Clinical Knowledge Base

Article Review-by Stephanie Bean, PT
Reading Berks Physical Therapy

Heel Pain- Plantar Fasciitis: Clinical Practice Guidelines Linked to the International Classification of Function, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association
Journal of Orthopedic and Sports Physical Therapy
Vol. 38, No.4, April 2008
WWW.JOSPT.ORG

Clinical guidelines are developed to promote evidence based practice in physical therapy. This article will review the full Clinical Practice Guidelines that can be found in the JOSPT journal. Experts were appointed by the Orthopedic section of the APTA to describe interventions and evidence for patients with plantar fasciitis. A systematic search and review of the evidence related to this diagnosis was performed. This guideline was issued in 2008 based upon publications in scientific literature prior to May 2007. It will continue to be updated on the orthopedic section website: www.orthopt.org.

The purposes of these guidelines are to:

1. Describe evidence-based practice of physical therapy.
2. Classify and define common musculoskeletal conditions using the World Health Organization’s terminology.
3. Identify interventions supported by the current best evidence.
4. Identify appropriate outcome measures to assess changes from physical therapy interventions.
5. Provide a description of the practice of orthopedic physical therapists using internationally accepted terminology.
6. Provide information to payers and claims reviewers about physical therapy for common musculoskeletal conditions.
7. Create a reference publication for clinicians, instructors, students, interns etc regarding the best practice of orthopedic physical therapy.

The article describes levels of evidence that were used to grade each research article reviewed by the committee. The levels range from I –Evidence obtained from high-quality randomized controlled trials, prospective studies or diagnostic studies to level V- Expert opinion. They also graded the overall strength of the evidence with grades from A to F. Grade A consists of strong evidence such as a preponderance of level I and /or level II studies. It changes from moderate to weak to conflicting evidence with the lowest grade of F. This grade denotes expert opinion which is best practice based on clinical experience of the guidelines development team.

McPoil et al describe plantar fasciitis as the most common foot condition treated by healthcare providers. It has been estimated that this condition affects as much as 10% of the population over a lifetime. The anatomy of the plantar fascia is described in the article in more detail. There are 3 bands of the plantar aponeurosis or fascia consisting of the lateral, medial and central bands. The central band is the area that can be shortened when the toes are extended resulting in the “windlass” effect of the plantar fascia.

A review of the research on causes of plantarfasciitis reveals that the cause is poorly understood and multifactorial. With an evidence level of II, studies have shown that the risk of plantar fasciitis increases with decreased ankle dorsiflexion range of motion and there is a strong association between a body mass index of 25 to 30kg/m and a calcaneal spur in a non-athletic population.

With an evidence level of II the diagnosis of plantar fasciitis can be made with a reasonable level of certainty based on the clinical assessment alone. The authors suggest that imaging studies are usually not necessary for the diagnosis but can rule out other causes of heel pain. With an evidence grade of B, the diagnosis involves the following symptoms: pain in the plantar medial heel, especially with initial steps after inactivity and often preceded by a recent increase in weight bearing activity. The physical examination techniques that may be useful include: palpation of the plantar fascia insertion, active and passive talocrural joint dorsiflexion range of motion, tarsal tunnel test, windlass test and the longitudinal arch angle. There is an outcome study that has been validated in a physical therapy setting that would be useful in the examination. It is the Foot and Ankle Ability Measure or FAAM. It has a high test-retest reliability and can measure change in function over time. It includes an ADL and a sports subscale. The minimally clinically important differences for the FAAM were 8 points for the ADL subscale and 9 points for the sports subscale. This was given an evidence grade of A.

The clinical guidelines also discuss interventions for treating plantar fasciitis. The interventions include (in order of best evidence to weakest): orthotics, modalities such as iontophoresis, stretching, night splints, taping and manual therapy.

With an evidence grade of A, the authors suggest that prefabricated or custom orthoses can be used for short term pain relief and increased function in patients with plantar fasciitis. They did not see a difference in pain or function when custom orthoses were compared to prefabricated orthoses. With an evidence grade of B, the authors conclude that iontophoresis with 0.4% dexamethasone or 5% acetic acid can provide short-term pain relief and increased function. Most of the studies reviewed were Level II and used iontophoresis rather than any other modalities. Stretching also received an evidence grade of B meaning moderate evidence. Calf muscle and/or plantar fascia specific stretching can provide short-term relief of pain. The stretching can be either sustained at 3 minutes or intermittent at 20 seconds since neither showed a better effect than the other. Night splints also received an evidence grade of B. They should be considered for patients with symptoms greater than 6 months and the type of splint used did not appear to affect the outcome. The splint should be used for 1 to 3 months. Taping received a lower evidence grade of C. There was a shortage of good, long term studies on taping. The authors conclude that calaneal or low-dye taping can provide short term (7 – 10 days) pain relief but did not show improved function. Manual therapy has minimal evidence to support its use. With an evidence grade of E for expert opinion, suggested manual therapy techniques include talocrural joint posterior glide, subtalar joint lateral glide, anterior and posterior glides of the first tarsometatarsal joint, subtalar joint distraction, soft tissue mobilization and passive neural mobilization techniques.

At the completion of the article, there is a page summarizing the recommendations for treating plantar fasciitis. These types of clinical guidelines can be helpful for treating patients and help us use the best available evidence.

Reading Berks Physical Therapy renders treatment for plantar fasciitis based on current best evidence. A clinical assessment is made confirming the diagnosis and establishing outcome measures. Treatment will include stretching exercises for the calf and plantar fascia. Home exercises are always established. Modalities such as iontophoresis with dexamethasone are often included in the treatment. Patients will require a prescription for their pharmacist for 4mg/ml dexamethasone. Difficult cases may require orthotics or a night splinting which are available for our patients. Everyone will receive individualized care based on the initial assessment.

Your patients need not continue to suffer from heel pain. Conservative, evidence-based physical therapy is often the best first choice of care for plantar fasciitis.

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