Heel Pain Plantar Fasciitis: Revision 2014
Clinical Practice GuidelinesROBROY L. MARTIN, PT, PhD TODD E. DAVENPORT, DPT STEPHEN F. REISCHL, DPT THOMAS G. MCPOIL, PT, PhDJAMES W. MATHESON, DPT DANE K. WUKICH, MD CHRISTINE M. MCDONOUGH, PT, PhDJournal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on December 26, 2014. For personal use only. No other uses without permission.Copyright 2014 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.Heel Pain—Plantar Fasciitis:Revision 2014Clinical Practice Guidelines Linked to theInternational Classification of Functioning,Disability and Health From the Orthopaedic Sectionof the American Physical Therapy AssociationJ Orthop Sports Phys Ther. 2014;44(11):A1-A23. doi:10.2519/jospt.2014.0303SUMMARY OF RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3METHODS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4CLINICAL GUIDELINES:Impairment/Function-Based Diagnosis. . . . . . . . . . . . . . . . . . . A7CLINICAL GUIDELINES:Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A10CLINICAL GUIDELINES:Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A11AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS. . . . . . . A20REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A21REVIEWERS: Roy D. Altman, MD Paul Beattie, PT, PhD Mark Cornwall, PT, PhDIrene Davis, PT, PhD John DeWitt, DPT James Elliott, PT, PhD James J. Irrgang, PT, PhDSandra Kaplan, PT, PhD Stephen Paulseth, DPT, MS Leslie Torburn, DPT James Zachazewski, DPTFor author, coordinator, contributor, and reviewer affiliations, see end of text. Copyright 2014 Orthopaedic Section, American Physical Therapy Association (APTA), Inc,and the Journal of Orthopaedic & Sports Physical Therapy . The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent tothe reproduction and distribution of this guideline for educational purposes. Address correspondence to: Joseph Godges, DPT, ICF-based Clinical Practice GuidelinesCoordinator, Orthopaedic Section, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: icf@orthopt.org44-11 Guidelines.indd 110/20/2014 7:10:39 PM
Heel Pain—Plantar Fasciitis: Clinical Practice Guidelines Revision 2014Summary of Recommendations*RISK FACTORSClinicians should assess the presence of limited ankledorsiflexion range of motion, high body mass index innonathletic individuals, running, and work-related weight-bearingactivities—particularly under conditions with poor shock absorption—as risk factors for the development of heel pain/plantarfasciitis.BEXAMINATION – ACTIVITY LIMITATION AND PARTICIPATIONRESTRICTION MEASURESClinicians should utilize easily reproducible performancebased measures of activity limitation and participation restriction measures to assess changes in the patient’s level of functionassociated with heel pain/plantar fasciitis over the episode of care.FEXAMINATION – PHYSICAL IMPAIRMENT MEASURESJournal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on December 26, 2014. For personal use only. No other uses without permission.Copyright 2014 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.DIAGNOSIS/CLASSIFICATIONPhysical therapists should diagnose the International ClasBsification of Diseases (ICD) category of plantar fasciitisand the associated International Classification of Functioning,Disability and Health (ICF) impairment-based category of heel pain(b28015 Pain in lower limb, b2804 Radiating pain in a segmentor region) using the following history and physical examinationfindings: Plantar medial heel pain: most noticeable with initial steps aftera period of inactivity but also worse following prolonged weightbearing Heel pain precipitated by a recent increase in weight-bearingactivity Pain with palpation of the proximal insertion of the plantarfascia Positive windlass test Negative tarsal tunnel tests Limited active and passive talocrural joint dorsiflexion rangeof motion Abnormal Foot Posture Index score High body mass index in nonathletic individualsWhen evaluating a patient with heel pain/plantar fasciitisover an episode of care, assessment of impairment of bodyfunction should include measures of pain with initial steps after a period of inactivity and pain with palpation of the proximal insertion ofthe plantar fascia, and may include measures of active and passiveankle dorsiflexion range of motion and body mass index in