Search results
A total of 11,765 studies were identified through electronic databases and clinical trial registries (Figure 1). After removal of duplicates, 6839 titles were screened. 6477 studies were subsequently excluded leaving 362 studies to be assessed for full text retrieval and PEDro analysis. Following the quality analysis, 51 studies met the eligibility criteria and were available for analysis (Figure 1). In total, the review included 4351 participants.
INSERT Figure 1. Flow diagram for study selection process
The characteristics of the included studies, including the treatment arms, outcome measures, and participant characteristics are detailed in Supplementary file 1. Most studies had a small sample size (mean=81, range 30 to 252). The mean duration of symptoms was 13 months (range 0.8 to 68.3 months) and 49% were female participants. Pain was evaluated in all studies either by a visual analogue scale or numerical pain rating scale. Other outcome measures included the Foot Function Index (9 studies), Roles and Maudsley score (7 studies), plantar fascia thickness (6 studies), Foot Health Status Questionnaire (10 studies), The Manchester-Oxford Foot Questionnaire (2 studies), Lower Extremity Functional Scale (3 studies), Foot Ankle Ability Measure (2 studies), Maryland Foot Score (1 study), Global Rating of Change (1 study), EQ-5D (1 Study), SF-36 (1 study) and the Foot and Ankle Outcome Score (1 study). Finally, the mean length of follow up was 20 weeks (range 2 - 104 weeks). Ninety six percent of studies evaluated outcomes in the short term, but only 27% in the medium and 13% in the long term.
Of the included studies, the type of interventions evaluated included ESWT (n=14), foot orthoses (n=8), night splints (n=1), footwear (n=1), flip-flop sandals (n=1), magnetised insoles (n=1), local injections [corticosteroid (n=11), botulinum toxin A injections (n=1), polydeoxyribonucleotide (n=2), hyaluronate injection (n=1), ozone (n=2), micronized dHACM (n=1), platelet rich plasma (n=1)] manual therapy and exercise (n=2), low level laser (n=2), radiation therapy (n=1), pulsed radiofrequency (n=2), stretching (n=1), trigger point dry needling (n=1), taping and iontophoresis (n=1), taping (n=1), electrolysis (n=1) and wheatgrass cream (n=1).
Quality assessment
The quality analysis results for studies that met the eligibility criteria are included in Supplementary file 1. The PEDro scores ranged from 8/10 to 10/10. Four studies scored 10/10. ‘Blinding of all therapists who administered the therapy’ was the criterion least met by the included studies (n=7). In contrast, item 11 (‘the study provides both point measures and measures of variability for at least one outcome’) was the item most successfully completed (n=51).
Evidence of efficacy
Table 1 provides a summary of the efficacy and strength of the evidence for interventions that were included for primary or secondary proof of efficacy. Supplementary file 1 includes the short, medium- and long-term results for each trial included in the analysis; a summary of those studies with evidence against efficacy and forest plots for the effectiveness of foot orthoses and ESWT.
