Foot orthoses for plantar heel pain: a systematic review and meta-analysis

Barefoot walking is beneficial for individuals with persistent plantar heel pain: A single-blind randomized controlled trial

BACKGROUND

A lack of data exist about the effectiveness of active treatments for persistent plantar heel pain (PPHP).

OBJECTIVES

To compare short-term functional and clinical effects of a 4-week barefoot or shod treadmill walking program for people with PPHP.

METHODS

A single-blinded clinical trial randomized 52 participants with PPHP into either a barefoot walking group (BWG), or a shod walking group (SWG). All participants received therapeutic ultrasound. Outcomes were measured at baseline (t0), following 4 weeks of treatment (t1), and at 1-month follow-up (t2). The SF-36 functional questionnaire score was the main outcome. Secondary outcomes were self-reported and clinically-assessed pain provocation levels, pressure pain thresholds and pain tolerance. Treadmill walking time and speed were measured at t0 and t1; people also recorded the time spent walking each day in a diary.

RESULTS

The BWG exhibited significant improvements in all SF-36 items (except "emotional well-being") (P < 0.05), whereas the SWG exhibited improvements only in "pain" and "health change" items (P = 0.0001; effect size 0.13-0.94). Greater improvements were observed in the BWG than the SWG for "physical function" (P = 0.019) and "role limitations due to physical health" items (P = 0.035). Both groups demonstrated significant improvements in pain, with greater improvements in the BWG (P = 0.0001; effect size 0.89). Only the BWG showed significant improvements in pain pressure thresholds (P < 0.05; effect size 0.70) and pain tolerance (P < 0.001; effect size 0.67). Both groups significantly increased their speed and time spent walking on the treadmill (BWG Δ=19.7 min and Δ=1.7 km/h; SWG Δ=16.7 min and Δ=1.1 km/h) and time outdoors (SWG ∆=38.2 min/week; BWG mean ∆=48.5 min/week) (P < 0.001). All clinical tests of pain were significantly less positive in the BWG at all time points (P < 0.05).

CONCLUSIONS

Both walking programs benefited people with PPHP by alleviating pain and improving function and quality of life. Greater improvements were observed in the BWG than the SWG overall.

Consensus statements and guideline for the diagnosis and management of plantar fasciitis in Singapore

Introduction

Plantar fasciitis (PF) is a common cause of heel pain among the general population. The lack of standard practice guideline in Singapore presents challenges in education and clinical practice for this painful condition. These consensus statements and guideline were developed to streamline and improve the management of PF, covering key aspects such as diagnosis, investigations, risk factors, treatment modalities, monitoring and return to work/play.

Method

A multidisciplinary expert panel consisting of 6 sports physicians, 2 orthopaedic surgeons, 2 podiatrists and 1 physiotherapist from SingHealth Duke-NUS Sport & Exercise Medicine Centre (SDSC) was convened based on their clinical and academic experience with PF. The Grading of Recommen-dations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of the evidence and subsequently prepare a set of clinical recommen-dations pertaining to the manage-ment of PF. A modified Delphi process was used to reach consensus.

Results

Eighteen consensus statements were developed to cover key components of PF management, from initial diagnosis to treatment modalities and finally, clinical progression. They were subsequently consolidated under a proposed treatment pathway guideline for PF.

Conclusion

The SDSC consensus statements and guideline provide concise recommendations for the management of PF in Singapore.

Common Painful Foot and Ankle Conditions: A Review

Importance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment.

Observations

Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used.

Conclusions and Relevance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.

Orthotic Devices for the Foot and Ankle

Millions of Americans wear ankle-foot orthotic devices for protection, pain relief, and deformity correction. Inquiries about off-the-shelf and custom devices are a common reason for evaluation with a foot and ankle surgeon or general orthopaedic surgeon. Despite limited high-quality evidence for their use, these devices can have a notable clinical impact on physical function. An up-to-date understanding of orthotic device options and their appropriate use in managing musculoskeletal pathologies applies to all orthopaedic providers. This review aims to categorize orthosis types and provide specific device recommendations for common adult conditions such as flatfoot, cavovarus foot, and ankle instability. Collaboration with a certified orthotist can help patients achieve functional and recreational goals with the use of appropriately designed and applied orthoses.

Heel Pain - Plantar Fasciitis: Revision 2023

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to nonarthritic heel pain. J Orthop Sports Phys Ther 2023;53(12):CPG1-CPG39. doi:10.2519/jospt.2023.0303.

Efficacy of pharmacological and non-pharmacological therapies on pain intensity and disability for plantar fasciitis: a systematic review and meta-analysis

OBJECTIVE

To investigate the effects of pharmacological and non-pharmacological therapies on pain intensity and disability for plantar fasciitis.

DESIGN

Systematic review of randomised controlled trials (RCTs).

DATA SOURCES

AMED, MEDLINE, PEDro, Cochrane, SPORTDiscus, CINAHL, EMBASE and PsycINFO without language or date restrictions up to 3 February 2023.

ELIGIBILITY CRITERIA

RCTs that evaluated the efficacy of any pharmacological and non-pharmacological therapies compared with control (placebo, sham, waiting list or no intervention) on pain intensity and disability in people with plantar fasciitis. Two reviewers independently screened eligible trials, extracted data, assessed the methodological quality of included trials and assessed the certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations framework. Mean differences (MDs) with 95% CIs were reported.

RESULTS

Seventeen different therapies investigated in 28 trials were included in the quantitative analysis. For non-pharmacological therapies, moderate certainty evidence showed short-term effects of customised orthoses on pain intensity when compared with control (MD of -12.0 points (95% CI -17.1 to -7.0) on a 0-100 scale). Low certainty evidence showed short-term effects of taping on pain intensity (-21.3 (95% CI -38.6 to -4.0)). Long-term effects and effects on disability are still uncertain. For pharmacological therapies, low to very low quality evidence from few trials with small samples was inconclusive and supports that high-quality trials are needed.

CONCLUSIONS

Moderate-quality and low-quality evidence demonstrates customised orthoses and taping, respectively, reduce pain intensity in the short term in patients with plantar fasciitis.

PROSPERO REGISTRATION NUMBER

CRD42021224416.

Use of orthotics with orthotic sandals versus the sole use of orthotics for plantar fasciitis: Randomised controlled trial

BACKGROUND

Plantar fasciitis (PF) affects around 10% of the population. Prefabricated orthotics with arch support has been shown to provide symptom relief in PF by decreasing the repetitive stress sustained by the plantar fascia. However, prefabricated orthotics are only effective when shoes are worn, meaning the foot may be left unsupported when it is impractical to wear shoes. Using orthotic sandals in conjunction with prefabricated orthotics may increase PF symptom relief, as they can be worn inside the home, extending the period in which the foot is supported.

AIM

To compare the combined use of prefabricated orthotics and orthotic sandals vs the sole use of prefabricated orthotics in the treatment of PF.

METHODS

98 participants with PF were randomised into two groups. The intervention group received the Aetrex L420 Compete orthotics and the Aetrex L3000 Maui Flips (orthotic sandals), whilst the control group received the Aetrex L420 Compete orthotics only. Foot pain was assessed both by the numerical rating scale (NRS) and the pain sub-scale of the foot health status questionnaire (FHSQ). Foot functionality was measured using the function sub-scale of the FHSQ. Symptom change was measured using the global rating of change scale (GROC).

RESULTS

Foot pain scores measured both by NRS and FHSQ pain sub-scale showed statistically significant reductions in foot pain in both groups (P < 0.05) at six months. Both groups also reported statistically significant improvements (P < 0.05) in function as measured by the FHSQ function subscale and improvement of symptoms as measured by the GROC scale. Between-group analysis showed that the intervention group with the combined use of orthotics and orthotic sandals scored better on all four outcome measures as compared to the control group with the sole use of orthotics. However, the between-group analysis only reached statistical significance on the NRS pain score (P < 0.05).

CONCLUSION

Combined use of prefabricated orthotics and orthotic sandals provides a greater decrease in foot pain and improvement in foot function in PF compared to using prefabricated orthotics alone.

The effects of a custom foot orthosis on dynamic plantar pressure in patients with chronic plantar fasciitis: A randomized controlled trial

BACKGROUND

Plantar fasciitis is one of the most common causes of heel pain. The plantar fascia supports the longitudinal arch and absorbs ground reaction forces during the static and dynamic phase(s) of weight-bearing. The purpose of this randomized controlled trial study was to determine the effects of CAD/CAM foot orthoses that were designed based on the dynamic plantar pressure in patients with plantar fasciitis.

METHODS

This study was performed on 34 patients with plantar fasciitis. Outcomes were compared based on plantar fascia thickness; peak pressure, mean pressure, and maximum force; and pain, activity of daily living, quality of life, and sports activity that were evaluated by ultrasound, plantar pressure platform, and the Foot and Ankle Outcome Score, respectively. The patients were randomly assigned into two groups: the experimental group (CAD/CAM orthoses and night splint) and the control group (night splint only). All data were recorded again after 4 weeks.

