April 2015

APTA’s revised heel pain guidelines spur dialogue

4plantar-shutterstock_102873212-copyBy Hank Black

The American Physical Therapy Association has updated its 2008 guidelines on the nonsurgical treatment of heel pain with a bolstered evidence base, but lower extremity practitioners continue to debate the clinical merits and most effective applications of certain newer therapies.

New treatment recommendations for heel pain published recently by the American Physical Therapy Association1 (APTA) update the group’s 2008 guidelines2 and continue the lower extremity community’s efforts to base practice guidelines on recently published scientific evidence.

Although there are no transformative changes to the previous APTA document, the new one includes stronger evidence for manual therapy and antipronation taping, among other changes.

Heel pain, specifically plantar fasciitis, is the most common of foot ailments and affects more than two million people in the US at any time. Some 10% of the population will be hobbled by chronic heel pain over the course of a lifetime.3 One report found that plantar fasciitis accounts for 15% of all adult foot complaints requiring professional care and is widespread in both athletic and nonathletic populations.4

The 2014 APTA guidelines address heel pain with a mechanical etiology rather than neurologic, arthritic, or traumatic causes.

Not all groups of specialists who treat heel pain offer clinical practice guidelines. The American Orthopaedic Foot and Ankle Society (AOFAS), for example, does not, while the American College of Foot and Ankle Surgeons (ACFAS) published its latest version in 2010.5 While the APTA and ACFAS clinical recommendations dovetail into a relative synchrony of tiered actions in an attempt to base clinical practice on published evidence, differences over some topics continue to spur discussion.

Adhering to practice guidelines is not mandatory, of course, but insurance auditors often use clinical guidelines to determine the appropriateness of payment.

As one would expect, differences in clinical perspective are at the root of a number of the disagreements. The scope of physical therapy practice obviously does not include surgery, corticosteroid injection, and some other types of treatment. And, even among individuals in surgical disciplines, there is disagreement about when or even whether to initiate corticosteroid injection and whether treatments such as extracorporeal shock wave therapy (ESWT) should be offered to patients. In addition, some clinicians are using newer treatments such as radiofrequency coblation, while most are awaiting additional accumulation of evidence before employing it.

Practice guidelines of the APTA and others rank evidence and make recommendations in similar ways. For example, the APTA grades evidence from Level I (the highest, based on randomized controlled trials) to Level V (expert opinion). The highest degree of recommendation is grade A (considered strong evidence based on Level I or II studies) and the lowest is grade F, which is based on expert opinion.

Rob Roy Martin, PT, PhD, one of the APTA guideline authors and a professor of physical therapy at Duquesne University in Pittsburgh, said, “I was excited to see the range and level of research support for some physical therapy interventions, particularly for manual therapy, stretching, and therapeutic taping, as well as the use of orthoses.”

Martin, who was also a coauthor of the 2008 APTA guidelines, said one of the goals of guideline development is to make physical therapy practice uniform, particularly when there’s evidence to support it.

“Different therapists may, based on their clinical practice, offer some different ways of treating the patient, but there should be at least some uniformity in the interventions,” he said. “Basically, patients should receive some type of manual therapy in the form of joint and soft tissue mobilization, as well as some form of arch taping. And hopefully the physical therapist will pay attention as evidence-based research is developed, and make it part of their routine practice.”

4plantar-iStock18950860-copyGuidelines prompt research

The development of earlier clinical guidelines may have helped spur research on particular treatment methods, Martin said.

“It’s good to see evidence accumulate and point toward additional standard modalities, whether or not the guidelines provoked or motivated people to research those areas,” he noted.

The development of a strong recommendation for manual therapy in the new document, for example, was supported by studies including a 2011 randomized clinical trial6 that found that exercise plus soft tissue mobilization techniques directed to gastroc­nemius and soleus trigger points was superior to exercise alone. The 2008 guidelines had found minimal evidence to support the use of manual therapy.

The new document provides general guidance–perhaps too general, said Michael Gross, PT, PhD, FAPTA, who is a professor in the Department of Physical Therapy at the University of North Carolina at Chapel Hill.

“I’m in agreement with most of the guidelines,” Gross said. “I like the emphasis on stretching but would like details on what kind of stretches to do. I use a standing heel-cord stretch, taking advantage of the windlass mechanism by having a towel roll propped under the toes so they are maintained in extension.”

