolgin et al22 and Davis et al23 plantar fascia (see Figure 7). It is possible this 90% for ADLs and from 50% to 80% for have demonstrated conservative treatment stretch could lead to greater patient compli- sports. An MCID was achieved on every leads to good outcomes for most patients. ance as it reduces the amount of time spent patient-reported measure. Her left ankle The current CPG for the treatment of plan- performing home exercises. Although other active dorsiflexion ROM improved from 0° tar fasciitis5 with strongest evidence level interventions were used, stretching is the at evaluation to 5° at discharge. The patient (A) were informative in treatment consider- most cost effective and is an active treatment was able to perform yoga in her home and ations. The primary interventions used for strategy the patient can incorporate through- was able to walk for more than 30 minutes this patient had grade A-level evidential sup- out the day. at a time without any increase in her left port from the CPG including soft tissue and The CPG ecommendsr patients who con- heel pain. Overall, she reported a subjective joint mobilization, targeted calf and plantar sistently have pain with the first step in the morning should use a night splint for 1 to 3 improvement of “at least 90%” and demon- fascia stretching, the use of a night splint, 5 strated independence with her home exercise the fabrication of a custom foot orthosis, and months. Sheridan et al demonstrated night program. taping. splints that provide a low load, prolonged At 7-month follow-up, patient reported Manual therapy for plantar fasciitis is ankle dorsiflexion stretch led to greater outcomes remained favorable. Her NPRS highly recommended by the CPG. Cleland reductions in plantar fascia-related pain com- pared to those who did not use the night score remained 0/10 with minimal flare ups et al showed patients with heel pain who 18 of left heel pain that returned to 0/10 after received manual therapy including anterior splints. Lee et al used night splints in addi-

32 Orthopaedic Practice volume 32 / number 1 / 2020

8378_OP_Jan_1218.indd 34 12/18/19 12:10 PM tion to foot orthoses and reported decreased recommends either option and does not state her work’s dress code. Changing her shoes pain at 2- and 8-week follow-up compared to a preference between the two. Further stud- to work-approved athletic shoes appeared to 45 use of foot orthoses alone. Beyzadeoğlu et ies are needed to determine if custom foot have been the most beneficial for the patient al reported a significant improvement in pain orthoses could serve as an improvement in in terms of both pain reduction and improve- and function in those who used a night splint care when prefabricated foot orthoses fail. ment of function, as it allowed her to consis- 46 versus those who did not after 8 weeks. The CPG recommends that anti-prona- tently wear her foot orthoses. The use of prefabricated versus custom tion taping be used for immediate pain relief Intrinsic foot strengthening is not specifi- 5 foot orthoses for plantar fasciitis is somewhat of up to 3 weeks. Van Lunen et al demon- cally recommended in the CPG. Cleland et 47 controversial. Hawke et al found that custom strated an immediate decrease in pain with al demonstrated strengthening of the plantar orthoses were no more beneficial than pre- walking and jogging using anti-pronation intrinsic muscles led to a reduction of heel 19 fabricated foot orthoses in terms of pain and taping. A systematic review by Landorf pain.38 Cheung et al identified greater atro- function. Uden et al, however, demonstrated and Menz found strong evidence that taping phy of the intrinsic muscles in patients with that custom foot orthoses led to reductions in reduced pain at 1 week and was of additional plantar fasciitis compared to asymptom- 49 pain and improvement in overall function for benefit when combined with stretching. atic patients.39 The patient was instructed 21 patients