nonathletic individuals.BINTERVENTIONS – MANUAL THERAPYClinicians should use manual therapy, consisting of joint andsoft tissue mobilization, procedures to treat relevant lowerextremity joint mobility and calf flexibility deficits and to decreasepain and improve function in individuals with heel pain/plantarfasciitis.AINTERVENTIONS – STRETCHINGClinicians should use plantar fascia–specific and gastrocnemius/soleus stretching to provide short-term (1 week to4 months) pain relief for individuals with heel pain/plantar fasciitis.Heel pads may be used to increase the benefits of stretching.ADIFFERENTIAL DIAGNOSISINTERVENTIONS – TAPINGClinicians should assess for diagnostic classifications otherthan heel pain/plantar fasciitis, including spondyloarthritis,fat-pad atrophy, and proximal plantar fibroma, when the individual’sreported activity limitations or impairments of body function andstructure are not consistent with those presented in the Diagnosis/Classification section of this guideline, or when the individual’ssymptoms are not resolving with interventions aimed at normalization of the individual’s impairments of body function.Clinicians should use antipronation taping for immediate(up to 3 weeks) pain reduction and improved function forindividuals with heel pain/plantar fasciitis. Additionally, cliniciansmay use elastic therapeutic tape applied to the gastrocnemius andplantar fascia for short-term (1 week) pain reduction.CAINTERVENTIONS – FOOT ORTHOSESClinicians should use foot orthoses, either prefabricated orcustom fabricated/fitted, to support the medial longitudinalarch and cushion the heel in individuals with heel pain/plantar fasciitis to reduce pain and improve function for short- (2 weeks) to longterm (1 year) periods, especially in those individuals who respondpositively to antipronation taping techniques.AEXAMINATION – OUTCOME MEASURESClinicians should use the Foot and Ankle Ability Measure(FAAM), Foot Health Status Questionnaire (FHSQ), or theFoot Function Index (FFI) and may use the computer-adaptive version of the Lower Extremity Functional Scale (LEFS) as validatedself-report questionnaires before and after interventions intendedto alleviate the physical impairments, activity limitations, andparticipation restrictions associated with heel pain/plantarfasciitis.Aa2 INTERVENTIONS – NIGHT SPLINTSClinicians should prescribe a 1- to 3-month program of nightsplints for individuals with heel pain/plantar fasciitis whoconsistently have pain with the first step in the morning.Anovember 2014 volume 44 number 11 journal of orthopaedic & sports physical therapy44-11 Guidelines.indd 210/20/2014 7:10:39 PM
Heel Pain—Plantar Fasciitis: Clinical Practice Guidelines Revision 2014Summary of Recommendations* (continued)INTERVENTIONS – PHYSICAL AGENTSElectrotherapy: clinicians should use manual therapy,stretching, and foot orthoses instead of electrotherapeuticmodalities, to promote intermediate and long-term (1-6 months)improvements in clinical outcomes for individuals with heel pain/plantar fasciitis. Clinicians may or may not use iontophoresis withdexamethasone or acetic acid to provide short-term (2-4 weeks)pain relief and improved function.tion in conjunction with a foot orthosis, and (2) shoe rotation duringthe work week for those who stand for long periods.Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on December 26, 2014. For personal use only. No other uses without permission.Copyright 2014 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.DLow-level laser: clinicians may use low-level laser therapy toreduce pain and activity limitations in individuals with heelpain/plantar fasciitis.CPhonophoresis: clinicians may use phonophoresis with ketoprofen gel to reduce pain in individuals with heel pain/plantarfasciitis.CCUltrasound: the use of ultrasound cannot be recommendedfor individuals with heel pain/plantar fasciitis.Clinicians may provide education and counseling on exercisestrategies to gain or maintain optimal lean body mass inindividuals with heel pain/plantar fasciitis. Clinicians may also referindividuals to an appropriate health care practitioner to addressnutrition issues.EINTERVENTIONS – THERAPEUTIC EXERCISEAND NEUROMUSCULAR RE-EDUCATIONClinicians may prescribe strengthening exercises andmovement training for muscles that control pronation andattenuate forces during weight-bearing activities.FINTERVENTIONS – DRY NEEDLINGFINTERVENTIONS – FOOTWEARCINTERVENTIONS – EDUCATION ANDCOUNSELING FOR WEIGHT LOSSTo reduce pain in individuals with heel pain/plantar fasciitis,clinicians may prescribe (1) a rocker-bottom shoe construc-The use of trigger point dry needling cannot be recommended for individuals with heel pain/plantar fasciitis.