The new evidence supporting longitudinal arch taping is also welcome, Gross said, particularly for recalcitrant cases.

“However, the technique requires some expertise, and many patients or family members may not be able to apply the tape effectively,” he said.

Gross also thinks practitioners need to determine the point in the gait cycle at which pain is most prominent in order to provide the most effective treatment.

“If pain occurs when the heel strikes the ground, the problem is compressive stress, so you need a soft, deformable material under the heel to attenuate the ground force and increase contact area,” he said. “But, if the pain comes when you’re pushing off, the heel is off the ground and the metatarsophalangeal joints are going into extension. That indicates that the windlass mechanism, in combination with a tight plantar fascia, is probably resulting in excess tensile stress within the fascia. In that case, heat and stretching of the fascia, along with a stiffer toe-break in the shoe and a rocker-bottom configuration, will probably help.”

Practice guidelines, of course, are not mandatory, and practitioners are expected to depend on their clinical judgment, as well. Martin noted, however, that insurance auditors often use clinical guidelines to determine the appropriateness of payment.

Martin said the new recommendation to provide weight-loss counseling is part of the APTA’s desire to consider the patient as a whole rather than just as someone with a painful foot problem.

“There hasn’t been a study to say that losing weight will improve foot pain, but it is a recognition that if you are overweight you are more likely to develop this problem,” he said. “We felt there is enough evidence7,8 to at least get in a conversation about it and remind the patient that this might be consequential to their foot health as well as their life as a whole.”

The physical therapy association’s guideline authors also pinpointed pain-related fear of movement as the greatest single contributor to disability in people who have plantar fasciitis and called for more research on pain-related fear.9 Additionally, the group noted the widespread, growing acknowledgement that chronic plantar foot pain involves a degenerative process and should be termed fasciosis rather than fasciitis, reserving fasciitis to describe acute inflammatory events.

Pathways and interventions

The APTA guidelines recommend pathways for diagnosing, evaluating, and treating plantar heel pain of mechanical origin. They noted that the physical exam should include palpation, talocrural joint dorsiflexion range of motion, tarsal tunnel syndrome and other peripheral nerve entrapment tests, and the windlass test, as well as functional assessment of joints and muscle groups from the gastrocnemius-soleus complex to the trunk, buttock, and thigh.

Initial interventions may include activity limitation, stretching of the plantar fascia and calf muscle, taping, night splints, heel cups, and prefabricated or custom foot orthoses. Also included are therapeutic exercises and neuromuscular re-education, which are expected to strengthen and train muscles to reduce pronation10,11 and improve weight management. For patients who present with acute pain, physical agents such as iontophoresis and phonophoresis may be recommended.

The APTA guideline authors formally evaluated research up to January 2013. Although the use of trigger point dry needling was not recommended based on those studies, the authors published a supplemental note concerning a 2014 randomized clinical study by Cotchett et al that found a significant effect of decreased pain and improved Foot Health Status Questionnaire scores at a six-week follow-up compared with sham dry needling.12

“It will be interesting to see if more research arises to support dry needling [so that it may possibly be included] in the development of future guidelines,” Martin said.

He said he believed the recommended APTA practices are generally similar to those practiced by specialists and noted that a surgeon was a coauthor and a professor of medicine was a reviewer. Disagreements among the practitioners include interventions such as ESWT, corticosteroid injections, and certain surgeries.

“There’s not a whole lot of evidence to support injections; we think the potential harm outweighs potential benefits,” Martin said. “Also, the better quality studies we evaluated found that ESWT was not the favored treatment and found the potential for adverse effects associated with it. ESWT did not appear to be more effective than stretching for reducing pain.”

Injection controversy

The 2010 clinical guidelines published by the ACFAS include the possibility of an anti-inflammatory injection in Tier 1 of the organization’s three-stage progression of treatment. Brandi Johnson, DPM, FACFAS, who practices in Brandon, FL, said her practice choices are driven by patient presentation, and if the pain level is extremely high she may inject on the first or second patient visit.

“It is rare to give more than two injections, and if they don’t provide relief we know we should look for other causes of the heel pain,” Johnson said. She mentioned spondyloarthritis, tarsal tunnel syndrome, and entrapped Baxter nerve as potential other causes.

Short of corticosteroid injection, Johnson uses oral anti-inflammatory medications in Tier 1 along with stretching, icing, over-the-counter heel cups, and prefabricated foot orthoses, and also considers taping regimens.