with plantar fasciitis. A review by Another systematic review by van de Water in strengthening of the intrinsic muscles to Hume et al reported moderate improvements and Speksnijder found taping reduced first improve dynamic arch support and decrease of pain and function in favor of prefabricated step pain compared to no taping and over- tensile stress on the plantar fascia during 48 versus sham foot orthoses. The same review all pain reductions after 1 week compared weight bearing. also found that custom semi-rigid foot ortho- to sham taping.50 Tsai et al reported elastic ses had moderate positive effects compared taping of the gastrocnemius and plantar CONCLUSION 48 to anti-inflammatories and stretching. Pre- fascia led to decreased pain after one week The highest quality research regard- fabricated orthoses cost less and are easier to compared to ultrasound and electrotherapy ing conservative treatment for heel pain 51 access for most patients. Since prefabricated alone. A trial of anti-pronation taping using caused by plantar fasciitis has been recently orthoses provided no relief for this patient, kinesiotape was not effective in reducing the updated.5 A combination of evidence-sup- she was fitted with custom sulcus length patient’s heel pain with walking. The thera- ported conservative interventions from the foot orthoses with increased arch fill. Given pist had limited experience with this style of recent update to the CPG for plantar fasciitis the patient’s significantly pronated foot pos- taping, which may have played a role in the are likely more effective than any one inter- ture, the custom orthoses likely provided the absence of this treatment for the patient. vention on its own. This case highlights the external support needed to offload the tensile The evidence is weak at grade C in the importance of performing a thorough sub- stress in her painful plantar fascia. The CPG CPG for the use of footwear such as rocker- jective history and detailed examination of bottom shoes and a the foot to identify a patient’s exacerbating rotation of shoes for factors for plantar heel pain. The use of best those who work on available evidence to address patient-specific their feet. Rocker-bot- intrinsic and extrinsic factors led to a favor- tom shoes lessen the able outcome for this patient at discharge and loading of the plantar at 7-month follow-up. aponeurosis.52 Fong et al found that combin- REFERENCES ing a rocker-bottom sole with foot orthoses 1. Sobhani S, Dekker R, Postema K, immediately reduced Dijkstra PU. Epidemiology of ankle and plantar heel pain sig- foot overuse injuries in sports: A sys- nificantly more than tematic review. Scand J Med Sci Sports. using either interven- 2013;23(6):669-686. tion in isolation.20 2. Tahririan MA, Motififard M, Tahmasebi Sullivan et al deter- MN, Siavashi B. Plantar fasciitis. J Res mined that females Med Sci. 2012;17(8):799-804. may face greater dif- 3. Lemont H, Ammirati KM, Usen N. ficulty with selection Plantar fasciitis: a degenerative process Figure 7. Demonstration of footwear that is (fasciosis) without inflammation. J Am of the stretch for the supportive of plantar Podiatr Med Assoc. 2003;93(3):234-237. 4. Wearing SC, Smeathers JE, Urry SR, involved posterior left heel pain.16 Due to Hennig EM, Hills AP. The pathome- leg muscles, Achilles the dress code at the Figure 6. Observation chanics of plantar fasciitis. Sports Med. tendon, and the plantar of abduction of the patient’s work, she was 2006;36(7):585-611. fascia with a towel roll forefoot on the rearfoot required to wear dress 5. Martin RL, Davenport TE, Reischl SF, et under the toes so that for the involved left shoes. The patient was al. Heel Pain—Plantar Fasciitis: Revi- the metatarsophalangeal lower extremity. educated on footwear sion 2014. J Orthop Sport Phys Ther. joints are in extension selection that would 2014;44(11):A1-A33. to take advantage of the accommodate her foot windlass mechanism. orthoses that also met