Table 1: Efficacy and strength of evidence for interventions considered for primary and secondary proof of efficacya
Intervention
|
Outcome measure
|
Short termb
|
Medium termb
|
Long Termb
|
|
Interventions with Primary proof of efficacy
|
|
Custom orthoses
|
Pain
|
Between group efficacy
|
Strong Positive26-29
-0.41 (-0.74, -0.07)
|
Limited Positive28
-0.55 (-1.02, -0.09)
|
Moderate Neutral26
-0.04 (-0.45, 0.37)
|
|
Within group outcome
|
-1.24 (-1.49, -1.00)26-30,c
|
-1.65 (-2.18, -1.12)28,c
|
|
|
|
First step pain
|
Between group efficacy
|
Limited Neutral27 29
-0.32 (-0.91, 0.26)
|
|
|
|
Within group outcome
|
|
|
|
|
|
Function
|
Between group efficacy
|
Moderate Neutral26 28 29
-0.21 (-0.48, 0.06)
|
Limited Neutral28
-0.39 (-0.85, 0.07)
|
Moderate Neutral26
--0.12 (-0.53, 0.29)
|
|
Within group outcome
|
|
|
|
|
Prefabricated orthoses
|
Pain
|
Between group efficacy
|
Moderate Neutral26 29
-0.25 (-0.59, 0.09)
|
|
Moderate Neutral26
-0.08 (-0.50, 0.33)
|
|
Within group outcome
|
|
|
|
|
|
First step pain
|
Between group efficacy
|
|
|
|
|
Within group outcome
|
|
|
Function
|
Between group efficacy
|
Moderate Neutral26 29
-0.06 (-0.40, 0.28)
|
|
Moderate Neutral26
-0.08 (-0.50, 0.33)
|
|
Within group outcome
|
|
|
|
|
Magnetised insoles
|
Pain
|
Between group efficacy
|
Moderate Neutral31
0.00 (-0.39, 0.39)
|
|
|
|
Within group outcome
|
|
|
|
|
Radial ESWT
|
Pain
|
Between group efficacy
|
Strong Positive32 33
-1.64 (-4.33, 1.06)
|
Positive limited33
-3.77 (-4.72, -2.82)
|
Strong positive32 33
-0.78 (-1.72, 0.15)
|
|
Within group outcome
|
-3.78 (-6.17, -1.38)32-35
|
-5.81 (-8.05, -3.57)33 34
|
-6.41 (-7.83, -4.99)32 33
|
|
|
First step pain
|
Between group efficacy
|
Moderate Neutral32,c
OR: 1.66 (0.9975, 2.76)
|
|
Moderate Positive32
OR: 1.78 (1.07, 2.96)
|
|
Within group outcome
|
-1.19 (-1.63, -0.76)36
|
-1.74 (-2.21, -1.26)36
|
-2.93 (-3.51, -2.34)36,b
|
|
|
Function
|
Between group efficacy
|
Moderate Positive32
-0.35 (-0.60, -0.10)
|
Positive Limited33
-2.39 (-3.12, -1.65)
|
Positive Limited33
-0.90 (-1.49, -0.32)
|
|
Within group outcome
|
-3.47 (-4.37, -2.57)33,b
|
-4.57 (-5.65, -3.48)33,b
|
-2.81 (-3.61, -2.02)33,b
|
|
Focused ESWT
|
Pain
|
Between group efficacy
|
Strong Positive37 38
-0.31 (-0.53, -0.09)
|
Moderate Neutral30
0.18 (-0.24, 0.60)
|
|
|
Within group outcome
|
-1.33 (-1.72, -0.94)29,30,35 39 40,c
|
-1.40 (-1.86, -0.94)38
|
|
|
|
First step pain
|
Between group efficacy
|
Strong Positive37-39
OR: 1.72 (1.14, 2.61)
|
Limited Positive41
-1.31 (-2.01, -0.61)
|
Limited Positive41
-1.67 (-2.45, -0.88)
|
|
Within group outcome
|
-2.11 (-3.48, -0.75)40 42 43
|
-2.84 (-3.73, -1.94)41
|
-3.33 (-3.87, -2.78)41
|
|
|
Function
|
Between group efficacy
|
Moderate Positive29
-0.36 (-0.61, -0.10)
|
|
|
|
Within group outcome
|
-1.26 (-1.53, -0.99)29
|
|
|
|
Combined Radial and Focused ESWT
|
Pain
|
Between group efficacy
|
Strong positive 32 33 37 38
-0.82 (-1.48, -0.16)
|
Strong neutral33 38
-1.77 (-5.64, 2.09)
|
|
|
Within group outcome
|
-2.72 (-4.05, -1.39)33-35 38
|
-4.33 (-7.55, -1.12)33 34 38
|
|
|
|
First step pain
|
Between group efficacy
|
Strong positive32 37-39
OR 1.70 (1.23, 2.34)
|
|
OR 1.95 (1.22, 3.12)32 41
|
|
Within group outcome
|
-1.79 (-2.66, -0.92)36 42 43
|
|
-3.14 (-3.54, -2.74)36 41 43
|
|
|
Function
|
Between group efficacy
|
Strong positive 33 37
-1.03 (-2.42, 0.36)
|
|
|
|
Within group outcome
|
-2.32 (-4.49, -0.16)33 37
|
|
|
|
Dry needling
|
Pain
|
Between group efficacy
|
Moderate Neutral44
-0.33 (-0.76, 0.10)
|
|
|
|
Within group outcome
|
|
|
|
|
|
First step pain
|
Between group efficacy
|
Moderate Neutral44
-0.42 (-0.85, 0.02)
|
|
|
|
|
|
|
Within group outcome
|
|
|
|
Function
|
Between group efficacy
|
Moderate Neutral44
0.11 (-0.31, 0.54)
|
|
|
