Best Practice Guide to Management of Plantar Heel Pain

incorporating the 3 EBP pillars

Dylan Morrissey Professor of Sports and MSK physiotherapy

NIHR/HEE Consultant Physiotherapist

d.morrissey@qmul.ac.uk@DrDylanM

Ian Griffiths, Trevor Prior, Christian Barton, Michael Rathleff, Bill Vincenzino,

Matt Cotchett

Marina Chan, Halime Gulle

1

Why a best practice guide?

Explosion of evidence.Much of it poor quality.

‘Agree’ guidelines not well followed

Clinical practice very variable and often not evidence-based

Outcomes not good enough.

Lin I, et al. Br J Sports Med 2018;52:337–343

3

Clinical reasoning

EvidencePatient values

BPG

British Medical Association Book Award Winner -

President's Award of the Year 2018

Clinical reasoning

EvidencePatient

values

Methods- Online survey with open

questions - Presented the evidence

synthesis and clinical reasoning

- Responses analysed with FRAMEWORK method

Clinical reasoning

Evidence

Patient values

• Thoughts on condition cause

• Thoughts on pathology

• Expectations

• Needed improvements

• Strengths of management

• Experience

• Key information and sources

8

Findings Illustrative quotes

Theme 7: patient values

Thoughts on

condition cause

Foot arch height; age; activity

pattern; new load increase; long

periods weight bearing; standing on

hard surfaces; minimally supportive

footwear; limb length asymmetry;

rapidly changing load; altered gait;

altered movement due to other conditions

Walking on the outside edge of my foot when I was having pain in my

second toe

Heel spurs, arthritis

Long shifts on my feet in facilities with hard floors.

Excess loads with inadequate progression

a number of contributory factors which is why is occurred now

Thoughts on pathology

Tissue irritation; degeneration;

inflammation ; tearing;

inadequate tissue capacity; contracture

Tissue band has become irritated through age/overuse

It feels like it is tearing. I think I have torn a ligament

Inflamed damaged pf which needs to heal/repair.

Struggling to cope with the demand and non adapted tissue

tendon contracture is wanting to happen all the time.

Expectations

More information; quick recovery-

unrealised; exercise programme

esp. foot strengthening; pain

elimination; access to orthoses;

specific treatments; better

explanation of treatment/condition

and causes

Expected to get a steroid shot, and was hoping for deep tissue manipulation

to break down the scaring or thickening tissue. Wasn’t offered

I assumed wrongly I would need insoles. I expected to be back on my feet

within a few weeks (very optimistic).

as swift as recovery as possible, relief from the pain and programme of

exercises to treat

Needed improvements

Facilitation of earlier recognition by

patients; better communication as

adherence promotion;

Intervention strategy for pain; Easier

access to, and more information on,

specific treatments; Standardised

treatment across sectors; Clarity of

treatment and expectations; reduced waiting times

better understanding of symptoms and types of patients prone to PHP

More explanation for the mechanism of the symptoms in order to

motivate me to do the exercise

Get rid of the pain forever

Standardised treatment from NHS across the country. I've gone private

as Dr can't refer.

Strengths of

management

From no strengths to positive

experiences; fast decisions; specific

interventions; clear plan; individual

preferences accounted for; detailed explanation; specific interventions

Q1: Range of options considered and clearly explained

Q2: Spent time explaining in detail the condition/cause/treatment

Experience

Restricted activity; intermittent

severe pain; reduced exercise;

altered activity; morning pain;

Painful; emotionally affected; large

impact on ADL; long, uncertain recovery

It restricted the activities I wished to carry out

It’s very painful under my heel when I get up in the morning

Miserable 6 months. Had a huge impact on daily activities.

Very long process and uncertain outcome

Key information

Time course of recovery; self-

management advice; how pain

relief works; long term effects;

explanation of what was not done;

unsure; statistics on usual

timescales for effects

What can I do to reduce my pain and improves function

Will pain reliever actually address the issue or just mask the pain?

When they could make the pain go away

Expected outcome at the end of rehab

Sources of

information

Range of online methods

predominated; clinicians; friends; magazines

I can google it all day, and there isn’t much out there

Patient groups on Facebook aren’t even very helpful, because everyone using

them hasn’t found relief.

online forums, confusing as everyone’s cause is different therefore treatment different

Expectations

More information; quick

recovery- unrealised; exercise

programme esp. foot

strengthening; pain

elimination; access to

orthoses; specific treatments;

better explanation of

treatment/condition and

causes

“Expected to get a steroid shot, and was

hoping for deep tissue manipulation to

break down the scaring or thickening

tissue. Wasn’t offered “

“I assumed wrongly I would need

insoles. I expected to be back on my feet

within a few weeks (very optimistic).”