RESULTS

Pain ( P = 0.002) and plantar fascia thickness ( P = 0.001) decreased significantly after 1 month of intervention. Activity of daily living ( P = 0.044) and quality of life ( P = 0.001) showed a significant increase. There was a trend in increasing peak pressure in all masking regions in both groups. The maximum force remarkably reduced in the experimental group in all regions.

CONCLUSIONS

The results demonstrated that CAD/CAM foot orthoses designed based on dynamic plantar pressure with night splint can reduce the plantar fascia thickness and pain associated with plantar fasciitis and increase the activity of daily living, quality of life, and sports activity.

Ultrasonographic Assessment of Indian Patients With Plantar Fasciitis and Its Clinical Correlation: A Prospective Observational Study

INTRODUCTION

Plantar fasciitis is a debilitating clinical condition and is one of the most common causes of heel pain. The risk factors include frequent and prolonged running, obesity, a sedentary lifestyle, work-related weight bearing, and inappropriate footwear. Ultrasonography being a non-invasive, cost-effective, and easily available modality is a useful adjunct in the diagnosis.

METHODS

A prospective observational study was conducted among 30 patients with unilateral plantar fasciitis. The diagnosis was based on history and examination. Heel pad thickness and plantar fascia thickness were recorded using ultrasonography.

RESULTS

The ultrasonography results showed increased plantar fascia and heel pad thickness in the affected limb with plantar fasciitis than the normal one (p<0.001). The BMI was positively correlated with the heel pad thickness (p<0.05). The receiver operating characteristic (ROC) curve showed 90% sensitivity and 60% specificity for heel pad thickness (p<0.001).

CONCLUSIONS

Ultrasonography is a sensitive and specific tool to identify patients with plantar fasciitis.

Radial Extracorporeal Shockwave Therapy (rESWT) is not superior to "minimal-dose" rESWT for patients with chronic plantar fasciopathy; a double-blinded randomised controlled trial

BACKGROUND

Investigating outcomes following radial-extra-corporeal-shockwave-therapy (rESWT) in patients with chronic plantar fasciopathy METHODS: This double-blinded RCT in a single NHS Sports medicine clinic recruited 117 patients with chronic plantar fasciopathy randomised equally to either 3 sessions of rESWT or "minimal-dose" respectively. Mean age 51.7 ± 9.6 years, 66 % female, symptom duration: 32.6 ± 30.8 months.

RESULTS

"Average pain" improved by 50 % at 6-months, (>1/3 at interim time-points). Statistically significant within-group improvements were identified in pain, local function, and "ability" PROMs in both groups. Fewer benefits in activity levels or mood. No between-group differences were seen at the interim or final time-points.

CONCLUSION

3 sessions of "recommended-dose" rESWT is non-superior to "minimal-dose" rESWT in patients with chronic plantar fasciopathy. rESWT may be ineffective in the treatment of patients with chronic plantar fasciopathy, "minimal-dose" rESWT may be sufficient for a therapeutic effect, or a greater number of treatment sessions may be required for benefit.

LEVEL OF EVIDENCE

Level I - Randomised controlled trial.

A cross-sectional analysis of podiatrist-initiated review processes after issuing prescribed foot orthoses

BACKGROUND

Foot orthoses are widely used in clinical practice to treat foot, lower limb and back pathology. As published information guiding the clinical use of foot orthoses is scarce, the aim of this study is to profile the review processes used by practicing podiatrists after issuing an orthotic device.

METHODS

A cross-sectional observational study design formed the basis for a self-administered online questionnaire. The questionnaire was distributed through podiatry networks based in Australia.

RESULTS

Two-hundred and thirty-eight practicing podiatrists participated in this study. Ninety-seven percent of respondents indicated that they would recommend a review appointment after the initial fitting of an orthotic device. Forty percent (n = 84) of respondents scheduled the first review appointment four weeks after the initial fitting, while 33% (n = 69) preferred a two-week review period. A second review consultation was standard practice for 32% (n = 68) or respondents, and were typically scheduled either two (23%, n = 12) or four (38%, n = 20) weeks after the initial review consultation. Annual review of orthotic devices was recommended by 64% (n = 123) of participants in the study, while 19% (n = 37) would suggest that yearly reviews were scheduled only if required.

CONCLUSIONS

Variation was identified in the orthotic review processes used by practicing podiatrists, although most respondents recommend a routine short-term review appointment for foot orthoses. It is not clear why practitioners adopt such varied approaches. In the absence of any clear evidence on this topic, it may be that the differing approaches to patient review reflect different philosophical perspectives regarding patient management.

Health-related quality of life is substantially worse in individuals with plantar heel pain

This study aimed to compare health-related quality of life (HRQoL) in people with and without plantar heel pain (PHP). This was a cross-sectional observational study that compared 50 adult participants with PHP to 25 participants without PHP who were matched for age, sex and body mass index (BMI). HRQoL measures included a generic measure, the Short Form 36 version 2 (SF-36v2), and foot-specific measures, including 100 mm visual analogue scales (VASs) for pain, the Foot Health Status Questionnaire (FHSQ), and the Foot Function Index-Revised (FFI-R). Comparisons in HRQoL between the two groups were conducted using linear regression, with additional adjustment for the comorbidity, osteoarthritis, which was found to be substantially different between the two groups. For generic HRQoL, participants with PHP scored worse in the SF-36v2 physical component summary score (p < 0.001, large effect size), but there was no difference in the mental component summary score (p = 0.690, very small effect size). Specifically, physical function (p < 0.001, very large effect size), role physical (p < 0.001, large effect size) and bodily pain (p < 0.001, large effect size) in the physical component section were worse in those with PHP. For foot-specific HRQoL, participants with PHP also scored worse in the VASs, the FHSQ and the FFI-R (p ≤ 0.005, huge effect sizes for all domains, except FHSQ footwear, which was large effect size, and FFR-R stiffness, activity limitation, and social issues, which were very large effect sizes). After accounting for age, sex, BMI and osteoarthritis, adults with PHP have poorer generic and foot-specific HRQoL.

What do we actually know about a common cause of plantar heel pain? A scoping review of heel fat pad syndrome

Background

The heel fat pad is an important structure of the foot as it functions as a cushion to absorb shock and distribute plantar force during ambulation. Clinical practice guidelines or decision support platforms emphasize that heel fat pad syndrome (HFPS) is a distinct pathology contributing to plantar heel pain. We aimed to identify and synthesize the prevalence, etiology and diagnostic criteria, and conservative management of HFPS.

Methods

A comprehensive search was conducted in May 2021 and updated in April 2022, using MEDLINE, Scopus, Cinahl, EMBASE, Cochrane Library, SPORTDiscus, and PEDro and ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform (ICTRP) for pertinent registrations. We included all study types and designs describing the prevalence; etiology and diagnostic criteria; and non-pharmacological, non-surgical interventions for HFPS.

Results

We found a small body of original research for HFPS (n = 7). Many excluded full-text articles were expert-opinion articles or studies of heel fat pad in participants with plantar fasciitis/fasciopathy or unspecified heel pain. HFPS may be the second leading cause of plantar heel pain, based on two studies. A number of differentiating pain characteristics and behaviors may aid in diagnosing HFPS vs. plantar fasciopathy. Thinning heel fat pad confirmed by ultrasonography may provide imaging corroboration. Randomized controlled trials assessing the efficacy of viscoelastic heel cups or arch taping for managing HFPS do not exist.

Conclusions

The research literature for HFPS is sparse and sometimes lacking scientific rigor. We have identified a substantial knowledge gap for this condition, frequent inattention to distinguishing HFPS from plantar fasciopathy when describing plantar heel pain, and an absence of robust clinical trials to support the commonly recommended conservative management of HFPS.

Custom-made foot orthoses with and without heel plugs and their effect on plantar pressures during treadmill walking

BACKGROUND

Foot orthoses have consistently demonstrated an improvement in pain scores for plantar fasciitis. The fabrication of custom-made foot orthoses (CFOs) can vary between clinicians and may include the use of different materials and casting techniques. This cross-sectional study's objective was to quantify plantar pressure for two CFOs, one with a heel plug (HP) and one without.

METHODS

Fourteen healthy participants (8 men and 6 women; 35.4 ± 7.7 years) were cast by the same practitioner. Both CFOs were made with the same materials and specifications, except for the HP orthosis, which replaced hard material under the heel with a softer blue PORON ® plug for added cushioning. Plantar pressures were recorded during treadmill walking for both devices in a running shoe. Average pressure, peak pressure, and pressure contact area were determined for three regions of the foot: hindfoot, midfoot, and forefoot. A paired samples t -test determined differences in each region ( P < 0.05).

RESULTS

The HP orthosis reduced the overall means of average pressure, peak pressure, and pressure contact area in the hindfoot while tending to increase these measures in the midfoot and forefoot. The three measures showed statistically significant decreases in the hindfoot, whereas a statistically significant increase was seen in average and peak pressures in the midfoot ( P < 0.05).