|
Within group outcome
|
|
|
|
|
Wheatgrass
|
Pain
|
Between group efficacy
|
Moderate Neutral45,c
|
|
|
|
Within group outcome
|
|
|
|
|
|
Function
|
Between group efficacy
|
Moderate Neutral45,c
|
|
|
|
Within group outcome
|
|
|
|
|
Calf stretching
|
First step pain
|
Between group efficacy
|
Moderate Neutral46
-0.39 (-0.80, 0.03)
|
|
|
|
Within group outcome
|
|
|
|
|
|
Pain
|
Between group efficacy
|
Moderate Neutral46
0.00 (-0.40, 0.41)
|
|
|
|
Within group outcome
|
|
|
|
|
|
Function
|
Between group efficacy
|
Moderate Neutral46
-0.24 (-0.65, 0.17)
|
|
|
|
Within group outcome
|
|
|
|
|
Low dye taping
|
First step pain
|
Between group efficacy
|
Moderate Positive47
-0.47 (-0.88, -0.05)
|
|
|
|
Within group outcome
|
-1.21 (-1.66, -0.77)47
|
|
|
|
|
Pain
|
Between group efficacy
|
Moderate Neutral47
0.30 (-0.11, 0.71)
|
|
|
|
Within group outcome
|
|
|
|
|
|
Function
|
Between group efficacy
|
Moderate Neutral47
-0.05 (-0.46, 0.36)
|
|
|
|
Within group outcome
|
|
|
|
|
Interventions with Secondary proof of efficacy
|
|
Plantar fascia stretching
|
First step pain
|
Between group efficacy
|
Moderate Positive36
1.21 (0.78, 1.63)
|
Moderate Positive36
0.64 (0.24, 1.04)
|
Moderate Neutral36
-0.04 (-0.43, 0.35)
|
|
Within group outcome
|
-2.81 (-3.35, -2.27)36
|
-3.25 (-3.83, -2.67)36
|
|
|
aIncluded below are definitions for efficacy and strength of the evidence. An analysis that revealed a significant effect in favour of the intervention was considered a positive effect. The strength of the evidence was rated as strong, moderate or limited based on the number of high quality trials and whether the trial was adequately powered:
Strong evidence/Positive effect: meta-analysis revealed multiple high-quality trials demonstrated efficacy/ a positive effect in favour of the intervention
Moderate evidence/Positive effect: analysis revealed one high quality trials demonstrated efficacy/ a positive effect in favour of the intervention
Limited evidence/Positive effect: analysis revealed one high quality trial, which did not meet the required sample size, demonstrated efficacy/ a positive effect in favour of the intervention
Strong evidence/Neutral effect: meta-analysis revealed multiple high-quality trials demonstrated no efficacy/evidence of no effect
Moderate evidence/Neutral effect: analysis revealed one high quality trial demonstrated no efficacy/evidence of no effect
Limited evidence/Neutral effect: analysis revealed one high quality trial, which did not meet the required sample size, demonstrated no efficacy/evidence of no effect
bAll effect sizes are reported as a Standardised Mean Difference (95%CI) unless otherwise stated.
cIncomplete data or within group calculations being based on different statistic to between-group, explains apparent discrepancy in results and references used.
Of the 51 trials included in the review, nine interventions could be considered for primary proof of efficacy. The nine interventions included an evaluation of radial ESWT,32 33 focused ESWT,37-39 41 custom foot orthoses,26-29 prefabricated foot orthoses,26 dry needling,44 magnetised insoles,31 calf stretching,46 foot taping,47 and wheatgrass cream.45 One trial that compared radial ESWT with plantar fascia stretching was considered for secondary proof of efficacy.36
Strong evidence was found for the efficacy of focused ESWT for overall pain (SMD: -0.31, 95% CI -0.53 to -0.09),37 38 first step pain (OR: 1.72 95% CI 1.14 to 2.61)37-39 in the short term and moderate evidence of effect for function in the short term (SMD: -0.36 95% CI -0.61 to -0.10).37 No, or minimal side effects were reported in each study however the procedure was noted to be unpleasant for patients in both study reports and semi-structured interviews.