*These recommendations and clinical practice guidelines are basedon the scientific literature published prior to January 2013.List of AcronymsAPTA: American Physical Therapy AssociationCI: confidence intervalCPG: clinical practice guidelineESWT: extracorporeal shockwave therapyFAAM: Foot and Ankle Ability MeasureFFI: Foot Function IndexFHSQ: Foot Health Status QuestionnaireFPI-6: Foot Posture Index-6ICD: International Classification of DiseasesICF: International Classification of Functioning,Disability and HealthICSI: intralesional corticosteroid injectionLEFS: Lower Extremity Functional ScaleMCID: minimal clinically important differenceNSAID: nonsteroidal anti-inflammatory drugSF-36: Medical Outcomes Study 36-Item Short-FormHealth SurveyVAS: visual analog scaleIntroductionAIM OF THE GUIDELINESThe Orthopaedic Section of the American Physical TherapyAssociation (APTA) has an ongoing effort to create evidencebased clinical practice guidelines (CPGs) for orthopaedicphysical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disabilityand Health (ICF).97journal of orthopaedic & sports physical therapy volume 44 number 11 november 2014 44-11 Guidelines.indd 3a310/20/2014 7:10:40 PM
Heel Pain—Plantar Fasciitis: Clinical Practice Guidelines Revision 2014Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on December 26, 2014. For personal use only. No other uses without permission.Copyright 2014 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.Introduction (continued)The purposes of these clinical guidelines are to: Describe evidence-based physical therapy practice, including diagnosis, prognosis, intervention, and assessmentof outcome for musculoskeletal disorders commonlymanaged by orthopaedic physical therapists Classify and define common musculoskeletal conditionsusing the World Health Organization’s terminology related to impairments of body function and body structure,activity limitations, and participation restrictions Identify interventions supported by current best evidenceto address impairments of body function and structure,activity limitations, and participation restrictions associated with common musculoskeletal conditions Identify appropriate outcome measures to assess changes resulting from physical therapy interventions in bodyfunction and structure as well as in activity and participation of the individual Provide a description to policy makers, using internationally accepted terminology, of the practice of orthopaedicphysical therapists Provide information for payers and claims reviewersregarding the practice of orthopaedic physical therapyfor common musculoskeletal conditions Create a reference publication for orthopaedic physicaltherapy clinicians, academic instructors, clinical instructors, students, interns, residents, and fellows regarding thebest current practice of orthopaedic physical therapySTATEMENT OF INTENTThese guidelines are not intended to be construed or to serve asa standard of medical care. Standards of care are determined onthe basis of all clinical data available for an individual patientand are subject to change as scientific knowledge and technologyadvance and patterns of care evolve. These parameters of practice should be considered guidelines only. Adherence to themwill not ensure a successful outcome in every patient, nor shouldthey be construed as including all proper methods of care orexcluding other acceptable methods of care aimed at the sameresults. The ultimate judgment regarding a particular clinicalprocedure or treatment plan must be made based on clinicianexperience and expertise in light of the clinical presentation ofthe patient; the available evidence; the available diagnostic andtreatment options; and the patient’s values, expectations, andpreferences. However, we suggest that significant departuresfrom accepted guidelines should be documented in the patient’smedical records at the time the relevant clinical decision is made.MethodsContent experts