CONCLUSIONS

CFOs with HPs are more effective than regular CFOs in offloading plantar pressures in the hindfoot while increasing pressures in the midfoot. This is an important finding because offloading the hindfoot is critical in pathologies such as plantar fasciitis to decrease pain and increase function.

Arch-Support Insoles Benefit the Archery Performance and Stability of Compound Archers

The purpose of this study was to analyze the effects of the use of arch-support insoles on the archery performance and center of plantar pressure (CoP) excursion in compound archers. Fifteen highly skilled compound archers were the subjects. A pressure plate was used to measure the CoP excursion and percentage distribution of plantar pressure. The parameters were compared between archers wearing flat and arch-support insoles using a paired-sample t-test. The results demonstrated that the shooting score in archers wearing the arch-support insole was significantly greater than in those wearing the flat insoles. The CoP excursion of the left foot, right foot, and both feet in archers wearing the arch-support insole were significantly smaller than in those wearing the flat insole. The distributed percentage of the plantar pressure showed that the arch-support insole significantly reduced the plantar pressure in the left posterior zone by 3.54% compared with the flat insole, and increased the plantar pressure in the right anterior zone by 2.54%. The principal conclusion was that compound archers wearing arch-support insoles during the arrow-release process can reduce the CoP excursion of the foot and increase their shooting score. The plantar pressure was distributed evenly in arch-support insoles.

The biomechanical effects of 3D printed and traditionally made foot orthoses in individuals with unilateral plantar fasciopathy and flat feet

BACKGROUND

Foot orthoses (FOs) are used to manage foot pathologies such as plantar fasciopathy. 3D printed custom-made FOs are increasingly being manufactured. Although these 3D-printed FOs look like traditionally heat-moulded FOs, there are few studies comparing FOs made using these two different manufacturing processes.

RESEARCH QUESTION

How effective are 3D-printed FOs (3D-Print) compared to traditionally-made (Traditional) or no FOs (Control), in changing biomechanical parameters of flat-footed individuals with unilateral plantar fasciopathy?

METHODS

Thirteen participants with unilateral plantar fasciopathy walked with shoes under three conditions: Control, 3D-print, and Traditional. 2 × 3 repeated measures analysis of variance (ANOVAs) with Bonferroni post-hoc tests were used to compare discrete kinematic and kinetic variables between limbs and conditions. Waveform analyses were also conducted using statistical parametric mapping (SPM).

RESULTS

There was a significant condition main effect for arch height drop (p = 0.01; ηp² =0.54). There was 0.87 mm (95% CI [-1.84, -0.20]) less arch height drop in 3D-print compared to Traditional. The SPM analyses revealed condition main effects on ankle moment (p < 0.001) and ankle power (p < 0.001). There were significant differences between control condition and both 3D-print and Traditional conditions. For ankle moment and power, there were no differences between 3D-print and Traditional conditions.

SIGNIFICANCE

3D-printed FOs are more effective in reducing arch height drop, whist both FOs lowered ankle plantarflexion moment and power compared to no FOs. The results support the use of 3D-printed FOs as being equally effective as traditionally-made FOs in changing lower limb biomechanics for a population of flat-footed individuals with unilateral plantar fasciopathy.

Effects of foot orthoses on the biomechanics of the lower extremities in adults with and without musculoskeletal disorders during functional tasks: A systematic review

BACKGROUND

Foot orthoses are among the most commonly used external supports to treat musculoskeletal disorders. It remains unclear how they change the biomechanics of the lower extremities during functional tasks. This systematic review aimed to determine the effects of foot orthoses on primary outcomes (i.e., kinematics, kinetics and electromyography of the lower extremities) in adults with and without musculoskeletal disorders during functional tasks.

METHODS

A literature search was conducted for articles published from inception to June 2021 in Medline, CINAHL, SPORTDiscus, Cochrane libraries and PEDro electronic databases. Two investigators independently assessed the titles and abstracts of retrieved articles based on the inclusion criteria. Of the 5578 citations, 24 studies were included in the qualitative synthesis as they reported the effects of foot orthoses on the primary outcomes. Risk of bias of included studies was determined using the modified Downs and Black Quality Index.

FINDINGS

During low impact tasks, foot orthoses decrease ankle inversion and increase midfoot plantar forces and pressure. During higher impact tasks, foot orthoses had little effects on electromyography and kinematics of the lower extremities but decreased ankle inversion moments.

INTERPRETATION

Even though the effects of foot orthoses on the biomechanics of the lower extremities seem task-dependent, foot orthoses mainly affected the biomechanics of the distal segments during most tasks. However, few studies determined their effects on the biomechanics of the foot. It remains unclear to what extent foot orthoses features induce different biomechanical effects and if foot orthoses effects change for different populations.

Similar Benefits Seen After Radial Extracorporeal Shockwave Therapy or Autologous Blood Injection in Patients With Chronic Plantar Fasciitis-A Retrospective Cohort Study

OBJECTIVE

To compare the outcomes for patients with chronic plantar fasciitis after extracorporeal shockwave therapy (ESWT) or autologous blood injection (ABI).

DESIGN

Cohort study-retrospective analysis of prospectively collected data.

SETTING

Hospital-based Sports Medicine Outpatient Clinic.

PATIENTS

One hundred two consecutive patients with chronic plantar fasciitis, treated with either radial-ESWT (rESWT) (n = 54) or ABI (n = 48), with minimum 3-month follow-up and 96% (98/102) having 6-month follow-up. Mean age 49.5 years and mean duration of symptoms 37.5 months before treatment.

INTERVENTIONS

Patients received either 3 sessions of radial ESWT (one session per week for 3 weeks), or a single ultrasound-guided dry needling and ABI (3 mL whole autologous blood). All patients received standardized after-care, including progressive structured home exercise program of flexibility, strengthening, and proprioception exercises.

MAIN OUTCOME MEASURES

0 to 10 numerical rating scale (NRS) for self-reported "average pain" and "average stiffness" values. Secondary outcome measures included assessments of local foot function [including Manchester-Oxford Foot Questionnaire (MOXFQ), revised-Foot Function Index] as well as markers of mental health functioning (HAD), global health (EQ-5D-5L), and physical activity (International Physical Activity Questionnaire).

RESULTS

This study demonstrated statistically significant improvements in self-reported measures of pain and local foot function after either procedure at 6 weeks, 3 months, and 6 months, but no statistically significant differences were seen between groups at any time-period studied. At 6 months, the average pain using a 0 to 10 NRS was improved from 6.8 ± 1.8 to 4.0 ± 2.7 (P < 0.001) after ESWT and from 7.1 ± 1.6 to 3.8 ± 2.7 (P < 0.001) after ABI. At 6 months, significant improvements were seen following either group using a number of different validated patient-rated outcome measures assessing local foot pain and function, eg, the total score for MOXFQ improved from 56.1 ± 12.8 to 42.5 ± 16.6 (P < 0.001) after ESWT and from 58.8 ± 13.2 to 44.2 ± 19.2 (P < 0.001) after ABI. However, measures of physical activity or wider aspects of patient functioning did not consistently improve from baseline values to follow-up periods.

CONCLUSIONS

Patients with chronic plantar fasciitis improved to statistically significant extent after either rESWT or ABI procedures, with no significant differences seen between groups. The lack of randomization in this pragmatic study is noted, which may have influenced the outcome seen. Potentially larger and more robust studies are required to investigate this treatment comparison further.

Can we predict which patients with plantar heel pain are more likely to benefit from insoles? A secondary exploratory analysis of a randomized controlled trial

Background

Plantar heel pain (PHP) is a common cause of foot complaints, for which treatment with custom-made insoles is frequently applied. So far few studies have investigated patient characteristics that predict response to these treatments. The aim of this secondary exploratory analysis was twofold; firstly, to identify patient characteristics that predict prognosis in patients with PHP treated with insoles, and secondly to identify characteristics that might interact with treatment with insoles.

Methods

Data from a randomized trial in which participants received either custom insoles (N = 70) or sham insoles (N = 69) were used. At baseline, information was collected on demographics, foot symptoms, foot and ankle range of motion, navicular drop, presence of neuropathic pain, physical activity and other illnesses in the last 12 months. The primary outcome of this study was the Foot Function Index score (FFI) at 26 weeks. Multivariable linear regression models were generated to identify patients characteristics that predict the outcome for each type of intervention (i.e. insoles and GP-led usual care).

Results

We found two variables associated with a better function score at 26 weeks in patients treated with insoles, female sex (β − 9.59 95%CI -17.87; − 1.31) and a lower FFI score at baseline (β 0.56 95%CI 0.30; 0.82). Explorative analyses in patients treated with insoles showed no significant interaction effects between the type of insole (custom-made versus sham) and any of the potential predictive factors.

Conclusion

When communicating about the effect of insoles for PHP clinicians should take sex and the amount of pain and disability at first presentation into account. Women and people with better foot function scores at baseline (according to FFI) might respond better to treatment with insoles in terms of foot function.