Significant and positive effects for pain in the short term were revealed for radial ESWT although pooling showed a large effect size but wide confidence intervals that crossed the line of no effect (SMD: -1.64 95% CI -4.33 to 1.06).32 33 Moderate evidence of efficacy was also revealed for first step pain in the long term (OR: 1.78 95% CI 1.07 to 2.96).32 Adverse events were reported as being minimal in each included study. Of note is that one high quality study found use of radial ESWT without local anaesthetic to be superior to ESWT with prior application of injected local anaesthetic.43 The systematic review findings were consistent with the opinions of experts who described the positive effect of ESWT:
“There’s enough evidence to suggest that patients with heel pain that have shockwave therapy tend to have less pain on review than the patients that don’t have shockwave therapy”. (Expert 14)
Strong evidence was found for the efficacy of custom foot orthoses versus sham for pain in the short term (SMD: -0.41 95% CI -0.74 to -0.07), although the results were conflicting.26-29 In addition, small effect sizes were reported for trials by Landorf,26 Oliveira28 and Wrobel,29 while a large effect was reported by Bishop.27 Qualitative data confirmed that foot orthoses, without specific reference to custom or prefabricated orthoses, can be used to unload tissues beneath the heel for short term relief particularly in situations where resting the foot is not feasible.
One study that met all the quality and power criteria evaluated the effectiveness of low dye taping and sham ultrasound versus sham ultrasound alone.47 There was moderate evidence of primary efficacy at 1 week for 'first-step' pain in favour of low dye taping (SMD: -0.47 95% CI -0.88 to -0.05). Some patients expressed the positive role for taping to alleviate symptoms:
“I think the strategies that I was given in the short term were helpful (e.g. taping and stretching” (Patient 12)
In addition, experts revealed that taping is a first line treatment that is an effective method to reduce pain in the short term and enhance patient confidence. Some experts used taping to predict the effectiveness of foot orthoses:
“If I tape them and their symptoms decrease and then I can say – okay, I think I can replicate what the tape is doing with either shoes or orthoses” (Expert 13)
There was moderate evidence of large effect that plantar fascia stretching is superior to radial ESWT for first step pain in the short term (SMD: 1.21 95% CI 0.78 to 1.63)36 and of medium effect in the medium term (SMD: 0.64 95% CI 0.24 to 1.04) but not in the long term (SMD: -0.04 95% CI -0.43 to 0.35). The sample was mainly early presenting PwPHP with acute PHP and this finding complements expert reasoning well, with there being clear guidance to continue stretching throughout rehabilitation, in a variety of ways targeting the plantar fascia and related structures:
“They can feel an immediate response, and there seems to be some adaptation to this stretching, but again I would say this is definitely not the cure for this” (Expert 4)
Expert interviews
Interview transcript analysis revealed six themes and 30 subthemes. The first two themes concerned diagnosis and patient education (Table 2) and particularly influenced the core approach (Figure 2), along with the findings on stretching in the ‘rehabilitation’ theme alongside ‘factors underlying management’ and ‘specific interventions’ (Supplementary file 1– Expert Reasoning results) which had particular influence on the stepped approach to care (Figure 3). ‘Perceptions of evidence’ (Supplementary file 1) was the final theme and informed the recommendations made concerning application of specific interventions for patients recovering too slowly or not responding at all (Figure 3).
