Managing Heel Pain – An Evidence Based Approach

Michael Ratcliffe

Sales Training Manager

Cuxson Gerrard & Co. Ltd.

Objectives

Offer a systematic approach to obtaining

appropriate evidence

Using this approach to review the current

evidence when managing heel pain

What constitutes evidence?

According to David Sackett, the

creator of the concept of

‘evidence-based medicine and

pilot user of The Cochrane

Library, it is;

‘…the integration of best

research evidence with clinical

expertise and patient values.’

(Sackett et al. 2000)

Evidence based practice is the

refining of the information on

which clinical decisions are

made.

Sackett DL, Strauss SE, Richardson WS,

Rosenberg W, Haynes RB. Evidence-

based Medicine: How to practice and

teach EBM. Edinburgh: Churchill

Livingstone, 2000

Introduction

Heel pain generally synonymous with

plantar/inferior heel pain but…

encapsulates all aspects of the heel/rearfoot complex so…

large number of considerations before making a therapy choice

when we look at searching for evidence to support our therapy choice we need to form an accurate search question

Sites of pain and structures involved

Posterior (Less common)

Achilles tendon insertion

Superficial calcaneal bursa

Posterior impingement of soft-tissues/os trigonum in active people

Calcaneal apophysis in adolescents

(Sural Nerve)

Inferior (Less common)

Plantar fascia

Calcaneal fat pad

(Medial or lateral calcaneal nerve, especially as they split from the tibial branch)

Deep Vague Pain (less common)

Subtalar joint

(Bone pain: calcaneus, talus, navicular)

Sites of pain and structures involved

Medial (less common)

Tibialis posterior tendon and

sheath

Tibialis posterior insertion

and apophysis in adolesents

(FHL and sheath, abductor

hallucis, deltoid and spring

ligaments, tibial nerve in

tarsal tunnel, medial

malleolus)

Lateral (less common)

Lateral ligaments on the

ankle

Sinus tarsi

(Peroneal tendonopathy or

tenosynovitis associated

with subluxation, peroneus

brevis insertion/apophysis of

base of 5th metatarsal in

adolescents or after ankle

sprain

Adapted from; Rio E., Mayers S. and Cook J. Heel pain: a practical

approach. Australian Family Physician 2015 Mar;44(3):96-101.

Forming a clinical question

The amount of evidence that is generated daily is vast – how can we keep up?

Do I need to?

How do we find out the information we need?

We must ask focused questions that ‘pull’ the answers from the research

Glasziou P., Del Mar C. and Salisbury

J. (2007) Evidence-Based Practise Workbook 2nd Ed.. BMJI Books –

Blackwell Publishing, Oxford.

What type of clinical question are we asking?

When managing heel pain generally we are asking an intervention question e.g. taping/strapping/splinting, stretching, orthoses, activity/footwear modification, ECSWT, injection, acupuncture, casting, surgery, weight loss, platelet-rich plasma injections, MMC, etc.

We could also ask questions about;

aetiology/risk factors e.g. fascial thickening/loss of elasticity, quantity of ankle joint dorsiflexion, diabetes/fat pad thickening, R/A and O/A, oedema, cancer, infection, age, BMI*, time standing*, trauma (repetitive loading), physical inactivity*

diagnosis e.g. site, structure, palpation/ROM, history taking/assessment, medical imaging, force/pressure measurements,

prognosis and prediction e.g. pain duration, time to functional restoration

frequency and rate i.e. prevalence e.g. 1 in 8 people > 50 years will develop posterior heel pain* and incidence

phenomena/thoughts i.e. more general questions

*Chatterton B.D., Muller S. and Roddy E. Epidemiology of posterior heel pain in the general population:

cross sectional findings from the Clinical Assessment Study of the Foot. Arthritis Care and Research

(Hoboken) 2015 Jan 20. (Accepted Article) doi: 10.1002/acr.22546.

Where do I look?

If you are employed by an academic

institution or the NHS you will probably have

access to a large range of databases e.g.

AMED, EMBASE, CINAHL, MEDLINE

If not then you still access to powerful search

engines and databases e.g. The Cochrane

Collaboration and MedLine through PubMed

Where do I look?

Cochrane Collaboration (Cochrane Database of

Systematic Reviews) – a database produced by

John Wiley and Sons Ltd. (a medical publisher)

containing approximately 5000 Cochrane Systematic

Reviews of high quality controlled experimental trials

in medicine and health care.