Trial registration

Trial registration: NTR5346.

Immediate comfort perception of 3D-printed foot orthoses in individuals with unilateral heel pain

BACKGROUND

Custom-made foot orthoses (FOs) play an integral part in managing foot disorders. Traditional FO fabrication is time-consuming and labor intensive. Three-dimensional (3D) printed FOs save time and cost compared with the traditional manufacturing process. To date, the differences in dimensions and comfort perception of these orthoses have not been compared in a pathological population.

OBJECTIVE

Compare the dimensions between 3D-printed and traditionally made FOs and comfort perception between 3D-printed, traditionally made, and no FOs in individuals with flatfeet and unilateral heel pain.

STUDY DESIGN

Within-subject single-blinded randomized crossover study design.

METHODS

Thirteen participants had custom-made FOs using 3D-printing and traditional processes. Orthotic lengths, widths, arch heights, and heel cup heights were compared. Participants performed walking trials under three conditions: (1) no orthoses, (2) 3D-printed orthoses, and (3) traditionally made orthoses. Comfort perception was recorded. Orthotic dimensions were compared using paired t tests, and comfort perception were compared using one-way multiple analysis of variance and Bonferroni post hoc tests.

RESULTS

Three-dimensional-printed orthoses were wider, have higher arch heights, and heel cup heights compared with traditionally made FOs (medium to large effect sizes). There was a difference in comfort perception between the three orthotic conditions, F(12,62) = 1.99, P = 0.04; Wilk Λ = 0.521, ηp2= 0.279. Post hoc tests show that there is no difference in comfort perception between the 3D-printed and traditionally made FOs. Both FOs were significantly more comfortable than no orthoses.

CONCLUSIONS

Three-dimensional printing seems to be a viable alternative orthotic fabrication option. Future studies should compare the biomechanical effects of 3D-printed and traditionally made FOs.

'Green podiatry' - reducing our carbon footprints. Lessons from a sustainability panel

Background

The eyes of the world will be on COP26 as it meets in Glasgow in November, 2021. Our planet is displaying weather extremes due to climate change which cannot be ignored, and which are deleterious for people’s health. Ironically, healthcare contributes to climate change, contributing approximately 5% of carbon emissions globally. Climate change due to global warming is ‘the biggest global health threat of the 21st century’.

Main body

The Australian Podiatry Association conference held a sustainability panel, hearing perspectives of industry and science, medicine and sport, fashion, and retail. Content unified a broad planet and human health message, which is highly relevant for podiatrists. Key themes included waste as a resource, exercise as evidence-based intervention, responsibility and circular economy recycling principles for end-of-life product (footwear) purchases, and wider ethical considerations of footwear and clothing.

The Anthropocene origin of climate change requires humanity to collaborate and to live more sustainably. Innovation is essential for better energy modes, cleaner air, human health and earth care.

Green Podiatry joins the concerted activity of medical and health groups within Australia. The UK’s NHS is an exemplar in this area, having already reduced healthcare emissions by 35%, and aiming for net zero by 2045, and perhaps sooner.

Conclusion

People are increasingly concerned about climate change, and COP26 is an important and imminent meeting for human and planet health.

This commentary on Green Podiatry directs us all to lighten our carbon footprint. A final, and forthcoming commentary will outline practical ways of positively incorporating climate change communication into the clinical setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00497-1.

A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis

The number of systematic review and meta-analyses on plantar fasciitis is expanding. The purpose of this review was to provide a comprehensive summary of reviews on the topic pertaining to plantar fasciitis, identify any conflicting and inconsistent results, and propose future research direction. A qualitative review of all systematic reviews and meta-analyses related to plantar fasciitis up to February 2021 was performed using PubMed, Embase, Web of Science, and the Cochrane Database. A total of 1052 articles were initially identified and 96 met the inclusion criteria. Included articles were summarized and divided into the following topics: epidemiology, diagnosis, and treatment. While the majority of reviews had high level of heterogeneity and included a small number of studies, there was general consensus on certain topics, such as BMI as a risk factor for plantar fasciitis and extracorporeal shockwave therapy as an effective mode of therapy. A qualitative summary of systematic reviews and meta-analyses published on plantar fasciitis provides a single source of updated information for clinicians. Evidence on topics such as the epidemiology, exercise therapy, or cost-effectiveness of treatment options for plantar fasciitis are lacking and warrant future research.

The immediate effect of foot orthoses on gluteal and lower limb muscle activity during overground walking in healthy young adults

BACKGROUND

Although foot orthoses are often used in the management of lower limb musculoskeletal conditions, their effects on muscle activation is unclear, especially in more proximal segments of the lower limb.

RESEARCH QUESTION

Primary aim: Is there an immediate effect of foot orthoses on gluteal muscle activity during overground walking in healthy young adults? Secondary aim: Is there an immediate effect of foot orthoses on the activity of hamstring, quadriceps and calf muscles?

METHODS

In eighteen healthy young adults, muscle activity was recorded using fine wire electrodes for gluteus minimus (GMin; anterior, posterior) and gluteus medius (GMed; anterior, middle, posterior); and surface electrodes for gluteus maximus (GMax), hamstring, quadriceps and calf muscles. Participants completed six walking trials for two conditions; shoe and shoe with prefabricated foot orthoses. Muscle activity was normalised to the peak activity of the shoe condition and analysed using one-dimensional statistical non-parametric mapping to identify differences across the gait cycle.

RESULTS

Activity of GMed (anterior, middle, posterior) and GMin (posterior) was reduced in early stance phase when the orthosis was worn in the shoe (p < 0.05). GMin (anterior) activity was significantly reduced during swing (p < 0.05). Muscle activity was also significantly reduced during the orthoses condition for the lateral hamstrings and calf muscles (p < 0.05).

SIGNIFICANCE

Using foot orthoses may provide a strategy to reduce demand on GMin, GMed, lateral hamstring and calf muscles while walking.

Self-assessed foot health in older people with rheumatoid arthritis-A cross-sectional study

BACKGROUND

Foot and ankle problems are especially common in patients with RA, causing significant disability and limitation in daily activities. Previous studies have mainly focussed on foot problems in the adult population whilst the evidence of foot health in the older population is scarce.

OBJECTIVES

The aim of the study was to analyse self-assessed foot health and associated factors in older people with rheumatoid arthritis (RA).

METHODS

The study applied a descriptive cross-sectional survey design and recruited older people with RA from the member register of one patient association. We collected the data in January 2019 with the Self-administered Foot Health Assessment Instrument, and sociodemographic and foot-related background questions and analysed the data with descriptive and inferential statistics.

RESULTS

Older people with RA had many self-reported foot problems. The most common problems were foot pain, dry skin and thickened toenails. In addition, structural deformities of the foot were prevalent. The level of foot health associated with the amount of daily walking or standing, and using walking or running shoes outdoors. Individuals who had consulted a physician due to their foot problems had more structural deformities in the foot. Foot problems limited their ability to perform daily activities.

CONCLUSIONS

This study demonstrates that older people with RA not only live with a long-term health condition, but they also live with complex foot problems. Older people with RA need healthcare services due to their foot problems. There is a need to develop and implement care practices to alleviate foot pain and support and promote foot health and functional ability in older people with RA.

IMPLICATION FOR PRACTICE

Understanding the nature and consequences of foot problems in older people with RA allows healthcare professionals to perform more accurate clinical foot evaluations and develop effective interventions to prevent further foot problems.

Online questionnaire, clinical and biomechanical measurements for outcome prediction of plantar heel pain: feasibility for a cohort study

BACKGROUND

Plantar heel pain (PHP) accounts for 11-15% of foot symptoms requiring professional care in adults. Recovery is variable, with no robust prognostic guides for sufferers, clinicians or researchers. Therefore, we aimed to determine the validity, reliability and feasibility of questionnaire, clinical and biomechanical measures selected to generate a prognostic model in a subsequent cohort study.

METHODS

Thirty-six people (19 females & 17 males; 20-63 years) were recruited with equal numbers in each of three groups: people with PHP (PwPHP), other foot pain (PwOP) and healthy (H) controls. Eighteen people performed a questionnaire battery twice in a randomised order to determine online and face-to-face agreement. The remaining 18 completed the online questionnaire once, plus clinical measurements including strength and range of motion, mid-foot mobility, palpation and ultrasound assessment of plantar fascia. Nine of the same people underwent biomechanical assessment in the form of a graded loaded challenge augmenting walking with added external weight and amended step length on two occasions. Outcome measures were (1) feasibility of the data collection procedure, measurement time and other feedback; (2) establishing equivalence to usual procedures for the questionnaire battery; known-group validity for clinical and imaging measures; and initial validation and reliability of biomechanical measures.

