managing heel pain – an evidence based approach · soft-tissues/os trigonum in active people...
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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