Table 2: Qualitative analysis of expert interview data pertaining to diagnosis and patient education
Findings Illustrative quotes
|
Theme 1: DIAGNOSIS
|
History
|
|
|
Overview of key elements to explore
|
high repetitive use vs change of use; mechanical history essential to establish; rest-activity balance important; typically insidious onset but important to check injury; importance of ruling out other causes; (inflammatory, tendinopathy and neuropathic masqueraders); reduction with movement.
|
Q: if you have had an increase in weight, and that’s why you’ve got your heel pain, then that’s probably a point of discussion (11)
Q: was there an acute incident, to rule out fat pad contusion (10)
Q: those for whom it is part of a systemic arthritis are generally younger because seronegative arthropathy is often in a younger age group (9)
|
relative importance
|
key factor in establishing diagnosis; sets priorities for physical and imaging
|
Q: the primary diagnosis, when you first see someone, is generally clinical (14)
Q: History essentially nails the diagnosis (8)
Q: only time I would really go for ultrasound would be if I am suspecting a tear or a rupture (8)
|
presentation of pain
|
am pain pathognomic; first step pain most informative; pain after inactivity; well-localised to medial-inferior heel; worse at start and at end / after aggravating activity; description as sharp at worst vs ache at other times; mechanical vs psychosocial;
|
Q: very localised pain at the medial tubercle of the calcaneum (3)
Q: first steps in the morning … after sitting for a long time … very good indication (4)
Q: …out of bed in the morning it’s like walking on shattered glass or walking on needles and pins (2)
|
sub-groups
|
lean vs high BMI; highly active vs relatively inactive; profession may indicate risk; overweight and standing job a particular risk
|
Q: one group is those with high BMI, and they stand up at work 7-8 hours a day, and other group is the lean runner maybe doing too much too soon (2)
Q: you also have these people standing a lot standing 8 hours a day at their working place (6)
Q: take a good history … profession and their sport and fitness regime per week (8)
|
examination
|
|
|
Physical testing
|
palpation at inferior medial heel (PF origin) or close to; check for ruptures; look for compensation movements; calf flexibility a key element
|
Q: I could leave out the US scan, but I would always do a through history on the patient, and palpate the area (4)
Q: also check their calf inflexibility (8)
Q: activate windlass mechanism to see if plantar fascia tightens (2)
|
Structures of interest
|
consider all aspects of fascia; consider old injuries (medial, lateral, distal); tendinopathy, neuropathy and bone key differentials
|
Q: squeeze the calcaneus … if that causes some discomfort then I assume that there’s probably some bony oedema (11) Q: dorsiflex the hallux, dorsiflex the ankle … start distally and palpate down the plantar fascia and work towards its origin (10)
Q: do some physical testing, I rule out other tendinopathy in the area (5)
|
imaging
|
|
|
decisions to use imaging
|
use is confirmatory not diagnostic; availability and speciality may dictate use; subordinate to history and examination
|
Q: US helps look at specific portion of fascia; check for tears and fibromas (8)
Q: if I do an US, diagnostic US in someone, I cannot tell them that they have PF, that’s how crazy it is (5)
Q: I think a lot of people go wrong, they look at imaging and try diagnosing, but really it comes down to the subjective features and the clinical features (4)
Q: ()
|
Perceptions of utility
|
sensitivity and specificity questionable; MRI unclear vs useful for bone oedema; US useful to exclude tears and lumps; US dimensions more useful than Doppler; changes likely bilateral even if unilateral pain
|
Q: the more imaging work I do the more I realise that there are other things that are going on (7)
Q: the other advantage is that MRI you can start to see there is inflammation, say, in the facets of the subtalar joint. You can start to see if there is some bone oedema (12)
Q: for the more resistant or long-term cases, then an MRI would be my investigation of choice (14)
|
Theme 2: Patient Education
|
Importance of Patient Education
|
education key to prevent recurrence; importance as for all MSK conditions; aetiology must be understood; key to patient engagement, self-management and treatment success; treatment rationale important for patient to learn; requires mixed communication methods; under-researched area; focus on key pain driver; relate to specific patient presentation; include physical and non-physical factors; reassure about positive long-term prognosis
|
Q: if we leave these maladaptive beliefs unchecked, then it will lead to chronicity (3)
Q: if they understand what the problem is and the course of it then it’s easier to have compliance (6)
Q: if you don’t address those issues then it could be that if you remove your orthotics, stop taping or stopped your stretching or whatever, the pain is just going to come back so that’s where the education side of things is really important. (7)
Q: overarching thing is that you’ve got to individualise it for the person (11)
|
Teaching about load Management
|