RESULTS

There were no systematic differences between online and face-to-face administration of questionnaires (p-values all > .05) nor an administration order effect (d = - 0.31-0.25). Questionnaire reliability was good or excellent (ICC2,1_absolute)(ICC 0.86-0.99), except for two subscales. Full completion of the survey took 29 ± 14 min. Clinically, PwPHP had significantly less ankle-dorsiflexion and hip internal-rotation compared to healthy controls [mean (±SD) for PwPHP-PwOP-H = 14°(±6)-18°(±8)-28°(±10); 43°(±4)- 45°(±9)-57°(±12) respectively; p < .02 for both]. Plantar fascia thickness was significantly higher in PwPHP (3.6(0.4) mm vs 2.9(0.4) mm, p = .01) than the other groups. The graded loading challenge demonstrated progressively increasing ground reaction forces.

CONCLUSION

Online questionnaire administration was valid therefore facilitating large cohort recruitment and being relevant to remote service evaluation and research. The physical and ultrasound examination revealed the expected differences between groups, while the graded loaded challenge progressively increases load and warrants future research. Clinician and researchers can be confident about these methodological approaches and the cohort study, from which useful clinical tools should result, is feasible.

LEVEL OF EVIDENCE

IV.

Self-management advice, exercise and foot orthoses for plantar heel pain: the TREADON pilot and feasibility randomised trial

BACKGROUND

Plantar heel pain (PHP) is common and impacts negatively on physical function and quality of life. Initial treatment usually comprises analgesia and self-management advice (SMA), with referral to a physiotherapist or podiatrist recommended only when symptoms persist. Systematic reviews highlight limitations of existing evidence for the effectiveness of exercises and orthoses. The objective of the TREADON pilot and feasibility trial was to inform the design of a future main trial to compare the clinical and cost-effectiveness of self-management advice (SMA), individualised exercises and foot orthoses for PHP.

METHODS

This was a four-arm randomised feasibility and pilot trial with 12-week follow-up. Adults aged ≥ 18 years with PHP were identified from primary care by general practice consultation, retrospective general practice medical record review or a population survey. Participants were randomised to either (i) SMA, (ii) SMA plus individualised exercises (SMA-exercises), (iii) SMA plus prefabricated foot orthoses (SMA-orthoses) or (iv) SMA plus combined individualised exercises and prefabricated foot orthoses (SMA-combined). Feasibility outcomes were recruitment; retention; intervention adherence, credibility and satisfaction; performance of three potential primary outcome measures (pain numeric rating scale (NRS), Foot Function Index-pain subscale (FFI-pain), Manchester Foot Pain and Disability Index-pain subscale (MFPDI-pain)); and parameters for informing the main trial sample size calculation.

RESULTS

Eighty-two participants were recruited. All three identification methods met the target number of participants. Retention at 12 weeks was 67%. All interventions were successfully delivered as per protocol. Adherence (range over 12 weeks 64-100%) and credibility (93%) were highest in the SMA-combined arm. Satisfaction with treatment was higher for the three clinician-supported interventions (SMA 29%, SMA-exercises 72%, SMA-orthoses 71%, SMA-combined 73%). Responsiveness (baseline to 12 weeks) was higher for FFI-pain (standardised response mean 0.96) and pain NRS (1.04) than MFPDI-pain (0.57). Conservative sample size parameter estimates for standard deviation were pain NRS 2.5, FFI-pain 25 and MFPDI-pain 4, and baseline-outcome correlations were 0.5-0.6, 0.4 and < 0.3, respectively.

CONCLUSIONS

We demonstrated the feasibility of conducting a future main randomised clinical trial comparing the clinical and cost-effectiveness of SMA, exercises and/or foot orthoses for PHP.

TRIAL REGISTRATION NUMBER

ISRCTN 12160508 . Prospectively registered 5^th July 2016.

Biomechanical effects of foot orthoses with and without a lateral bar in individuals with cavus feet during comfortable and fast walking

Background/purpose

The biomechanical effects of foot orthoses (FOs) with and without a lateral bar compared to a control condition during walking at different speeds are still unknown. The objective of this study was to compare the biomechanical effects of functional FOs with and without a lateral bar to a control condition during comfortable walking in individuals with cavus feet and determine if their effects change at a fast speed.

Methods

Fifteen individuals with cavus feet (age: 25.3 ± 5.8 yrs) walked under two experimental conditions (FOs with and without a lateral bar) and a control condition (shoes only) at comfortable (CW) and fast (FW) speeds. The outcome measures were ankle and knee angles and gluteus medius, vastus lateralis, gastrocnemius lateralis, gastrocnemius medialis, peroneus longus and tibialis anterior electromyography (EMG) amplitudes during the stance phase of walking and were compared between the FOs and a control condition using one-dimensional statistical parametric mapping.

Results

During CW, both FOs decreased ankle dorsiflexion and increased knee extension angles compared to no FOs. FOs with a lateral bar also decreased peroneus longus EMG amplitudes. During FW, FOs with and without a lateral bar decreased ankle dorsiflexion angles compared to no FOs.

Conclusion

Both types of FOs had different effects on the biomechanics of the lower limb compared to a control condition. The decreased peroneus longus EMG amplitudes during CW in individuals with cavus feet could have important clinical implications in other populations, such as individuals with painful cavus feet. The orthoses only affected the ankle dorsiflexion angles at a fast speed and no EMG amplitude or knee kinematics effects were observed. Further studies assessing the ankle kinematics and kinetics effects of these orthoses are needed to improve our understanding of their mechanism of action and inform future efficacy trials.

Objective measurement of adherence to wearing foot orthoses using an embedded temperature sensor

The objective of this study was to evaluate the validity of a temperature sensor for the measurement of adherence to wearing foot orthoses. Ten participants were provided with foot orthoses containing an embedded temperature sensor and wore the orthoses for a randomly-determined duration over a five-day period. Sensor-detected wear time was compared to a reference standard (objectively measured wear time using a smart-phone application). Ambient temperature and physical activity were recorded with a temperature gauge and wearable activity tracker, respectively. A simple peak detection algorithm which identified the largest one-minute changes in sensor temperature provided highly accurate wear time values (r = 0.999, coefficient of variation=0.2%). Ambient temperature and physical activity did not significantly influence temperature sensor scores. These findings demonstrate that the temperature sensor provides accurate foot orthosis wear time data and may therefore be a useful tool for documenting adherence in clinical practice and intervention studies.

Comparison between customised foot orthoses and insole combined with the use of extracorporeal shock wave therapy in plantar fasciitis, medium-term follow-up results: A randomised controlled trial

OBJECTIVE

To determine the clinical results of custom-made foot orthoses versus placebo flat cushioning insoles combined with an extracorporeal shock wave therapy on pain and foot functionality in patients with plantar fasciitis.

DESIGN AND SETTING

A randomised controlled clinical trial with follow-up at six months. Faculty of Podiatry and Centre Clinical private of Physiotherapy, Seville, Spain.

SUBJECTS AND INTERVENTIONS

Patients with plantar fasciitis were randomly assigned to either group A (n = 42), which received custom-made foot orthoses, or group B (n = 41), which received placebo insoles. All the participants received active extracorporeal shock wave therapy including stretching exercises. Recruitment period was from Mach 2019 to July 2020.

MAIN MEASUREMENTS

The main outcome was foot pain, measured by visual analogue scale and the secondary outcome measures were recorded by Roles and Maudsley scores respectively, at the beginning and at one week, one month and six months.

RESULTS

Eighty-eight patients were assessed for eligibility. Eighty-three patients were recruited and randomised. This study showed significant differences between both groups according to the visual analogue scale. In control group, the difference was at baseline (P 0.01) and, in the experimental group was at the one- and six-month follow-up (P 0.001). The mean (SD) visual analogue scale at baseline were Control group 6.31 (1.69) and Experimental group 5.27 (1.64); and at six months were 7.52 (3.40) and 3.29 (4.26), respectively. The custom-made foot orthosis was perceived as 'good' (85%) and 'excellent' (97.5%) at medium-long term.

CONCLUSION

Wearing a custom-made foot orthosis leads to a improvement in patients with plantar fasciitis; it reduced foot pain and improved foot functionality.

Custom insoles versus sham and GP-led usual care in patients with plantar heel pain: results of the STAP-study - a randomised controlled trial

OBJECTIVES

To compare custom-made insoles to sham insoles and general practice (GP)-led usual care in terms of pain at rest and during activity at 12 weeks follow-up in individuals with plantar heel pain.

METHODS

In this randomised clinical trial 185 patients aged 18 to 65 years, with a clinical diagnosis of plantar heel pain for at least 2 weeks, but no longer than 2 years were recruited. Patients were randomly allocated into three groups: (1) GP-led treatment, plus an information booklet with exercises (usual care; n=46), (2) referral to a podiatrist for treatment with a custom-made insole plus an information booklet with exercises (custom-made insole; n=70) and (3) referral to a podiatrist and treatment with a sham insole plus an information booklet with exercises (sham insole; n=69). As well as the primary outcome of pain severity (11-point Numerical Rating Scale) we used the Foot Function Index (0 to 100) as a secondary outcome.