Of the ACFAS’s Tier 2 interventions, she may prescribe custom foot orthoses, night splints if the patient can tolerate them, and, if indicated, a second corticosteroid injection. In Johnson’s experience, some 95% of patients with heel pain due to plantar fasciitis find relief of symptoms from nonoperative techniques. But, after a year of insufficient pain relief or functional disability she goes to Tier 3, including open or minimally invasive fascia release surgery.

“I primarily use the endoscopic release technique, but no surgery is justified except as a last resort due to the prolonged recovery period and a small risk of injury,” Johnson said.

If she does commit to fascia surgery, she said, she often concurrently performs a gastrocnemius recession if the patient presents with a tight heel cord.

Johnson noted that evidence13-15 is beginning to accumulate in favor of using platelet-rich plasma (PRP) treatments for heel pain, particularly in sports medicine applications. Neither set of heel pain guidelines have addressed this potential treatment, however.

“Although this intervention is not yet included in our recommendations, research is generally favorable and has no major side effects,” she said. “I have seen patient improvement in extremely recalcitrant cases after use of PRP.”

While Johnson does not believe evidence for dry needling12 is strong enough to support its use to bring healing cells into the chronically degenerative process of fasciosis, she said PRP, a form of wet needling, accomplishes the same result. A similar mechanism is used with ultrasound debridement and radiofrequency coblation, neither of which Johnson currently uses due to lack of evidence of efficacy, she said.

As for ESWT, which also causes microscopic damage to the fascia to enable new blood vessel formation and increased delivery of nutrients to the affected area, Johnson echoed the ACFAS guidelines’ conclusion that there is insufficient evidence for its use, and noted that many insurers do not reimburse for it. Yet, some other practitioners disagree. ESWT is sometimes prescribed by Robert Anderson, MD, FAOFAS, a past president of the AOFAS, who practices in Charlotte, NC. Anderson, however, concurred with Johnson’s assessment of its reimbursability.

“Both low- and high-energy ESWT are difficult to get approved. The three-thousand dollar price tag, however, is prohibitive for many who must pay cash,” Anderson said.

Whereas Johnson depends primarily on endoscopic surgery for fascia release, Anderson leans toward the open technique, usually performing a distal tarsal tunnel release and a partial plantar fascia release. When a tight Achilles tendon can’t be sufficiently stretched with physical therapy, he said, “I may opt to offer not a plantar fascia release but gastrocnemius recession surgery, releasing the gastroc tendon and leaving the soleus muscle intact so the Achilles complex is not overly weakened.” A recent publication by Molund et al described results and complications associated with this procedure.16

Anderson estimated that about 95% of patients he sees with heel pain experience reduced pain and increased mobility with the initial treatments, which include activity modification, shoe inserts, icing, heel pads, foot orthoses with good arch support, and over-the-counter nonsteroidal anti-inflammatory oral medication.

“The heart of the initial treatment is Achilles tendon stretching to take the tension off the plantar fascia, along with windlass stretches,” he said.

If patients have insufficient relief from these initial treatments, Anderson refers them to physical therapy for deep tissue massage, a more formal stretching regimen, physical agents, and night splints or casting. At this point he may provide a single intralesional corticosteroid injection (ICSI).

“I avoid a second injection because studies have shown it may lead to spontaneous rupture of the fascia,” he said. The ACFAS guideline5 includes ICSI in its Tier 1 and Tier 2 pathways; the APTA guidelines state that systemic reviews failed to find evidence of a substantive clinical benefit of ICSI and that fascia rupture is among its potential adverse effects.17,18

Foot orthoses

The 2008 APTA heel-pain guidelines recommended that practitioners “may use” prefabricated or custom foot othoses to give pain reduction and function improvement for up to three months. Now, based on a number of studies,19-21 the recommendation is that clinicians should use arch-supporting and heel-cushioning features for periods as short as two weeks and as long as a year.

Anderson includes prefabricated shoe inserts or heel cups as part of his initial treatment, but if those are not effective he presents custom orthoses as an option for chronic pathologic conditions of the plantar fascia.

“Although custom orthoses are expensive and sometimes not covered by insurance, they are very beneficial, in particular for people with underlying cavus foot, pes planus, and other conditions,” he said.

Rob Sobel, CPed, who practices in New Paltz, NY, and is the president of the Pedorthic Footcare Association, believes prefabricated insoles are sufficient for some patients.