A primary goal of treatment; consider both static and dynamic weight-bearing load; change of overall load a risk factor for exacerbation; focus on function by unbundling erroneous patient perception of pain and pathology link; useful for patient to understand and self-manage a stepped approach to load increase with guidance; weight loss and associated metabolic factors poorly understood but impact on load management approach; need to address weight sensitively; therapists may not have weight management skills; key therapeutic effect mediator
|
Q: load tolerance is probably a good way to describe the key treatment (3)
Q: obviously there’s more load if you’ve got more weight, so if we can reduce that it’s going to help reduce the load on the plantar fascia (1)
Q: get down to business and talk to him about his training programme and talk about how many miles they do a week (2)
|
Advice on footwear
|
Comfort is key modification guide; consider softness, shock absorption, rearfoot to forefoot drop and support; new shoes need to be socially acceptable; can use to offload tissue
|
Q: getting patients into good footwear that has a small heel on it, because it takes the tension off the calf muscle and therefore the fascia, and having good cushioning or shock absorbency, are some key factors (14)
Q: I don’t think minimalist (footwear) is made for everybody (13)
|
INSERT Figure 2: Core approach to the management of plantar heel pain based on the best available evidence, expert opinion and the patient voice. The top layer (‘DO’) of taping, stretching and education are required initial interventions with each patient. The individual assessment (‘DECIDE’) is of which specific educational aspects are needed. LTCs = long-term conditions. RF = rearfoot, FF = forefoot, BMI = body mass index”.
INSERT Figure 3: Management approach for plantar heel pain when a person progressively fails to recover with addition of ESWT at 4 weeks if the core approach is not working and then addition of orthoses at 12 weeks if there is still sub-optimal improvement.
Patient survey
Forty people responded to the online survey with the Framework analysis resulting in one overarching theme of ‘patient experience’ with 8 sub-themes (Table 3). The quantitative check showed 95% of 266 specific treatment components or approach descriptions mentioned in the responses were consistent with the core approach initially derived from the review and expert interviews therefore indicating good agreement between the evidence, experts and patient experience.
Table 3: Framework analysis of 40 patient survey responses yielding 8 sub-themes.
Theme 1: Patient values
|
Sub-Theme Findings Illustrative quotes
|
Thoughts on condition cause
|
Foot arch height; age; activity pattern; new load increase; long periods weight bearing; standing on hard surfaces; minimally supportive footwear; limb length asymmetry; rapidly changing load; altered gait; altered movement due to other conditions
|
Q: Walking on the outside edge of my foot when I was having pain in my second toe (PN)
Q: Heel spurs, arthritis
Q: Long shifts on my feet in facilities with hard floors.
Q: Excess loads with inadequate progression
Q: a number of contributory factors which is why is occurred now
|
Thoughts on pathology
|
Tissue irritation; degeneration; inflammation; tearing; inadequate tissue capacity; contracture
|
Q: Tissue band has become irritated through age/overuse
Q: It feels like it is tearing. I think I have torn a ligament
Q: Inflamed damaged pf which needs to heal/repair.
Q: Struggling to cope with the demand and non adapted tissue
Q: tendon contracture is wanting to happen all the time.
|
Expectations
|
More information; quick recovery-unrealised; exercise programme esp. foot strengthening; pain elimination; access to orthoses; specific treatments; better explanation of treatment/condition and causes
|
Q: Expected to get a steroid shot and was hoping for deep tissue manipulation to break down the scaring or thickening tissue. Wasn’t offered
Q: I assumed wrongly I would need insoles. I expected to be back on my feet within a few weeks (very optimistic).
Q: as swift a recovery as possible, relief from the pain and programme of exercises to treat
|
Needed improvements
|
Facilitation of earlier recognition by patients; better communication as adherence promotion;
Intervention strategy for pain; Easier access to, and more information on, specific treatments; Standardised treatment across sectors; Clarity of treatment and expectations; reduced waiting times
|
Q: better understanding of symptoms and types of patients prone to PHP
Q: More explanation for the mechanism of the symptoms in order to motivate me to do the exercise
Q: Get rid of the pain forever
Q: Standardised treatment from NHS across the country. I've gone private as Dr can't refer.
|
Strengths of management
|
From no strengths to positive experiences; fast decisions; specific interventions; clear plan; individual preferences accounted for; detailed explanation; specific interventions
|
Q: Range of options considered and clearly explained
Q: Spent time explaining in detail the condition/cause/treatment
|
Experience
|
Restricted activity; intermittent severe pain; reduced exercise; altered activity; morning pain; painful; emotionally affected; large impact on ADL; long, uncertain recovery
|
Q: It restricted the activities I wished to carry out
Q: It’s very painful under my heel when I get up in the morning
Q: Miserable 6 months. Had a huge impact on daily activities.