RESULTS

Of 185 randomised participants, 176 completed the 12-week follow-up. There was no difference in pain or function between the insole and the sham groups at 12 weeks. Participants in the GP-led usual care group reported less pain during activity at 12 weeks, (mean difference (MD) 0.94, 95% CI 0.23 to 1.65), less first step pain (MD 1.48, 95% CI 0.65 to 2.31), better function (MD 7.37, 95% CI 1.27 to 13.46) and higher recovery rates (RR 0.48, 95% CI 0.24 to 0.96) compared with participants in the custom insole group.

CONCLUSIONS

Referral to a podiatrist for a custom-made insole does not lead to a better outcome compared to sham insoles or compared to GP-led usual care.

TRIAL REGISTRATION NUMBER

NTR5346.

Feasibility Study of a Rapid Evaluate and Adjust Device (READ) for Custom Foot Orthoses Prescription

OBJECTIVE

Custom foot orthoses (CFOs) are typically used for the prevention and cure of lower extremity injuries (LEIs). Typically, CFOs are designed and prescribed based on iterative loops including: (1) follow-up loops between the patient and the physician, and (2) design feedback loops between the physician and the fabricator. The current prescription methodology has some deficiencies, i.e. excessive time to satisfactory treatment, and low repeatability in custom fabrication because of missing alignment, soft tissue considerations, and subjective feedback. There are significant opportunities to develop a new CFOs prescription procedure which can improve accuracy prior to the fabrication process by reducing time through minimizing iterations.

METHODS

First, a novel "rapid evaluate and adjust device" (READ) prescription methodology is proposed for CFO design by combining the follow-up loops with design feedback loop. To support the idea of the READ prescription method a novel 3D ergonomic measurement system (3DEMS) is developed. The 3DEMS is designed for the following key targets to: (1) improve the communication between the patient/physician and the fabricator, (2) reduce time to satisfactory treatment, (3) improve repeatability by considering the alignment and the soft tissue deformations, (4) archive digitally with minimal data, (5) reduce the system complexity, and (6) validate with plantar pressure measurements (i.e. Novel Pedar^®). The design process of the 3DEMS involved the following steps: (1) 3D data collection at the desired loading, (2) nested optimization to determine optimal segment design, and (3) system fabrication considering alignment and feedback control.

RESULTS

The results show that the READ prescription method with 3DEMS can be used to recreate the medial longitudinal arch for a range of arch height indices (AHI) by using a minimal number of parameters i.e. 6 parameters, and significant increases in mean peak pressure are observed between optimized and barefoot or flat segments.

CONCLUSION

This study establishes that the proposed READ prescription method with the 3DEMS may be used for CFOs prescription due to better communication between individuals in the follow-up and design loops, less time for satisfactory treatment, improved repeatability, archivable data, and low system complexity.

SIGNIFICANCE

The developed system may be used as measurement systems for CFOs, and in the future the proposed 3DEMS may prove highly important for the measurement of CFOs for flat feet.

The effectiveness of radial extracorporeal shock wave therapy (rESWT), sham-rESWT, standardised exercise programme or usual care for patients with plantar fasciopathy: study protocol for a double-blind, randomised, sham-controlled trial

Background

Plantar fasciopathy is a common cause of plantar heel pain, with a reported prevalence of up to 10%. The choice of best practice in these patients is debated. Two randomised studies reported that radial extracorporeal shock wave therapy is effective, but a meta-analysis concluded that due to methodological limitations, the evidence is questionable. There are few studies reporting the effect of exercise programs with high-load strength training, despite widespread use. The objective of this placebo-controlled, observer-blinded and partly patient blinded trial is to compare rESWT, sham-rESWT, standardised exercise programme and usual care for alleviating heel pain at 6 and 12 months follow-up.

Methods/design

A double-blind, randomised, sham-controlled trial is conducted at a hospital outpatient clinic of physical medicine and rehabilitation. Patients with chronic (> 3 months) pain due to plantar fasciopathy, aged 18 to 70 years old, are eligible for inclusion in the trial. Patients will be randomly allocated in 1:1 ratio to receive rESWT, sham-rESWT, standardised exercises or usual care. The sample size is estimated to 200 patients, 50 in each group. rESWT or sham-rESWT will be given once a week for 3 weeks. A physiotherapist will supervise the exercises, with a total of 8 sessions over 12 weeks. The patients in the usual care group will receive information, advice and foot orthosis only. All patients, regardless of group, will receive the same information and get an individual customised foot orthosis made by an orthopaedic technician. The primary outcome measure is heel pain intensity during activity in the last week, using a numeric rating scale (NRS, 0 to 10) at the 6 months follow-up adjusted for baseline pain intensity. The secondary outcomes are at the 6- and 12-month follow-up and include Foot Functional Index Revised Short Version (FFI-RS), Patient Global Impression of Change Scale (7-point Likert scale), RAND-12 Health Status Inventory (RAND-12), NRS during rest and NRS during activity (12 months). The patients receiving rESWT/sham-rESWT and the outcome assessor will be blinded to the group assignment.

Discussion

This trial is designed in order to provide results important for future clinical practice.

Trial registration

ClinicalTrials.gov NCT03472989. Registered on 14 March 2018

The effect of high-intensity versus low-level laser therapy in the management of plantar fasciitis: randomized participant blind controlled trial

Objectives:

To evaluate and compare the efficacy of high-intensity laser therapy (HILT) and low-level laser therapy (LLLT) for plantar fasciitis.

Design:

A participant blind randomized controlled trial with parallel group design and an active comparator with follow-up at four weeks.

Settings:

Outpatient, University hospital.

Subjects:

Unilateral plantar fasciitis participants (n = 102) were randomly assigned into two groups. Recruitment period was from January 2017 to April 2019.

Interventions:

Interventions included eight sessions of laser therapy over three weeks and single session of patient education. The HILT group (n = 51) received HILT and the LLLT group (n = 51) received LLLT.

Main measures:

Primary outcomes: visual analogue scale; secondary outcomes: pressure algometry, sonography of plantar fascia thickness (time frame: baseline to three-week and four-week follow-up) and numeric rating scale (0%–100%) for opinion of participants on effect of treatment (time frame: three weeks). Data presented: mean (SD) or n (%).

Results:

There was no statistically significant difference between the groups according to visual analogue scale (pain in general reduction in three weeks: 2.57(3.45) vs. 2.88(3.28) cm), pressure algometry (pain threshold difference between healthy and affected heel reduction in three weeks: 1.80(6.39) vs. 1.77(2.85) kg) and sonography measurements (plantar fascia thickness difference between healthy and affected heel reduction in three weeks: 0.19(0.56) vs. 0.30(0.57) mm). There was a statistically significant difference between the groups in participants’ opinion in favor to HILT group (efficacy of treatment better than 50%: 26(51%) vs. 37(73%)).

Conclusion:

No statistically significant difference between groups was observed.

Foot exercise plus education versus wait and see for the treatment of plantar heel pain (FEET trial): a protocol for a feasibility study

Background

Plantar heel pain (PHP) is present in a wide range of individuals and creates significant burden to quality of life and participation in physical activity. The high recurrence rates and persistence of PHP suggests current management options may not address all potentially modifiable factors associated with the condition. Reports of intrinsic foot muscle (IFM) atrophy in individuals with PHP, together with biomechanical evidence of their important contribution to optimal foot function, suggests that an intervention focused on IFM training may be beneficial in managing PHP. We will test the feasibility of a prospective, assessor-blinded, parallel-group, randomised clinical trial that compares foot exercise plus education to brief advice in individuals with PHP.

Methods

Twenty participants with PHP will be randomly allocated to one of two groups for a 12-week intervention period: (i) foot exercise plus education, or (ii) brief advice. The foot exercise plus education group will attend eight sessions with a physiotherapist and receive detailed education on self-management strategies as well as a progressive exercise program for the IFMs. The brief advice group will attend one session with a physiotherapist and receive brief information about self-management strategies and reassurance. Outcome measures will be obtained at baseline and the primary end-point of 12 weeks. Primary outcomes will be the feasibility of conducting a full-scale randomised clinical trial (RCT), and the credibility and acceptability of the foot exercise plus education intervention. Secondary outcomes will explore treatment effects, which will consist of pain, physical function, physical activity level, pain self-efficacy, perceived treatment effect, magnetic resonance and ultrasound image measurement of IFM morphology, ultrasound imaging measurement of plantar fascia thickness, IFM motor performance, foot posture, foot mobility, ankle dorsiflexion range of motion, toe flexor and plantar flexor strength/endurance.

Discussion

To reduce the burden of PHP on individuals and society, there is a need to establish effective treatments that are feasible and accepted by patients and health professionals. This trial will be the first to evaluate the feasibility of conducting a full-scale RCT, as well as the credibility, acceptability, and treatment effects, of education and foot exercise for PHP. The findings of this study will inform the development of a full-scale RCT.

Trial registration

The trial protocol was prospectively registered with the Australia and New Zealand Clinical Trial Registry (ACTRN12619000987167) on 11th July 2019.