were appointed by the Orthopaedic Section,APTA to conduct a review of the literature and to developan updated heel pain/plantar fasciitis CPG as indicated bythe current state of the evidence in the field. The aims ofthe revision were to provide a concise summary of the evidence since publication of the original guideline and to develop new recommendations or revise previously publishedrecommendations to support evidence-based practice. Theauthors of this guideline revision worked with research librarians with expertise in systematic review to perform asystematic search for concepts associated with heel pain orplantar fasciitis in articles published since 2007 related toclassification, examination, and intervention strategies forheel pain or plantar fasciitis, consistent with previous guideline development methods related to ICF classification.91Briefly, the following databases were searched from 2007 tobetween December 13 and 19, 2012: MEDLINE (PubMed)(2007 to date), Cochrane Library (2007 to date), Web of Science (2007 to date), CINAHL (2007 to date), ProQuest Dissertations and Theses (2007 to date), PEDro (2007 to date),a4 and ProQuest Nursing and Allied Health Source (2007 todate). See APPENDIX A (available online) for full search strategies and APPENDIX B (available online) for search dates andresults.The authors declared relationships and developed a conflictmanagement plan, which included submitting a conflict-ofinterest form to the Orthopaedic Section, APTA. Articlesthat were authored by a reviewer were assigned to an alternate reviewer. Funding was provided to the CPG development team for travel and expenses for CPG developmenttraining. The CPG development team maintained editorialindependence.Articles contributing to recommendations were reviewedbased on specified inclusion and exclusion criteria, with thegoal of identifying evidence relevant to physical therapist clinical decision making for adult persons with heel pain/plantarfasciitis. The title and abstract of each article were reviewedindependently by 2 members of the CPG development teamnovember 2014 volume 44 number 11 journal of orthopaedic & sports physical therapy44-11 Guidelines.indd 410/20/2014 7:10:40 PM
Heel Pain—Plantar Fasciitis: Clinical Practice Guidelines Revision 2014Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on December 26, 2014. For personal use only. No other uses without permission.Copyright 2014 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.Methods (continued)for inclusion. See APPENDIX C (available online) for inclusionand exclusion criteria. Full-text review was then similarlyconducted to obtain the final set of articles for contributionto recommendations. The team leader (R.L.M.) provided thefinal decision for discrepancies that were not resolved by thereview team. See APPENDIX D (available online) for a flow chartof articles and APPENDIX E (available online) for articles included in recommendations by topic. For selected relevant topicsthat were not appropriate for the development of recommendations, such as shockwave therapy, injection, and imaging,articles were not subject to the systematic review processand were not included in the flow chart. Evidence tables forthis CPG are available on the CPG pages of the OrthopaedicSection of the APTA's website (www.orthopt.org).This guideline was issued in 2014 based on the publishedliterature up to December 2012. This guideline will be considered for review in 2017, or sooner if new evidence becomesavailable. Any updates to the guideline in the interim period will be noted on the Orthopaedic Section of the APTA'swebsite (www.orthopt.org).strength of evidence, including how directly the studies addressed the question and heel pain/plantar fasciitis population. In developing their recommendations, the authorsconsidered the strengths and limitations of the body of evidence and the health benefits, side effects, and risks of testsand interventions.GRADES OF RECOMMENDATIONBASED ONSTRENGTH OF EVIDENCEBIIIEvidence obtained from high-quality diagnostic studies,prospective studies, or randomized controlled trialsEvidence obtained from lesser-quality diagnostic studies,prospective studies, or randomized controlled trials (eg,weaker diagnostic criteria and reference standards, improperrandomization, no blinding, less than 