Introduction
A previous review of the literature on risk factor assessment and management of heel pain (PHP) found lack of support for any commonly used assessment and treatment options for this condition. [1][2][3][4] This highlights the need for proper methods to assess and administration of PHP, and led to the development of new tools for PHP. [5] The agreement involves:
- an assessment tool
- manual therapy and
- exercises
Assessment Tools for Plantar Heel Pain
A comprehensive physical examination is essential for the effective diagnosis and management of heel pain syndrome (PHPS) and requires effective assessment tools. Assessment tools have become more sophisticated and technologically advanced over time, but even these advances have not Enhanced evaluation of PHP. Historically, physical examination tests have been an important part of clinical evaluation because they are more readily available and less costly than diagnostic imaging methods. [6]
In an attempt to find an accurate way to assess PHP, two tests were found to reproduce the heel pain experienced by people with PHPS during routine foot and ankle assessments. These are: [5]
- Single leg heel raise
- Single-leg mini squat (half squat) (Figure 1)
Figure 1. Two clinical trials reproducing PHP
This raises the question of why these tests cause heel pain (Figure 2). [5] Given that PHPS is associated with weight bearing, can the recurrence of pain be attributed to increased weight bearing? However, in these moves, the weight is shifted from the heels to the The forefoot thus reduces the load on the heel.
Would these tests have resulted in increased plantar fascia pressure if not for increased weight bearing? But when analyzing these movements again, this seems unlikely. [5] Increased toe extension may increase fascial tension during single-leg heel raises, but Plantarflexion of the heel reduces this tension. Similarly, dorsiflexion of the ankle increases fascial tension during a single-leg mini-squat, but flexion of the knee decreases fascial tension. [5] Therefore, if fascial tension increases, this will be minimal given how these movements counteract each other out.
Figure 2. Proposed Causes of Provocation for Heel Pain
Based on these findings, Saban and Masharawi [4] investigated whether these tests could reproduce heel pain in a larger population and conducted a clinical trial involving 40 patients with typical PHP manifestations (Fig. 3). [5]
Figure 3. Inclusion criteria for trial participants evaluating the reliability of the three clinical trials used to assess PHP[4][5]
The study consisted of three tests — the single-leg static stance test, the single-leg half squat, and the single-leg heel raise. The test measures are shown in Figure 4[4][5]
Figure 4. Description of the clinical trials used [4][5] (P1 refers to the presentation of pain)
Measures used for assessment testing include (Figure 5):[4][5]
- Appearance of the first pain sensation (P1) assessed with a visual analog scale (VAS). Performance (i.e. repeats/sec) is also recorded
- Measure patient functional status using a computerized version of the Lower Limb Function Scale (LEFS)
Figure 5. The resulting measure used [4][5]
The purpose of this study was to investigate whether:
- These tests are reliable and valid in PHPS patients
- Combining these three tests will increase the likelihood of a positive test response for each patient[4][5]
The study procedure was as follows:
- Patients were interviewed and completed a functional status questionnaire
- Patients were subsequently assessed by assessor 1 using three clinical trials
- These same tests were reassessed by rater 2 after 30 minutes as a measure of test-rater reliability
- One week later, the patient was reassessed by rater 1 to determine the intra-rater reliability of the clinical test (Figure 6) [4]
Figure 6. Clinical trial process[4][5]
All tests reported moderate to high levels of inter-rater and intra-rater reliability and reported correlations between pain levels (VAS) and functional scales (LEFS) (Figure 7). [4]
Figure 7. Reliability indicators for clinical trials [4][5]
Figure 8 illustrates the frequency of positive pain responses for each individual test and test combination. [4][5]
Figure 8. Frequency of Positive Pain Responses in Clinical Trials
It is worth mentioning that some patients experienced pain only at the end of the testing protocol, suggesting that multiple repetitions may be required to reproduce the patient’s pain.
With regard to assessment tools, the study by Saban and Masharawi [4] demonstrated the existence of simple relevant and reliable clinical tests that are performance-based and readily applicable for the assessment of PHPS.