Effectiveness of a Double Air-Cushioned Shoe Compared with Physiotherapy in the Treatment of Plantar Fasciitis

Objective

This study was aimed at comparing the plantar fasciitis treatment effect of a double air-cushioned shoe to that of physiotherapy combined with ESWT.

Methods

Retrospective chart review of 40 patients diagnosed with plantar fasciitis was performed. Group 1 wore a double air-cushioned shoe for 2 months, and group 2 underwent physiotherapy with ESWT once/week over a 4-week period. The foot function index (FFI) score was obtained at the initial visit, 1 month, and 2 months.

Results

There were 25 patients in group 1 and 15 patients in group 2. The pretreatment FFI was 62.6 for group 1 and 50 for group 2. The 1-month posttreatment FFI was 45.6 for group 1 and 35.7 for group 2. The 2-month posttreatment FFI was 35 for group 1 and 43.1 for group 2. In both groups 1 and 2, follow-up FFIs were significantly improved from the initial FFI (p < 0.05) and there were no significant differences between two groups (p > 0.05).

Conclusions

The double air-cushioned shoe can be considered an alternative treatment option for noninvasive treatment of early-stage plantar fasciitis.

Lived experience and attitudes of people with plantar heel pain: a qualitative exploration

Background

Plantar heel pain is a common source of pain and disability. Evidence-based treatment decisions for people with plantar heel pain should be guided by the best available evidence, expert clinical reasoning, and consider the needs of the patient. Education is a key component of care for any patient and needs to be tailored to the patient and their condition. However, no previous work has identified, far less evaluated, the approaches and content required for optimal education for people with plantar heel pain. The aim of this study was to gather the patients’ perspective regarding their lived experience, attitudes and educational needs in order to inform the content and provision of meaningful education delivery approaches.

Methods

Using a qualitative descriptive design, semi-structured interviews were conducted with participants with a clinical diagnosis of plantar heel pain. A topic guide was utilised that focused on the experience of living with plantar heel pain and attitudes regarding treatment and educational needs. Interviews were audio recorded, transcribed verbatim and analysed using the Framework approach. Each transcription, and the initial findings, were reported back to participants to invite respondent validation.

Results

Eighteen people with plantar heel pain were interviewed. Descriptive analysis revealed eight themes including perceptions of plantar heel pain, impact on self, dealing with plantar heel pain, source of information, patient needs, patient unmet needs, advice to others and interest in online education. Participants revealed doubt about the cause, treatment and prognosis of plantar heel pain. They also expressed a desire to have their pain eliminated and education individually tailored to their condition and needs. Respondent validation revealed that the transcripts were accurate, and participants were able to recognise their own experiences in the synthesised themes.

Conclusion

Plantar heel pain has a negative impact on health-related quality of life. Participants wanted their pain eliminated and reported that their expectations and needs were frequently unmet. Health professionals have an important role to be responsive to the needs of the patient to improve their knowledge and influence pain and behaviour. Our study informs the content needed to help educate people with plantar heel pain.

Effectiveness of physical therapy treatment in addition to usual podiatry management of plantar heel pain: a randomized clinical trial

Background

Many patients will seek care from a podiatrist for plantar heel pain (PHP), while few of these patients will also be seen by a physical therapist. Physical therapists can provide treatment that is not a part of routine podiatric care for PHP and may provide additional improvement. Therefore, the purpose of this study was to examine the effects of interdisciplinary care for PHP that incorporated physical therapy treatment after initiating podiatric treatment.

Methods

Eligible individuals with PHP that presented to a podiatrist were randomized to receive usual podiatric care (uPOD) or usual podiatric care plus physical therapy treatment (uPOD+PT). The primary outcome was change in foot and ankle ability measure (FAAM) at 6-months. Secondary outcomes included change in numeric pain rating scale (NPRS), patient-reported success, and 6-week and 1-year endpoints. Patient-reported success was defined as the top two global rating of change scale rankings. Primary analysis was intention-to-treat (ITT) using analysis by covariance adjusted to baseline scores, and a secondary per-protocol (PP) analysis was performed analyzing only those who completed treatment.

Results

Ninety-five individuals participated and were included in the ITT analysis, and 79 were included in the PP analysis. For the primary outcome of FAAM change from baseline to 6-months, both groups improved significantly (uPOD+PT: 26.8 [95% CI 21.6, 31.9]; uPOD: (20 [15.6, 24.4]), but there was no between-group difference (4.3 [− 1, 9.6]). For secondary outcomes, the uPOD+PT group demonstrated greater improvement in NPRS at 6 weeks (0.9 [0.3, 1.4]) and 1 year (1.5 [0.6, 2.5]) in the ITT analysis. In the PP analysis, the uPOD+PT group demonstrated greater improvement in FAAM at 6 months (7.7 [2.1, 13.3]) and 1 year (5.5 [0.1, 10.8]), NPRS at 6 weeks (0.9 [0.2, 1.6]), 6 months (1.3 [0.6, 2.1]) and 1 year (1.3 [0.6, 2.1]), and in patient-reported success (relative risk [95% CI]) at 6 weeks (2.8 [1.1, 7.1]), 6 months (1.5 [1.1, 2.1]), and 1 year (1.5 [1.1, 1.9]).

Conclusions

There was no significant benefit of uPOD+PT in the primary outcome of FAAM change at 6 months. Secondary outcomes and PP analysis indicated additional benefit of uPOD+PT, mostly observed in individuals who completed treatment.

Trial registration

Prospectively registered May 24, 2013 at www.clinicaltrials.gov (NCT01865734).

Incidence, prevalence, and management of plantar heel pain: a retrospective cohort study in Dutch primary care

BACKGROUND

Plantar heel pain (PHP) is a common cause of foot complaints in general practice. However, information on the occurrence and practical management is scarce.

AIM

The aim of this study was to determine the incidence and prevalence of PHP in Dutch primary care and to gain insight into the types of treatments provided to patients with PHP in primary care.

DESIGN AND SETTING

A cohort study was conducted using a healthcare database containing the electronic general practice medical records of approximately 1.9 million patients throughout the Netherlands.

METHOD

A search algorithm was defined and used to identify cases of PHP from January 2013 to December 2016. Descriptive statistics were used to obtain the incidence and prevalence. Data on the management of PHP were manually validated in a random sample of 1000 patients.

RESULTS

The overall incidence of PHP was 3.83 cases (95% confidence interval [CI] = 3.77 to 3.89) per 1000 patient-years, the incidence in females was 4.64 (95% CI = 4.55 to 4.72), and 2.98 (95% CI = 2.91 to 3.05) in males. The overall prevalence of PHP was 0.4374% (95% CI = 0.4369 to 0.4378%). Incidence of PHP peaked in September and October of each calendar year. The most commonly applied strategies were a wait-and-see policy (18.0%, n = 168), use of non-steroidal anti-inflammatory drugs (NSAIDs) (19.9%, n = 186), referral to a paramedical podiatric specialist (19.7%, n = 184), and advice to wear insoles (16.4%, n = 153). Treatment strategies varied greatly among GPs.

CONCLUSION

There was large variation in treatment strategies of GPs for patients with PHP. GPs should be aware of conflicting evidence for interventions, such as insoles, and focus more on exercises for which there is evidence for effectiveness.

Effectiveness of Mechanical Treatment for Plantar Fasciitis: A Systematic Review

CONTEXT

Plantar fasciitis is one of the most common foot injuries. Several mechanical treatment options, including shoe inserts, ankle-foot orthoses, tape, and shoes are used to relieve the symptoms of plantar fasciitis.

OBJECTIVES

To investigate the effectiveness of mechanical treatment in the management of plantar fasciitis.

EVIDENCE ACQUISITION

The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. A systematic search was performed in PubMed, CINAHL, Embase, and Cochrane up to March 8, 2018. Two independent reviewers screened eligible articles and assessed risk of bias using the Cochrane Collaboration's risk of bias tool.

EVIDENCE SYNTHESIS

A total of 43 articles were included in the study, evaluating 2837 patients. Comparisons were made between no treatment and treatment with insoles, tape, ankle-foot orthoses including night splints and shoes. Tape, ankle-foot orthoses, and shoes were also compared with insoles. Follow-up ranged from 3 to 5 days to 12 months. Cointerventions were present in 26 studies.

CONCLUSIONS

Mechanical treatment can be beneficial in relieving symptoms related to plantar fasciitis. Contoured full-length insoles are more effective in relieving symptoms related to plantar fasciitis than heel cups. Combining night splints or rocker shoes with insoles enhances improvement in pain relief and function compared with rocker shoes, night splints, or insoles alone. Taping is an effective short-term treatment. Future studies should aim to improve methodological quality using blinding, allocation concealment, avoid cointerventions, and use biomechanical measures of treatment effects.

Managing the patient with heel pain

Heel pain presents frequently to primary care, commonly affecting athletic and elderly patients. Its presentation can be a common source of confusion for clinicians given the wide variety of differential diagnoses and the similarities in presenting symptoms and signs. This review classifies heel pain according to site of pain and explores the common pathologies clinicians may encounter. A brief summary of common imaging modalities used is provided. The literature is reviewed to guide evidence-based practice and to provide a framework to help clinicians investigate and manage heel pain before onward referral for specialist intervention. A linked article detailing the imaging of heel pain is included in this issue ( https://doi.org/10.12968/hmed.2019.80.4.192 ).