80% follow-up)Case-control studies or retrospective studiesCase seriesExpert opinionA preponderance of level I and/or level IIstudies support the recommendation.This must include at least 1 level I studyModerateevidenceA single high-quality randomized controlledtrial or a preponderance of level II studiessupport the recommendationWeak evidenceA single level II study or a preponderance oflevel III and IV studies, including statementsof consensus by content experts, support therecommendationConflictingevidenceHigher-quality studies conducted onthis topic disagree with respect to theirconclusions. The recommendation isbased on these conflicting studiesTheoretical/foundationalevidenceA preponderance of evidence from animalor cadaver studies, from conceptual models/principles, or from basic science/benchresearch supports this conclusionExpert opinionBest practice based on the clinicalexperience of the guidelinesdevelopment teamCDLEVELS OF EVIDENCEIndividual clinical research articles were graded according to criteria adapted from the Centre for Evidencebased Medicine, Oxford, UK for diagnostic, prospective,and therapeutic studies.62 In 3 teams of 2, each reviewerindependently assigned a level of evidence and evaluatedthe quality of each article using a critical appraisal tool.See APPENDICES F and G (available online) for the evidencetable and details on procedures used for assigning levels ofevidence. An abbreviated version of the grading system isprovided below.Strong evidenceAEFREVIEW PROCESSThe Orthopaedic Section, APTA selected content experts andstakeholders to serve as reviewers of the early drafts of theseCPGs. The draft was posted for public comment on th
Clinical Practice Guidelines ROBROY L. MARTIN, PT, PhD TODD E. DAVENPORT, DPT STEPHEN F. REISCHL, DPT THOMAS G. MCPOIL, PT, PhD JAMES W. MATHESON, DPT DANE K. WUKICH, MD CHRISTINE M. MCDONOUGH, PT, PhD Heel Pain—Plantar Fasciitis: Revision 2014 Clinical Practice Guidelines Linked to the
THE HEEL PAIN PATIENT WHO DOES NOT HAVE PLANTAR FASCIITIS If every patient who came in with "heel pain" had plantar fasciitis, things would be much simpler. We have all had the self diagnosed plantar fasciitis patient, or the "my sister, my aunt, my friend or co-worker" had plantar fasciitis and told me I have it. Or the patient who looked up their symptoms online, so it .
Plantar Fasciitis: Home Care Instructions Your Care Instructions Plantar fasciitis is pain and inflammation of the plantar fascia, the tissue at the bottom of your foot that connects the heel bone to the toes. The plantar fascia also supports the arch. If you strain the plantar fascia, it can develop small tears and
diagnose and treat plantar fasciitis. The syndrome of plantar fasciitis has been referred to as heel spur syn-drome, medial arch sprain, calcaneal periostitis and calcaneodynia. Plantar fasciitis is a clinical syndrome with Continued on page 166 Continuing Medical Education Figure 1E: Asymptomatic lateral band of plantar fascia
Plantar fasciitis (PF): PT refers to inflammation of the connective tissue on the sole of the foot (the plantar fascia), which may occur as a result of overuse of the plantar fascia. Plantar fasciitis is a common cause of heel pain, and affects approximately 10% of the United States population over the course of a lifetime.
Chronic plantar fasciitis is the most common cause of foot complaint in the United States. Up to 11% to 15% of these complaints require professional care among adults.6,21 The incidence of plantar fasciitis peaks in persons between the ages of 40 and 60 years, with no bias toward either sex.30 The underlying condition that causes plantar fasciop-
Chronic plantar fasciitis is the most common cause of foot complaints in the United States, making up 11 to 15% of the foot symptoms requiring professional care among adults [1,2]. The incidence of plantar fasciitis peaks in people between the ages of 40 to 60 years with no bias towards either sex [3].
therapy (ESWT) combined with usual care (exercise and orthotic support) was comparable to usual care in improving foot function and walking velocity in patient with plantar fasciitis. Patients with plantar fasciitis pain persisting for at least one month with a minimum score of 5 on the 10-point visual analog scale (VAS); pain felt in
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