Orthopaedic Practice volume 32 / number 1 / 2020 33

8378_OP_Jan_1218.indd 35 12/18/19 12:10 PM Figure 8. Ankle dorsiflexion night splint used by the patient.

Figure 10. End range, anterior- 6. Hicks J. The mechanics of the foot, II: the to-posterior talocrural joint plantar aponeurosis and the arch. J Anat. Figure 9. End range, anterior- mobilization with stabilizing force 1954;88:25-30. to-posterior talocrural joint over the anterior talus combined 7. Hills A, Hennig E, McDonald M, mobilization with ankle dorsiflexion and a posterior-to-anterior directed Bar-Or O. Plantar pressure differences over-pressure. between obese and non-obese adults: force of the distal leg with patient a biomechanical analysis. Int J Obes. in half-kneeling to improve ankle 2001;25(11):1674-1679. dorsiflexion. 8. Prichasuk S. The heel pad in plan- tar heel pain. J Bone Joint Surg Br. 1994;76(1):140-142. 9. Taunton JE, Clement DB, McNicol K. Plantar fasciitis in runners. Can J Appl Sport Sci. 1982;7(1):41-44. 18. Sheridan L, Lopez A, Perez A, John MM, 25. Acevedo JI, Beskin JL. Complications 10. Irving DB, Cook JL, Young MA, Menz Willis FB, Shanmugam R. Plantar fasci- of plantar fascia rupture associated with HB. Obesity and pronated foot type may opathy treated with dynamic splinting: a corticosteroid injection. Foot Ankle Int. increase the risk of chronic plantar heel randomized controlled trial. J Am Podiatr 1998;19(2):91-97. pain: a matched case-control study. BMC Med Assoc. 2010;100(3):161-165. 26. Jarde O, Diebold P, Havet E, Boulu G, Musculoskelet Disord. 2007;8(1):41. 19. Van Lunen B, Cortes N, Andrus T, Vernois J. Degenerative lesions of the 11. Cornwall MW, McPoil TG. Plantar Walker M, Pasquale M, Onate J. Imme- plantar fascia: surgical treatment by Fasciitis: Etiology and Treatment. J Orthop diate effects of a heel-pain orthosis fasciectomy and excision of the heel spur. Sport Phys Ther. 1999;29(12):756-760. and an augmented low-dye taping on A report on 38 cases. Acta Orthop Belg. 12. Solan MC, Carne A, Davies MS. Gastroc- plantar pressures and pain in subjects 2003;69(3):267-274. nemius Shortening and Heel Pain. Foot with plantar fasciitis. Clin J Sport Med. 27. Wheeler P, Boyd K, Shipton M. Surgery Ankle Clin. 2014;19(4):719-738. 2011;21(6):474-479. for patients with recalcitrant plantar fasci- 13. Riddle DL, Pulisic M, Pidcoe P, Johnson 20. Fong DT, Pang KY, Chung MM, Hung itis: good results at short-, medium-, and RE. Risk factors for Plantar fasciitis: a AS, Chan KM. Evaluation of combined long-term follow-up. Orthop J Sport Med. matched case-control study. J Bone Joint prescription of rocker sole shoes and 2014;2(3):2325967114527901. Surg Am. 2003;85-A(5):872-877. custom-made foot orthoses for the treat- 28. Leerar PJ, Boissonnault W, Domholdt 14. Bolgla LA, Malone TR. Plantar fasciitis ment of plantar fasciitis. Clin Biomech E, Roddey T. Documentation of red and the windlass mechanism: a biome- (Bristol, Avon). 2012;27(10):1072-1077. flags by physical therapists for patients chanical link to clinical practice. J Athl 21. Uden H, Boesch E, Kumar S. Plantar with low back pain. J Man Manip Ther. Train. 2004;39(1):77-82. fasciitis: to jab or to support? A system- 2007;15(1):42-49. 15. Singh N, Armstrong DG, Lipsky BA. atic review of the current best evidence. J 29. Mehta SP, Fulton A, Quach C, Thistle M, Preventing Foot Ulcers in Patients With Multidiscip Healthc. 2011;4:155. Toledo C, Evans NA. Measurement prop- Diabetes. JAMA. 2005;293(2):217. 22. Wolgin M, Cook C, Graham C, Mauldin erties of the lower extremity functional 16. Sullivan J, Pappas E, Adams R, Crosbie D. Conservative Treatment of plantar heel scale: a systematic review. J Orthop Sport J, Burns J. Determinants of footwear dif- pain: long-term follow-up. Foot Ankle Int. Phys Ther. 2016;46(3):200-216. ficulties in people with plantar heel pain. J 1994;15(3):97-102. 30. Martin RL, Irrgang JJ, Burdett RG, Conti Foot Ankle Res. 2015;8:40. 23. Davis PF, Severud E, Baxter DE. SF, Van Swearingen JM. Evidence of 17. Rompe JD, Cacchio A, Weil L, et al. Plan- Painful heel syndrome: results of non- validity for the Foot and Ankle Abil- tar Fascia-Specific Stretching Versus Radial operative treatment. Foot Ankle Int. ity Measure (FAAM). Foot Ankle Int. Shock-Wave Therapy as Initial Treatment 1994;15(10):531-535. 2005;26(11):968-983. of Plantar Fasciopathy. J Bone Jt Surg Am. 24. Buchanan BK, Kushner D. Plantar Fasci- 31. Hafner S, Han N, Pressman MM, Wallace 2010;92(15):2514-2522. itis. Stat Pearls Publishing; 2018. C. Proximal plantar fibroma as an etiology