Topographical Pressure Pain Sensitivity Maps of the Feet Reveal Bilateral Pain Sensitivity in Patients With Unilateral Plantar Heel Pain

BACKGROUND

Plantar heel pain is one of the most common foot pain conditions treated by health care providers.

OBJECTIVES

To investigate differences in topographical pressure pain sensitivity maps of the feet between patients with unilateral plantar heel pain and healthy individuals, and to determine the relationship between topographical pressure maps, pain intensity, disability, and fascia thickness.

METHODS

Thirty-five patients with unilateral plantar heel pain and 35 matched healthy controls participated in this cross-sectional, case-control study. Pressure pain thresholds (PPTs) were assessed over 7 plantar locations on each foot. Topographical pressure pain sensitivity maps of the plantar region were generated using the averaged PPT of each assessed point. Pain and related disability were assessed with a numeric pain-rating scale (0-10) and the Foot and Ankle Ability Measure, respectively. Plantar fascia thickness was measured via ultrasound. All outcomes were obtained by an assessor blinded to the participants' condition.

RESULTS

Topographical pressure sensitivity maps revealed lower bilateral PPTs in patients with plantar heel pain compared to healthy controls, and a higher PPT on the calcaneus bone (P<.01). Women had lower PPTs than men in all areas (P<.001). Individuals with plantar heel pain also had thicker fascia, but only on the affected side, compared to healthy controls. Higher pressure pain sensitivity in the foot was associated with higher pain intensity at first step in the morning and thicker fascia at the calcaneus bone.

CONCLUSION

People with unilateral plantar heel pain had generalized bilateral pressure pain sensitivity in the plantar region of the foot. Greater pain intensity and fascia thickness were associated with higher pressure pain sensitivity in people with plantar heel pain.

LEVEL OF EVIDENCE

Case-control study, level 4. J Orthop Sports Phys Ther 2019;49(9):640-646. Epub 26 Mar 2019. doi:10.2519/jospt.2019.8813.

Effectiveness of Foot Orthoses Versus Corticosteroid Injection for Plantar Heel Pain: The SOOTHE Randomized Clinical Trial

BACKGROUND

Plantar heel pain is a common foot complaint that causes significant disability and poorer health-related quality of life. Foot orthoses and corticosteroid injection are effective treatments for plantar heel pain; however, it is unclear whether one is more effective than the other.

OBJECTIVE

The aim of this trial was to compare the effectiveness of foot orthoses and corticosteroid injection for plantar heel pain.

METHODS

In this parallel-group, assessor-blinded, randomized clinical trial, participants received prefabricated, arch-contouring foot orthoses or a single ultrasound-guided corticosteroid injection. The primary outcome measure was the foot pain subscale of the Foot Health Status Questionnaire at 4 and 12 weeks.

RESULTS

One hundred three participants aged 21 to 72 years (63 female) with plantar heel pain were recruited from the community and received an intervention. For the primary outcome of foot pain, corticosteroid injection was more effective at week 4 (adjusted mean difference, 8.2 points; 95% confidence interval: 0.6, 15.8 points). However, foot orthoses were more effective at week 12 (adjusted mean difference, 8.5 points; 95% confidence interval: 0.2, 16.8 points). Although these findings were statistically significant, the differences between the interventions did not meet the previously calculated minimal important difference value of 12.5 points.

CONCLUSION

Corticosteroid injection is more effective than foot orthoses at week 4, but this effect does not last; and appropriately contoured foot orthoses are more effective than corticosteroid injection at week 12. However, patients may not notice a clinically worthwhile difference between the interventions.

LEVEL OF EVIDENCE

Therapy, level 1b. J Orthop Sports Phys Ther 2019;49(7):491-500. Epub 26 May 2019. doi:10.2519/jospt.2019.8807.

The effect of a heel-unloading orthosis in short-term treatment of calcaneus fractures on physical function, quality of life and return to work - study protocol for a randomized controlled trial

BACKGROUND

There are no standardized therapy guidelines for rehabilitation of calcaneus fractures. While there is consensus on non or partial weight-bearing, the use of supporting devices such as specific foot ankle orthosis is still a matter of debate. Recently, a heel-unloading orthosis ("Settner shoe") was introduced for aftercare of these fractures, allowing walking by shifting the load to the middle-foot and forefoot. This orthosis enables early mobilization of patients suffering from either one-sided or two-sided fractures. The Settner shoe can be applied in non-operative therapy and after surgery. Specifically in calcaneus fractures, early regain of physical activity has been highlighted as one of the key factors for quality of life and the ability to return to work. Thus, we hypothesize that mobilization with the Settner shoe results in improved quality of life and greater physical activity within the first 3 months.

METHODS

This is going to be analyzed by a randomized controlled study comparing treatment with and without this specific orthosis. The secondary outcome measure is the time point of return to work in patients aged between 18 and 60 years, with calcaneus fracture. Furthermore, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 3-dimensional gait analysis, and the Euroqol-5 dimension-3 level (EQ-5D-3 L) questionnaire for quality of life are assessed.

DISCUSSION

This is the first trial applying a standardized rehabilitation protocol in patients with calcaneus fractures, aiming to improve the non-operative part of treatment by use of an orthosis.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03572816 . Registered on 27 July 2018.

Effectiveness of Manual Therapy, Customised Foot Orthoses and Combined Therapy in the Management of Plantar Fasciitis-a RCT

Background: Plantar fasciitis (PF) is one of the most common causes of plantar heel pain. Objective: To evaluate the effectiveness of three different treatment approaches in the management of PF. Methods: Sixty-three patients (44 female, 19 men; 48.4 ± 9.8 years) were randomly assigned into a manual therapy (MT), customised foot orthosis (FO) and a combined therapy (combined) group. The primary outcomes of pain and function were evaluated using the American Orthopaedic Foot and Ankle Society-Ankle Hindfoot Scale (AOFAS-AHS) and the patient reported outcome measure (PROM) Foot Pain and Function Scale (FPFS). Data were evaluated at baseline (T0) and at follow-up sessions after 1 month, 2 months and 3 months (T1–T3). Results: All three treatments showed statistically significant (p < 0.01) improvements in both scales from T0 to T1. However, the MT group showed greater improvements than both other groups (p < 0.01). Conclusion: Manual therapy, customised foot orthoses and combined treatments of PF all reduced pain and function, with the greatest benefits shown by isolated manual therapy.

Effectiveness of interventions to increase physical activity in individuals with intellectual disabilities: a systematic review of randomised controlled trials

BACKGROUND

People with intellectual disabilities (ID) often do not meet recommended guidelines for physical activity. The aim of this study was to systematically review available evidence that evaluated the effectiveness of interventions to increase physical activity in individuals with ID.

METHOD

Five electronic databases (MEDLINE, CINAHL, EMBASE, SPORTDiscus and Cochrane Central Register of Controlled Trials) were searched from inception of the database to July 2017 to identify randomised controlled trials that evaluated the effectiveness of interventions to improve physical activity among people with ID. Trials were included if they measured at least one objective measure of physical activity. Quality appraisal was completed by two independent reviewers using the Cochrane Risk of Bias Tool. The magnitude of treatment effect was estimated for each intervention by calculating the standardised mean difference (SMD) and associated 95% confidence interval.

RESULTS

Nine randomised controlled trials (976 participants, 501 women, age range 9 months to 83 years) were included. Four trials evaluated unimodal interventions and five trials evaluated multimodal health promotion programmes based on using supportive environments to enable sustained behavioural changes in physical activity. None of the trials were rated as low risk of bias as all had at least one item on the Cochrane Risk of Bias Tool that was considered to be high risk. No trials were able to implement participant blinding. Three trials found statistically significant beneficial effects of interventions for increasing physical activity. Results showed that a 10-week progressive resistance training programme led to maintenance of physical activity levels at 24 weeks in adolescents with Down syndrome (SMD 0.78, 95% CI 0.17 to 1.40). Additionally, a 12- to 16-month multicomponent diet and physical activity programme produced improvement in physical activity at programme completion in adults with ID (reported effect size of 0.29). Finally, an 8-month physical activity and fitness programme increased physical activity at 8 months in adults with ID (SMD 0.91, 95% CI 0.20 to 1.60). Findings regarding other interventions were inconclusive with small effects that were not statistically significant.

CONCLUSIONS

There is inconsistent evidence of the effects of interventions for improving physical activity levels in individuals with ID. A progressive resistance training programme was found to maintain physical activity levels in adolescents with Down syndrome, while a multicomponent diet and physical activity programme and a physical activity and fitness programme were found to improve physical activity levels in adults with ID. Future trials using rigorous research designs are required to confirm these findings and establish whether other interventions designed to increase physical activity in people with ID are effective.