When considering heel pain in PHPS, it is often assumed that the source of the pain is at the level of the heel. This is a prime example of the thinking distortion described by Daniel Kahneman when he came up with the quiz question depicted in Figure 9. [7] If one opens one’s heart, Looking further, it’s clear that the pain PHPS is going through may not be on its heels after all. [5]
Figure 9. Quiz question by Daniel Kahneman [5][7]
Treatment Protocol for PHP
Due to the lack of high-quality evidence, no definitive conclusions can be drawn regarding the treatment of PHPS. [1][2][3][4][8] Therefore, after the above discussion about PHP evaluation, it is necessary to consider how to further handle this situation. If pain in the heel is Was the test not caused by weight bearing or increased fascial pressure, possibly due to contraction of the calf muscles? This should be considered in light of the following:
- The heel raise test incorporates concentric contractions of the calf muscles
- The half squat test involves an eccentric contraction of the calf muscles
Manual palpation of the plantar flexor muscles at the posterior calf of the affected leg in a patient with PHPS revealed soft tissue stiffness, non-compliance, and pain. [9] Therefore, Saban et al. proposed a treatment protocol targeting the posterior calf muscles [9]. The purpose of their research is Compare deep soft tissue massage on the back of the calf to more common heel-focused treatments (Fig. 10). [9]
Figure 10. The purpose of the study by Saban et al. [9]
In this study, participants were divided into a study group and a control group. The control group received a stretching protocol and ultrasound in common settings, while the study group received the same stretching protocol combined with deep tissue massage of the posterior calf muscles and Nerve stretch (Fig. 11). [9]
Figure 11. Study protocol by Saban et al. [9]
The primary outcome measure of this study was the Functional Status Questionnaire (a computerized version of the LEFS). A secondary measure was the level of morning pain pain (VAS). [9] A visual representation of the flow of a patient through the study can be found in Figure 12. [9]
Figure 12. Patient flow for the study by Saban et al. [9]
Patient characteristics at baseline were also compared by group to look for similarities between groups at baseline. No statistically significant differences were found between the groups at baseline (i.e. age-chronicity of heel pain and functional scale scores were similar) VAS intake table) (Figures 13 and 14). [9]
Figure 13. Baseline Patient Characteristics by Treatment Group [5][9]
Figure 14. Baseline Patient Characteristics by Treatment Group [5][9]
Completion rates were similar across groups and consistent with completion rates in two other studies that investigated aspects similar to this study (Figure 15). [9][10][11]
Figure 15. Treatment Completion Rate[9][10][11]
The main results of the study showed that while 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 group (USS) (Figure 16) .[9]Wang et al.[12] showed a An 8-point change is required for any change to be clinically meaningful. Thus, even though the USS group improved statistically, there was no real clinical change, whereas the DMS group improved both statistically and clinically (Fig. 16). [9]
Figure 16. Functional Scale Scoring Results [5][9]
Decreases in first morning pain (VAS) levels were similar in both groups, without significant differences (Fig. 17). [9] This may suggest that the complaint of first-morning pain may simply be part of PHPS and that the patient has other functional limitations Obtained by Functional Scale Scale (LEFS). [5]
Figure 17. VAS results for morning first step pain [5][9]
In a study by Saban et al. [9], deep massage therapy and nerve mobilization combined with stretching exercises for the posterior calf muscles had better short-term functional scale outcomes compared to ultrasound therapy for stretching exercises. The treatment is easy to use and Works on PHP so can be recommended for people with PHPS. [5][9]
However, this study has several limitations, including: [9]
- No daily self-exercise compliance record
- Short-term results only
- The DMS group performed an additional exercise (SLR with dorsiflexion), thus introducing an additional variable into the trial
This therapeutic approach is also supported by two other studies by Renan-Ordine et al. [13] (Fig. 18) and Ajimsha et al. [14] (Fig. 19). Renan-Ordine et al[13] suggested calf myofascial trigger point therapy for PHP, but the results of the research are not clear, clinical The effect is unknown (Figure 18). Amjisha et al. [14] investigated the effect of calf myofascial release on PHP and found significant differences between the groups, with the myofascial release group performing better compared to the control sham ultrasound group (Fig. 19).
