Week 3: Management of the foot and ankle (Masterclass) Flashcards
Plantar Heel pain
- Common in …… and ……
* …. ….. pain is very common ie when they get out of bed (it will warm-up after a minutes)
* Diagnosis largely derived from …… ……. – can do windlass test (passively dorsiflex the big toe)
* Specificity = 100%, sensitivity = ……% –> likely to miss a lot of people who have the condition
Athletes & middle-aged
First step pain
Patient history
30%
Where does the plantar fascia run from?
Tuberosity of the calcaneus (heel bone) forward to the heads of the metatarsal bones
In plantar fascia more often than not the main culprit is……
Ttraining load error/increase in load
Other risk factors other than load for PF include….
Running
Standing for long periods
BMI
Advice and education for PFP?
- Relative rest/modify activity* Pain monitoring (Silbernagel, 2007)
- Pain levels up to 5/10
- Flexibility ~specific to individual = use clinical reasoning not recipe!
- No residual pain within 24h
- No exacerbation after
- How much and for how long is guided by irritability
**Same traffic light system as tendinopathy even though the pathology is slightly different)
PHP study:
* Group 1: Shoe insert + stretch (calf & big toe stretch)
* Group 2: Shoe insert + 12 weeks heavy slow strength training (calf raises included)
Key findings/What did the strengthening program consist of?
- Heavy slow loading + shoe insert (heel cups) are significantly better than stretching + shoe inserts at 3 months
- Use heavy slow loading to manage plantar heel pain
Strengthening program
- Towel insert under the toes to activate windlass mechanism
- Every heel rise had a 3s concentric phase and 3s eccentric phase with a 2second isometric hold at the top
- Started at 12RM for 3 sets (increased load and dropped to 10RM for 4 sets, then 8RM for 5 sets
Advice for PHP
- You should not begin to run before your heel has been pain free for ….. weeks and you can walk …. kilometres without pain during the walk, or the morning after.
Four weeks pain free and can walk 10km
What is the foot function index for PFP? Minimal clinically important difference
- Score /230 (23 questions scored from 1 – no pain, to 10 – worse pain imaginable)
- Then calculated as a percentage
- Higher score = higher disability
- Note the minimal clinically important difference (MCID) is 7 points
What are the three main subscales of the foot function index?
- Pain scale
- Disability scale
- Activity limitation
Efficacy of foot orthoses for the treatment of plantar heel pain: a systematic review and meta-analysis
What were the findings? Do orthotics work for some patients?
- Found no difference between prefabricated orthoses and sham orthoses for pain at short term
- Foot orthoses are not superior for improving pain and function compared with sham or other conservative treatment in patients with PHP
But do orthotics work for some patients?
* Treatment direction test:
- Perform a painful activity (e.g. jogging/walking)
- Take NRS (numerical
- Apply anti-pronation tape
IF THE PATIENT RESPONDS WELL TO ANTI-PRONATION TAPE = Arch supporting insole could be beneficial
Manual therapy for plantar fascia?
You CANNOT
* “Release” muscles and fascia
* Or reduce stiffness of the plantar fascia
* Steer clear of calcaneal tuberosity
It is therefore….
* Not an important player
* Little use/efficacy
* Can use clinical reasoning to address impairments – but must be alongside a progressive rehabilitation program
Effectiveness of trigger point dry needling for plantar heel pain: a randomised controlled trial
- Dry needling vs sham needling
- At 6 weeks
- First step pain: Dry needling > sham: -14.4 (-23.5 to -5.2)
- Pain: Dry needling > sham: -10.0 (-19 to -1)
- Adverse events: 32% vs <1%;
- NNH: 3 !!!! (Number need to harm – 3 = if you dry needle 3 patients, you will harm 1 patient)
Dry needling provided statistically significant reductions in plantar heel pain, but the magnitude of this effect should be considered against the frequency of minor transitory adverse events.
What strike might overload the PF?
How does this affect plantar connective tissue stress and plantar tensile force?
Forefoot strike may overload the plantar fascia and impose risk of plantar fasciitis.
Forefoot strike….
- Increased plantar connective tissues stress by 18.28-200.11%
- Increased the plantar fascia tensile force by 18.71-109.10%
How would you differentiate MTSS vs tibial stress fracture?
Stress fracture would be more localised (pain not as spread as MTSS)
MTSS is an insidious onset common in…
Athletes & military personnel
*Runners 13.6-20% & Military personnel (7.2% to 35%)