“as swift as recovery as possible, relief

from the pain and programme of

exercises to treat”

Key

information

Time course of recovery;

self-management advice;

how pain relief works; long

term effects; explanation of

what was not done;

unsure; statistics on usual

timescales for effects

“What can I do to reduce my pain and improve

function”

“Will pain reliever actually address the issue

or just mask the pain? “

“When they could make the pain go away”

“Expected outcome at the end of rehab “

9

Clinical reasoning

EvidenceALL interventions

RCTs to 7/18

Patient values

Quality• ≥ 8/10 on the PEDro• risk of bias <= 2/6 • adequate sample size,

calculated to be 38

To be considered efficacious(i) primary proof of superiority compared to a no treatment control, sham or placebo(ii) secondary proof of efficacy when compared to another treatment of proven efficacy.

N = 42, 3627 patients, focus on efficacy

What do you

see and what

do you NOT

see

InterventionOutcome

measureShort term Medium term Long Term

Primary Primary Primary

Custom

orthosesPain

Positive Moderate

-1.24 [-1.49, -1.00]

Positive limited

-1.65 [-2.18, -1.12]

Negative moderate

-0.04 [-0.45, 0.37]

First step

painNegative Limited

-0.32 [-0.91, 0.26]

FunctionNegative Moderate

-0.21 [-0.48, 0.06]

Negative limited

-0.39 [-0.85, 0.07]

Negative moderate

--0.12 [-0.53, 0.29]

Prefabricated

orthosesPain

Negative Moderate

-0.25 [-0.59, 0.09]

Negative moderate

-0.08 [-0.50, 0.33]

First step

pain

None

FunctionNegative Moderate

-0.06 [-0.40, 0.28]

Negative moderate

-0.08 [-0.50, 0.33]

Magnetised

insolesPain

Negative Moderate

0.00 [-0.39, 0.39]

Radial ESWT PainPositive Moderate

-3.78 [-6.17, -1.38]

Positive limited

-5.81 [-8.05, -3.57]

Positive moderate

-6.41 [-7.83, -4.99]

First step

pain

Positive Moderate

-1.19 [-1.63, -0.76]

Positive moderate

-2.93 [-3.51, -2.34]

FunctionPositive Moderate

-3.47 [-4.37, -2.57]

Positive Limited

-4.57 [-5.65, -3.48]

Positive Limited

-2.81 [-3.61, -2.02]

Focused ESWT PainPositive strong

-1.33 [-1.72, -0.94]

Negative Moderate

0.18 [-0.24, 0.60]

First step

pain

Positive strong 2003

-2.11 [-3.48, -0.75]

Positive Limited

-2.84 [-3.73, -1.94]

Positive limited

-3.33 [-3.87, -2.78]

FunctionPositive moderate

-1.26 [-1.53, -0.99]

Dry needling PainPositive moderate

-1.24 [-1.71, -0.76]

First step

painPositive moderate

-2.30 [-2.86, -1.74]

FunctionPositive moderate

-1.32 [-1.80, -0.84]

Wheatgrass Pain Negative moderate

Function Negative moderate

Plantar fascia

stretching

First step

painPositive moderate

-2.81 [-3.35, -2.27]

Positive moderate

-3.25 [-3.83, -2.67]

Negative moderate

-0.10 [-1.06, 0.86]

Function

10

Small ES = 0.4-0.7Medium = 0.7 – 1.0 Large > 1.0.

Short term = 0-3mMedium term = 3<6mLong = >6m

Evidence

11

Custom orthoses versus sham orthoses for pain in the short term

Radial ESWT versus sham for pain in the long term

Study or Subgroup

Bishop 2018

Landorf 2006

Oliveira 2015a

Wrobel 2015

Total (95% CI)

Heterogeneity: Tau² = 0.05; Chi² = 5.19, df = 3 (P = 0.16); I² = 42%

Test for overall effect: Z = 2.37 (P = 0.02)

Mean

15.3

-71.8

3.5

22.4

SD

13.9

20.6

2.7

9.31

Total

20

46

37

25

128

Mean

38.3

-63.4

4.2

23.5

SD

26.7

21.5

3.2

8.64

Total

20

46

37

23

126

Weight

17.9%

31.5%

28.4%

22.2%

100.0%

IV, Random, 95% CI

-1.06 [-1.73, -0.39]

-0.40 [-0.81, 0.02]

-0.23 [-0.69, 0.22]

-0.12 [-0.69, 0.45]

-0.41 [-0.74, -0.07]

Custom foot orthoses Sham foot orthoses Std. Mean Difference Std. Mean Difference