Figure 18. Results of Renan-Ordine et al. [13][5]
Figure 19. Results from Ajimsha et al. [14][5]
Conclusion
This new protocol for the assessment and treatment of PHP shows promising results for the management of PHPS. [9][13][14][15] The next lesson in this series will examine the anatomy behind this protocol and then detail how to apply the technique and manage the treatment Meet with patients.
References
- ↑ Jump up to:1.0 1.1 Morrissey D, Cotchett M, J’Bari AS, Prior T, Griffiths IB, Rathleff MS, Gulle H, Vicenzino B, Barton CJ. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British Journal of Sports Medicine. 2021 Mar 30.
- ↑ Jump up to:2.0 2.1 Salvioli S, Guidi M, Marcotulli G. The effectiveness of conservative, non-pharmacological treatment, of plantar heel pain: a systematic review with meta-analysis. The Foot. 2017 Dec 1;33:57-67.
- ↑ Jump up to:3.0 3.1 Babatunde OO, Legha A, Littlewood C, Chesterton LS, Thomas MJ, Menz HB, van der Windt D, Roddy E. Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. British Journal of Sports Medicine. 2019 Feb 1;53(3):182-94.
- ↑ Jump up to:4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Saban B, Masharawi Y. Three single leg standing tests for clinical assessment of chronic plantar heel pain syndrome: static stance, half-squat and heel rise. Physiotherapy. 2017 Jun 1;103(2):237-44.
- ↑ Jump up to:5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 5.23 5.24 Saban B. A New Protocol for Plantar Heel Pain Course. Plus. 2021.
- ↑ Schwieterman B, Haas D, Columber K, Knupp D, Cook C. Diagnostic accuracy of physical examination tests of the ankle/foot complex: a systematic review. International journal of sports physical therapy. 2013 Aug;8(4):416.
- ↑ Jump up to:7.0 7.1 Kahneman D. Thinking, fast and slow. New York: Farrar, Straus & Giroux. 2011.
- ↑ Rasenberg N, Bierma-Zeinstra SM, Bindels PJ, van der Lei J, van Middelkoop M. Incidence, prevalence, and management of plantar heel pain: a retrospective cohort study in Dutch primary care. British Journal of General Practice. 2019 Nov 1;69(688):e801-8.
- ↑ Jump up to:9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 9.18 9.19 9.20 9.21 9.22 Saban B, Deutscher D, Ziv T. Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial. Manual Therapy. 2014 Apr 1;19(2):102-8.
- ↑ Jump up to:10.0 10.1 Bezalel T, Carmeli E, Katz-Leurer M. The effect of a group education programme on pain and function through knowledge acquisition and home-based exercise among patients with knee osteoarthritis: a parallel randomised single-blind clinical trial. Physiotherapy. 2010 Jun 1;96(2):137-43.
- ↑ Jump up to:11.0 11.1 Deutscher D, Horn SD, Dickstein R, Hart DL, Smout RJ, Gutvirtz M, Ariel I. Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice. Archives of physical medicine and rehabilitation. 2009 Aug 1;90(8):1349-63.
- ↑ Wang YC, Hart DL, Stratford PW, Mioduski JE. Clinical interpretation of a lower-extremity functional scale–derived computerized adaptive test. Physical therapy. 2009 Sep 1;89(9):957-68.
- ↑ Jump up to:13.0 13.1 13.2 13.3 Renan-Ordine R, Alburquerque-SendÍn F, Rodrigues De Souza DP, Cleland JA, Fernández-De-Las-Penas C. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2011 Feb;41(2):43-50.
- ↑ Jump up to:14.0 14.1 14.2 14.3 Ajimsha MS, Chithra S, Thulasyammal RP. Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Archives of physical medicine and rehabilitation. 2012 Apr 1;93(4):604-9.
- ↑ Pollack Y, Shashua A, Kalichman L. Manual therapy for plantar heel pain. The Foot. 2018 Mar 1;34:11-6.