“If a patient has multiple bouts of plantar inflammation, chances are it’s a biomechanical issue, which custom foot orthoses are designed to correct,” Sobel said.

Orthosis design should be influenced by the patient’s weight, lifestyle, and other factors, he said.

“The thickness of the polypropylene shell varies depending on a patient’s weight, and if the shell is too hard for the patient to tolerate, we may shift to a higher durometer EVA [ethylene vinyl acetate] to provide more ‘give’ but still maintain proper foot position,” he said.

In determining the best type of orthosis for a given patient, it’s helpful to have as much input from possible from other practitioners, Sobel said.

“When you have multiple practitioners working toward the same goal from different perspectives, the result is a better outcome for the patient,” he said.

Hank Black is a medical writer in Birmingham, AL.

  1. Martin RL, Davenport TE, Reischl SF, et al. Heel pain—plantar fasciitis: revision 2014. J Orthop Sports Phys Ther 2014;44(11):A1-A23.
  2. McPoil TG, Martin RL, Cornwall MW, et al. Heel pain—plantar fasciitis: clinical practice guidelines. J Orthop Sports Phys Ther 2008;4(38):A1-A18.
  3. Cleland JA, ASbbott JH, Kidd MO, et al. Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther 2009;39(8):573-585.
  4. Rompe JD, Cacchio A, Weil L Jr, et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am 2010;92(15):2514-2522.
  5. Thomas JL, Christensen, JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline—revision 2010. J Foot Ankle Surg 2010;49(3 Suppl):S1-S19.
  6. Renan-Ordine R, Alburque-Sendin F, de Souza DP, et al. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther 2011;41(2):43-50.
  7. Butterworth PA, Landorf KB, Smith SE, Menz HB. The association between body mass index and musculoskeletal foot disorders: a systematic review. Obes Rev 2012;13(7):630-642.
  8. Tanamas SK, Wluka AE, Berry P, et al. Relationship between obesity and foot pain and its association with fat mass, fat distribution, and muscle mass. Arthritis Care Res 2012;64(2):262-268.
  9. Lentz TA, Sutton Z, Greenberg S, et al. Pain-related fear contributes to self-reported disability in patients with foot and ankle pathology. Arch Phys Med Rehabil 2010;91(4):557-561.
  10. Kulig K, Popovich JM Jr, Noceti-Dewit LM, et al. Women with posterior tibial tendon dysfunction have diminished ankle and hip muscle performance. J Orthop Sports Phys Ther 2011;41(9):687-694.
  11. Snyder KR, Earl JE, O’Connor KM, et al. Resistance training is accompanied by increases in hip strength and changes in lower extremity biomechanics during running. Clin Biomech 2009;24(1):26-34.
  12. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled study. Phys Ther 2014;94(8):1083-1094.
  13. Kumar V, Millar T, Murphy PN, Clough T. The treatment of intractable plantar fasciitis with platelet-rich plasma injection. Foot 2013;23(2-3):74-77.
  14. Akşahin E, Doğruyol D, Yüksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg 2012;132(6):781-785.
  15. Ragab EM, Othman AM. Platelet rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg 2012;132(8):1065-1070.
  16. Molund M, Paulsrud Ø, Ellingsen HE. Patient treatment with gastrocnemius recession for plantar fasciitis demonstrates good clinical results with a complication rate higher than reported by others. Foot Ankle Surg 2014;20(4):272-275.
  17. Landorf KB, Menz HB. Plantar heel pain and fasciitis. BMJ Clin Evid 2008;2008:1111.
  18. Uden H, Boesch E, Kumar S. Plantar fasciitis—to jab or to support? A systematic review of the current best evidence. J Multidiscip Healthc 2011;4:155-164.
  19. Hume P, Hopkins W, Rome K, et al. Effectiveness of foot orthoses for treatment and prevention of lower limb injuries: a review. Sports Med 2008;38(9):759-779.
  20. Lee WC, Wong WY, Kung E, et al. Effectiveness of adjustable dorsiflexion night splint in combination with accommodative foot orthosis on plantar fasciitis. J Rehabil Res Dev 2012;49(10):1557-1564.
  21. Marabha T, Al-Anani M, Dahmashe Z, et al. The relation between conservative treatment and heel pain duration in plantar fasciitis. Kuwait Med J 2008;40:130-132.

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