Look here first for any systematic reviews

www.cochrane.org

Where do I look?

PubMed - a free internet search engine that is maintained by the National Center for Biotechnology Information (NCBI), at the U.S. National Library of Medicine (NLM)

www.pubmed.gov

PubMed draws from MedLine (amongst others including U.K. based BioMed Central) – the database of the U.S. National Library of Medicine consisting primarily of scholarly, peer reviewed journals (approximately 5600 worldwide from 1945 to present) and concentrating on biomedicine and health.

Let’s form a focused intervention/management question - (P.I.C.O.)

Glasziou et al. 2007, points out that to help us find the answer we what from the evidence (if it exists), then it is useful to think about and form your question by first breaking down what it is that you want to know

P – population and problem i.e who are the relevant people

I – intervention/indicator i.e the treatment you want to find out more about

C – comparator i.e. an alternative to the intervention you want to find out about

O – outcome i.e. what you or your patient want to happen (or not)

Glasziou P., Del Mar C. and Salisbury J. (2007) Evidence-Based Practise Workbook 2nd Ed.. BMJI Books – Blackwell Publishing, Oxford p.24

Question

Mr. X attends your clinic c/o pain on the

bottom his heel which has build up gradually

over some months and is now painful

following periods of rest. He would like to be

without pain. You have heard that low dye

taping provides initial pain relief and would

like to find out if there is any evidence to

support this

Using PICO

Population – adult/plantar heel pain/plantar

fasciitis

Intervention – low dye taping

Comparator – nothing

Outcome – pain reduction

Further Help

What did we find?

Authors/date Study design/n Findings

Podolsky R, Kalichman L.

2014

Systematic review Low dye and calcaneal taping

best in short term, no long

term studies

Van Lunen B. et al. 2011 Cross over, (orthosis, l/d,

control) n=17

Stat and clinically lower VAS

scores short term

Abd El Salam MS, Abd Elhafz

YN. 2011

Randomised clinical trial, l/d v.

med.arch support ( U/S +

stretching) n=30

mas.>l/d stat sig

‘improvement’ in VAS short

term

Radford JA et al. 2006 Single blinded RCT

(control=sham U/S) n=92

L/d = stat sig. reduc. in VAS

‘1st step’ 1/52 t/t

Osbourne HR, Allison GT.

2006

Double blinded RCT

iontopheresis

dexamethosone/acetic acid

(l/d + stretching) n=31 (42f)

Acetic acid>dexa in reducing

stiffness symptoms over 4/52

Lansdorf KB. et al. 2005 Comparison study n=60 with

and 45 without, 3-5 days

L/d>without in reducing pain

31mm on VAS

Searching for an intervention e.g. most effective intervention in Sever’s Disease

Search terms - (child* OR adolescents) AND calcaneal apophysitis in PubMed (no results from Cochrane) (Google Scholar – 97,700 results!)

Search results – 10 trials and 1 systematic review

Systematic Review – James AM. et al. (2013), results – ‘The limited evidence indicated that orthoses provided greater short-term pain relief than heel raises.’

2 trials since SR

1. Wiegerinck JL et al. (2015) pragmatic trial– wait and see/silicone heel cup/eccentric stretching over 10/52, all sig. reduced pain at 3/12 – agree with parents on acceptable course

2. James et al. (2015) - early management focusing on the anthropometric differences (BMI, weight waist circ., foot posture, A/J ROM, and height) may minimize the intensity and duration of pain experienced.

Searching for evidence of efficacy via intervention/treatment

Extracorporeal shock wave therapy

Stretching

Orthosis therapy

Weight Loss

Radiofrequency microtenotomy

Platelet-rich plasma injections

Micromobile compression

Kinesiotaping

Extracorporeal shock wave therapy

Search term (extracorporeal

shock wave therapy) AND

(chronic plantar fasciitis)

Results 29 clinical trails

1997 – 2015 and 11

systematic reviews 1997 –

2014

General agreement in

reviews (Yin MC. et al.

