February 2015

Heel pain gains: Studies support multimodal treatment

In the moment: Rehabilitation

2ITMrehab-iStock_47636266Large-copyBy Jordana Bieze Foster

Multimodal physical therapy is associated with significant symptom relief in patients with plantar heel pain, but may be most effective for those with symptoms lasting less than seven months, according to research presented in February at the annual Combined Sections Meeting of the American Physical Therapy Association.

Investigators from Bellarmine University in Louisville, KY, assessed self-reported pain and function in 19 patients with chronic heel pain who completed one of two four-week therapy protocols. Ten patients did stretching only, while nine patients did the same stretching protocol plus strengthening exercises and roller massage.

After four weeks, only patients in the multimodal group demonstrated significant improvement from baseline, specifically for the Foot and Ankle Ability Measure (FAAM) sports and activities of daily living subscales, a visual analog scale weekly pain rating, and an average score for daily first-steps pain.

The differences between groups might have been even greater with a few more weeks of therapy, said Corey Malone, PT, DPT, a former Bellarmine doctoral student who is now a physical therapist at the Rubin Institute for Advanced Orthopedics in Baltimore, MD, and who presented the findings at the Combined Sections Meeting.

“Typically it takes six to eight weeks to see physiological changes with exercise,” Malone said. “So with a longer protocol, the strengthening component would have had more of a chance to shine.”

Malone also noted that the duration of symptoms in the overall study population ranged from two months to three years, and that this variability could have affected the results.

“Patients with a longer duration of symptoms might not have had as much improvement,” he said.

This assessment was consistent with the findings of a second study presented at the Combined Sections Meeting, in which patients with a shorter duration of heel pain symptoms were most likely to respond to multimodal physical therapy.

In that study, researchers from Des Moines University in Iowa analyzed data from an earlier clinical trial to identify significant predictors of a positive response to physical therapy for heel pain. The earlier trial, which was published in the August 2009 issue of the Journal of Orthopaedic and Sports Physical Therapy, randomized 60 patients to one of two four-week therapy protocols: electrophysical agents plus exercise, or manual therapy plus exercise. In the secondary analysis, the two groups were combined.

Treatment success was defined by achieving a minimal clinically important change in the FAAM and numeric pain rating scale, with a second, more stringent definition that included the global rating of change scale.

Patients with symptoms for less than 7.2 months were 4.2 times (based on the more stringent definition) or 8.5 times (based on the less stringent definition) more likely to respond than those with a longer history of symptoms.

The study, which was epublished in November 2014 by Foot & Ankle International, also found that age and body mass index did not predict treatment response. The latter result is particularly encouraging, said Shane McClinton, DPT, an assistant professor of physical therapy at Des Moines University who presented the findings at the Combined Sections Meeting.

“On average we do see individuals with this condition who are overweight, but these findings suggest that these patients do respond to treatment,” McClinton said.

McClinton also noted that the age of the oldest patient in the study was 63 years, so the finding that age did not predict treatment response may not apply to populations with larger numbers of older patients.


Malone CT, Chorley S, Brosky JA, Topp R. Comparison of a stretching protocol with the first step to foot relief protocol on selected clinical outcome measures in patients with heel pain. J Orthop Sports Phys Ther 2015;45(1):A24-A25.

McClinton S, Cleland J, Flynn T. Investigation of age, body mass index, and symptom duration as predictors of response to physical therapy intervention for plantar heel pain: A retrospective cohort analysis. J Orthop Sports Phys Ther 2015;45(1):A23.

Cleland JA, Abbott 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.

McClinton SM, Cleland JA, Flynn TW. Predictors of response to physical therapy intervention for plantar heel pain. Foot Ankle Int 2014 Nov 3. [Epub ahead of print]

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