A New Protocol for Plantar Heel Pain

Question 1

Introduction

Answer 1

• Plantar heel pain (PHP) is a common condition with an estimated prevalence of 3,6-9.6%
  
  • Predominately impacts middle-aged and older adults who are sedentary and is known to have a significant impact on health-related quality of life.
  • Previous literature reviews on risk factors, evaluation and management of PHP identified a lack of support for any of the commonly used assessment and treatment options for this condition. This highlighted that there was a need for appropriate methods to assess and manage PHP and led to the development of a new tool for PHP. This protocol involves an assessment tool, manual therapy, and exercises.

Question 2

Assessment Tools For Plantar Heel Pain

Answer 2

• A comprehensive physical examination is essential for the effective diagnosis and management of plantar heel pain syndrome (PHPS) and effective assessment tools are required.
  
  • Assessment tools have, over time, become more sophisticated and technologically advanced, but even these advancements have not enhanced the assessment of PHP.
  • Historically, physical examination tests have been an essential part of clinical assessments as they are more readily available and less expensive than diagnostic imaging methods.
  • In an attempt to find an accurate means of assessing PHP, two tests were found to reproduce the heel pain experienced by an individual with PHPS during a regular foot and ankle evaluation. These were the single leg heel raise and single leg mini squat.
  • Considering that PHPS is associated with weight-bearing, could the reproduction of the pain be attributed at an increase in weight-bearing. Yet during these movements, the weight is shifted from the heel to the forefoot, thus reducing weight-bearing on the heel.
  • If not because of increased weight-bearing, could it be causing increased stress in the plantar fascia. When analysing the movements, it doesn’t seem likely. During the single-leg heel raise, the increased extension of the toes might increase tension in the fascia, but plantarflexion at the heel reduces this tension. Similarly, during single leg mini squat, dorsiflexion of the ankle increases fascial tension, but this is reduced by flexion of the knee. Thus, if there is an increase in fascial tension, it will be minimal considering how these movements cancel each other out.
  • Saban and Masharawi investigated if these tests were able to reproduce heel pain in a larger population, and conducted a clinical trial involving 40 patients with a typical presentation of PHP.
  • Three tests were included in the study - the single leg static stance test, single leg half squat, and single leg heel raise.
  • The measures used to assess the tests included: - the appearance of the first painful sensation assessed with the visual analogue scale. The performance was also recovered. The functional status of the patient, measured using a computerised version of the Lower Extremity Functional Scale.
  • The aims of this study were to investigate whether these tests were reliable and valid in patients with PHPS and combining the three tests would enhance the possibility of a positive test response from each patient.
  • The study procedure was as follows: the patient was interviewed and completed the functional status questionnaire. This was followed by an assessment of the patient by Rater 1 using the three clinical tests. These same tests were re-assessed 30 minutes later by Rater 2 as a measurement of the interrater reliability of the tests. The patient was then reassessed by Rater 1 one week later in order to establish the intrarater reliability of the clinical tests.
  • Moderate to high levels of interrater and intrarater reliability were reported for all the tests and a correlation was reported between the level of pain (VAS) and the functional scale (LEFS).
  • Some patients only experienced pain towards the end of the testing protocol, which indicates that many repetitions might be needed to reproduce the patient’s pain.
  • The study indicates the existence of simple, relevant, and reliable clinical tests that are performance-based, easily applied, and appropriate for the assessment of PHPS.
  • Considering the presence of pain in the heel with PHPS, the source of pain has often been assumed to be at the level of the heel. This is a prime example of the thought distortions described by Daniel Kahneman. If one open their mind and looks further, it becomes clear that the pain experienced in PHPS might not be in the heel after all.