2014), from good quality

trails that ECSWT is

efficacious and indicated in

providing pain relief from 6

months + plantar fasciitis

although long term effects

are not clear as long term

follow up studies are lacking

Care; post 6 months may

indicate fibroma – should

image to confirm

Stretching and plantar heel pain

Search term; stretching AND (heel pain)

Results – 18 trials from 1996 – 2015 and 9

systematic reviews 2003 – 2015

General consensus that (eccentric)

stretching relieves pain and improves

function in the Achilles tendon and stretching

relieves pain in the p/f in the short term; long

term follow up is inconclusive

Orthosis therapy and plantar heel pain

Search terms; (prefabricated orthoses) AND plantar OR lateral OR medial OR posterior (heel pain)

Results 20 trials 1995 – 2015 but only 10 were relevant and 6 systematic reviews 1993 – 2015 but only 2 relevant

Changing the search terms; (prefabricated orthoses) AND plantar fasciitis offered 9 trials and 2 systematic reviews

Generally both prefabricated and custom made orthoses offer 1st step relief and general pain relief and improved comfort on walking (but not specific on effect of ‘sham’ devices

Weight Loss and plantar heel pain

.Search terms; (weight loss) AND (foot pain)

Results – 2 relevant trials and 1 relevant systematic review

‘…BMI of 25 (the target for decreased cardiovascular risk) represents a reasonable goal for weight loss that may reduce heel pain’ (Rano et al. 2001)

‘…there is currently limited evidence to support weight loss to reduce foot pain.’ (Butterworth et al. 2012)

‘The evidence indicates that obesity is strongly associated with planus (low-arched) foot posture, pronated dynamic foot function and increased plantar pressures when walking.’ (Butterworth et al. 2014

Evidence for heel raises in shoe for retro-calcaneal bursitis

Search terms; retrocalcaneal bursitis AND treatment

Results; 13 trials (4 relevant to non surgical

intervention in RB) no evidence could be found

specifically for heel raises in PubMed.

Google Scholar; retrocalcaneal bursitis and

treatment – 9,500 results! (1 relevant paper- Lee et

al. 1987 in Europe PubMed Central database), heel

raises between 1.9 to 5.7 cm reduces the gastroc.

activity and is therefore indicated in the t/t of RCB

Emerging therapies for chronic plantar fasciitis

Radiofrequency microtenotomy – used to treat chronic tendinopathies, creates acute inflammatory response around tendon and encourages an ‘…extensive proliferation of vascular cells and new blood vessel formation within 28 days’. Case series only/no comparative studies to date – promising outcomes for chronic p/f

Miller LE., Latt DL. Chronic Plantar Fasciitis is Mediated by Local Haemodynamics:

Implications for Emerging Therapies. North American Journal of Medical Science. 2015;

7(1): 1-5

Image from cosmanmedical.com

Emerging therapies for chronic plantar fasciitis

Platelet-rich plasma injections – not new but of increasing interest in chronic p/f treatment. Patient’s own platelets are re-injected around site – thought to enhance fibroblast migration and proliferation, increase local vascularisation and collagen deposition. Case series only, no comparative studies but satisfaction rates 45% at 6 months and 79-96% at 1 year follow up.

Miller LE., Latt DL. Chronic Plantar Fasciitis is Mediated by Local Haemodynamics:

Implications for Emerging Therapies. North American Journal of Medical Science. 2015;

7(1): 1-5

Emerging therapies for chronic plantar fasciitis

Micromobile compression – non-invasive and encourages deep vein circulation via pulsed pressure to the plantar venous plexus.Theory - Increases perfusion through p/f microvasculature and promote healing – 1 case study (2 year history of pain) to date led to increased activity over a 2 month period. Planned RCT this year.

Image from footbeat.com

Miller LE., Latt DL. Chronic Plantar Fasciitis is Mediated by Local Haemodynamics:

Implications for Emerging Therapies. North American Journal of Medical Science. 2015;

7(1): 1-5

Kinesio Taping and Plantar Fasciitis

Search term; kinesiotaping AND ‘plantar fasciitis’ general search in PubMed as Clinical Queries search gave no result. 1 systematic review (Morris D. et al. 2013) featuring 1 RCT where kinesiotape combined with physiotherapy beneficial in the short term. Concluded insufficient evidence that kinesiotape can be used over other interventions

Summary

Important to keep up to date with interventions for heel pain

Form a search question

Use the words from the question to enter into a database or search engine

Decide what is relevant to your search

Reflect on findings/inferences and use or shelve