34 Orthopaedic Practice volume 32 / number 1 / 2020

8378_OP_Jan_1218.indd 36 12/18/19 12:10 PM of recalcitrant plantar heel pain. J Foot clinical trial. J Orthop Sports Phys Ther. on plantar fasciitis. J Rehabil Res Dev. Ankle Surg. 2011;50(2):153-157. 2009;39(8):573-585. 2012;49(10):1557-1564. 32. Bachmann LM, Kolb E, Koller MT, Steu- 39. Cheung RTH, Sze LKY, Mok NW, Ng 46. Beyzadeoğlu T, Gökçe A, Bekler H. The rer J, ter Riet G. Accuracy of Ottawa ankle GYF. Intrinsic foot muscle volume in effectiveness of dorsiflexion night splint rules to exclude fractures of the ankle experienced runners with and without added to conservative treatment for plan- and mid-foot: systematic review. BMJ. chronic plantar fasciitis. J Sci Med Sport. tar fasciitis. Acta Orthop Traumatol Turc. 2003;326(7386):417. 2016;19(9):713-715. 2007;41:220-224. 33. Ahmad M, Tsang K, Mackenney PJ, 40. Young CC, Rutherford DS, Niedfeldt 47. Hawke F, Burns J, Radford JA, du Toit V. Adedapo AO. Tarsal tunnel syndrome: MW. Treatment of plantar fasciitis. Am Custom-made foot orthoses for the treat- A literature review. Foot Ankle Surg. Fam Physician. 2001;63(3):467-474, ment of foot pain. Cochrane Database Syst 2012;18(3):149-152. 477-478. Rev. 2008;(3):CD006801. 34. Abouelela AAKH, Zohiery AK. The 41. Kase K, Wallis J, Kase T. Clinical Thera- 48. Hume P, Hopkins W, Rome K, Maulder triple compression stress test for diag- peutic Applications of the Kinesio Taping P, Coyle G, Nigg B. Effectiveness of foot nosis of tarsal tunnel syndrome. Foot. Method. Japan: Ken Ikai; 2003. orthoses for treatment and prevention of 2012;22(3):146-149. 42. Baumbach SF, Brumann M, Binder J, lower limb injuries : a review. Sports Med. 35. De Garceau D, Dean D, Requejo Mutschler W, Regauer M, Polzer H. 2008;38(9):759-779. SM, Thordarson DB. The association The influence of knee position on ankle 49. Landorf KB, Menz HB. Plantar heel pain between diagnosis of plantar fasciitis dorsiflexion - a biometric study. BMC and fasciitis. BMJ Clin Evid. 2008;2008. and windlass test results. Foot Ankle Int. Musculoskelet Disord. 2014;15(1):246. 50. van de Water ATM, Speksnijder CM. 2003;24(3):251-255. 43. Sweeting D, Parish B, Hooper L, Chester Efficacy of taping for the treatment of 36. Yi TI, Lee GE, Seo IS, Huh WS, Yoon R. The effectiveness of manual stretch- plantar fasciosis: a systematic review of TH, Kim BR. Clinical characteristics of ing in the treatment of plantar heel pain: controlled trials. J Am Podiatr Med Assoc. the causes of plantar heel pain. Ann Reha- a systematic review. J Foot Ankle Res. 100(1):41-51. bil Med. 2011;35(4):507-513. 2011;4:19. 51. Tsai C-T, Chang W-D, Lee J-P. Effects of 37. Looney B, Srokose T, Fernández-de-las- 44. Digiovanni BF, Nawoczenski DA, Malay Short-term Treatment with Kinesiotaping Peñas C, Cleland JA. Graston instrument DP, et al. Plantar fascia-specific stretch- for Plantar Fasciitis. J Musculoskelet Pain. soft tissue mobilization and home stretch- ing exercise improves outcomes in 2010;18(1):71-80. ing for the management of plantar heel patients with chronic plantar fasciitis. 52. Lin S-C, Chen CPC, Tang SFT, Wong pain: a case series. J Manipulative Physiol A prospective clinical trial with two- AMK, Hsieh J-H, Chen W-P. Changes Ther. 2011;34(2):138-142. year follow-up. J Bone Joint Surg Am. in windlass effect in response to different 38. Cleland JA, Abbott JH, Kidd MO, et 2006;88(8):1775-1781. shoe and insole designs during walking. al. Manual physical therapy and exer- 45. Lee WCC, Wong WY, Kung E, Leung Gait Posture. 2013;37(2):235-241. cise versus electrophysical agents and AKL. Effectiveness of adjustable dor- 53. Redmon A. The Foot Posture Index: Six exercise in the management of plantar siflexion night splint in combination Item Version FPI-6. 2005. heel pain: a multicenter randomized with accommodative foot orthosis

THE LUMBOPELVIC COMPLEX: TWO EDUCATIONAL OFFERS!

PATIENT EDUCATIONAL THE LUMBOPELVIC COMPLEX: RESOURCES FOR THE SPINE ADVANCES IN EVALUATION PATIENT & TREATMENT

Evidence-based information for clinicians 6-Monograph Independent Study Course and 39 educational brochures for patients (Includes Patient Educational Resources for the Spine Patient)

Online Only Online Only AOPT Member: $50 | Non-Member: $75 AOPT Member: $200 | Non-Member: $300 Online + Print AOPT Member: $235 | Non-Member: $335

Orthopaedic Practice volume 32 / number 1 / 2020 35

8378_OP_Jan_1218.indd 37 12/18/19 12:10 PM