IV, Random, 95% CI

-2 -1 0 1 2

Favours custom Favours sham

Study or Subgroup

Gerdesmeyer 2008

Ibrahim 2016

Total (95% CI)

Heterogeneity: Tau² = 0.00; Chi² = 1.01, df = 1 (P = 0.32); I² = 1%

Test for overall effect: Z = 3.34 (P = 0.0009)

Mean

-61.9

-6.2

SD

43.6

8.2768

Total

125

25

150

Mean

-46.5

-2.04

SD

45.5

2.7233

Total

118

25

143

Weight

83.3%

16.7%

100.0%

IV, Random, 95% CI

-0.34 [-0.60, -0.09]

-0.66 [-1.24, -0.09]

-0.40 [-0.63, -0.16]

Radial ESWT Sham Std. Mean Difference Std. Mean Difference

IV, Random, 95% CI

-0.5 -0.25 0 0.25 0.5

Radial ESWT Sham

12

Clinical reasoning

13 world experts, 4 continents, 5 disciplines, mean 51 papers (12-115), mostly clinical-

academic

Framework analysis

Data saturation reached, respondent validation ongoing

EvidencePatient values

13

Clinical reasoning

6 themes: 47 sub-themes

1. Diagnosis 2. Principles guiding management 3. Rehabilitation 4. Specific interventions 5. Education 6. Evidence considerations

EvidencePatient values

14

15

16

Clinical reasoning

6 themes: 48 sub-themes

1. Straightforward 2. Compliance a problem 3. ‘tensions’ abound 4. Matched evidence / combinations 5. Mismatch with patients 6. stratification + combinations

EvidencePatient values

ThemesDiagnosis

Principles guiding management Rehabilitation

Specific interventions Education

Evidence considerations

BPG

Clinical reasoning

EvidencePatient values

STAR

T OF

TR

EATM

ENT

Education and self management is the core approach

Severity

dete

rmine

d by repeated

PRO

Ms

✓ ✗

SCENARIO 1:

0 2 4 6 8 10 12 14 16 18

✓✓

OPTIMA

L

PROGRESSIVE RECOVERY OF

VARYING SPEED

TIME

IN W

EEKS

acceptable patient outcomeBEST PRACTISE GUIDEPLANTAR HEEL PAIN MANAGEMENT

FINDINGS FROM SYSTEMATIC REVIEW

CORE APPROACH

stretching taping

DO

footweareducation

related aspects

footwearpain

CHALLENGE BELIEFS

PAIN MONITORING

REASSURE

load

STATICDYNAMIC BMI

LTCsRF/FF DROP

COMFORT

SOFT + SHOCK

SOCIALLY ACCEPTABLE

Individual aetiological analysis

PLANTAR HEEL PAIN MANAGEMENT

BEST PRACTISE

GUIDE

COMBINED SR/SSI/SURVEY FINDINGS

EVIDENCE LEVEL: INTERVENTION

STRONG

MODERATE

EXPERIMENTAL

NO BENEFIT

CORE APPROACHESWT

CUSTOM ORTHOSESDRY NEEDLING

INJECTIONSURGERY

WHEATGRASSMAGNETIZED INSOLESPREFAB ORTHOSES

FINDINGS FROM SYSTEMATIC REVIEW

BEST PRACTISE

GUIDE

PLANTAR HEEL PAIN MANAGEMENT

STAR

T OF

TR

EATM

ENT

Education and self management is the core approach

Severity

dete

rmine

d by repeated

PRO

Ms

✓

SCENARIO 2:

0 2 4 6 8 10 12 14 16 18

✓

OPTIMA

L

FAILURE TO PROGRESSIVELY

RECOVER

TIME

IN W

EEKS

BEST PRACTISE GUIDEPLANTAR HEEL PAIN MANAGEMENT

FINDINGS FROM SYSTEMATIC REVIEW

CORE APPROACHESWT

CUSTOM ORTHOSESDRY NEEDLING

INJECTIONSURGERY

22

Thank you

23

Thank you

Applying the Best Practice Guide to Management of

Plantar Heel Pain

Dylan Morrissey Professor of Sports and MSK physiotherapy

NIHR/HEE Consultant Physiotherapist

d.morrissey@qmul.ac.uk@DrDylanM

25

Case scenarios

• Meet Sally

42 year old

CEO logistics firm

BMI 29 and dropping

Started running 6/52 ago

using an app

Now pain every am,

unable to run

• Meet John

– 54 year old father of

three

– BMI 31 and rising

– Works in a shop –

concerned he will lose

his job

– 24 months of pain, two

episodes of rehab and

four injections, 6 pairs

of insoles

26