Q: Very long process and uncertain outcome
|
Key information
|
Time course of recovery; self-management advice; how pain relief works; long term effects; explanation of what was not done; unsure; statistics on usual timescales for effects
|
Q: What can I do to reduce my pain and improve function
Q: Will pain reliever actually address the issue or just mask the pain?
Q: When they could make the pain go away
Q: Expected outcome at the end of rehab
|
Sources of information
|
Range of online methods predominated; clinicians, friends, magazines; lack of clear guidance
|
Q: I can google it all day, and there isn’t much out there
Q: Patient groups on Facebook aren’t even very helpful, because everyone using them hasn’t found relief.
Q: online forums, confusing as everyone’s cause is different therefore treatment different
|
|
|
|
|
Best practice guide
The BPG was produced from synthesis of quantitative (review) and qualitative (expert interviews and patient survey) data. A core approach was determined (Figure 2) prior to stepped care for patients progressing slowly, or inadequately (Figure 3). The core approach consists of the evidence-based interventions of plantar fascia stretching and low-dye taping complemented by an individualised education approach, with all components recommended to be used for approximately 6 weeks before consideration of adjunctive interventions such as ESWT or orthoses, with the expert interviews strongly emphasising the need to implement an education and self-management approach prior to applying the interventions with the strongest evidence (Table 2).
“The nature of the condition is that you need to be doing a range of things, but all together for a sustained period of time” (Expert 14)
Of the three components of the core approach, taping and plantar fascia stretching should be universally applied and were annotated as ‘DO’ in Figure 2. Individualised decisions about education content are needed and were annotated as ‘DECIDE’ in Figure 2. Education content had four sub-areas. For load management, the keys were to reduce overall tissue compressive load by breaking up long periods of static load such as standing and reducing injurious compressive and stretch-related dynamic load from activities such as running in the more active population. For pain education, clarity about the meaning of pain and its relation to tissue state needs to be clearly understood, alongside realistic expectations of the prognosis being good but resolution likely to be slow. Techniques such as pain-monitoring were strongly recommended. The possible impact of other presenting long-term conditions and an adverse body mass need to be addressed. Finally, the requirement for footwear to be supportive, comfortable, incorporate a rearfoot to forefoot drop and be socially acceptable is required with specific advice to avoid barefoot walking and open sandals until symptoms have entirely resolved.
“the number one thing is educating (sic) PwPHP to have some understanding about the most likely reason they felt the pain, and then based on that, the key things that they need to do long term” (Expert 9)
Where the core approach is only partially successful or taking greater than six weeks to yield suitable effects, adjunct interventions are recommended based on the strength of the quantitative evidence and expert reasoning. The use of simple but validated patient reported outcome measures, such as a global rating of change scale (Kamper et al., 2009) or equivalent may help guide these decisions. Patient experience had little influence on this section, with adjunctive interventions such as ESWT and orthoses having less prominence in responses. The primary recommendation was that ESWT – applied using either radial or focussed approaches – should be applied if a PwPHP is not deriving optimal benefit from the core approach as it has the strongest overall evidence.
Where the core approach and ESWT are still not successful, the stepped care approach recommended custom orthoses and if still not successful – as marked by an X in Figure 3 – then experimental approaches may be tried, although expert reasoning suggests that a return to the core approach and repeat application ensuring that accuracy and adherence is also a feasible fourth line approach. Where interventions have been tried and shown to be ineffective, they should not be used except in formal trials, whereas inadequately tested interventions with no primary or secondary proof of efficacy – such as injection therapy – where the evidence is inadequate or not present may be considered – again preferably in an RCT or with structured evaluation.