Managing Heel Pain An Evidence Based Approach. Michael Ratcliffe Sales Training Manager Cuxson Gerrard & Co. Ltd.

Transcription

1 Managing Heel Pain An Evidence Based Approach Michael Ratcliffe Sales Training Manager Cuxson Gerrard & Co. Ltd.

2 Objectives Offer a systematic approach to obtaining appropriate evidence Using this approach to review the current evidence when managing heel pain

3 What constitutes evidence? According to David Sackett, the creator of the concept of evidence-based medicine and pilot user of The Cochrane Library, it is; the integration of best research evidence with clinical expertise and patient values. (Sackett et al. 2000) Evidence based practice is the refining of the information on which clinical decisions are made. Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB. Evidencebased Medicine: How to practice and teach EBM. Edinburgh: Churchill Livingstone, 2000

4 Introduction Heel pain generally synonymous with plantar/inferior heel pain but encapsulates all aspects of the heel/rearfoot complex so large number of considerations before making a therapy choice when we look at searching for evidence to support our therapy choice we need to form an accurate search question

5 Sites of pain and structures involved Posterior (Less common) Achilles tendon insertion Superficial calcaneal bursa Posterior impingement of soft-tissues/os trigonum in active people Calcaneal apophysis in adolescents (Sural Nerve) Inferior (Less common) Plantar fascia Calcaneal fat pad (Medial or lateral calcaneal nerve, especially as they split from the tibial branch) Deep Vague Pain (less common) Subtalar joint (Bone pain: calcaneus, talus, navicular)

6 Sites of pain and structures involved Medial (less common) Tibialis posterior tendon and sheath Tibialis posterior insertion and apophysis in adolesents (FHL and sheath, abductor hallucis, deltoid and spring ligaments, tibial nerve in tarsal tunnel, medial malleolus) Lateral (less common) Lateral ligaments on the ankle Sinus tarsi (Peroneal tendonopathy or tenosynovitis associated with subluxation, peroneus brevis insertion/apophysis of base of 5 th metatarsal in adolescents or after ankle sprain Adapted from; Rio E., Mayers S. and Cook J. Heel pain: a practical approach. Australian Family Physician 2015 Mar;44(3):

7 Forming a clinical question The amount of evidence that is generated daily is vast how can we keep up? Do I need to? How do we find out the information we need? We must ask focused questions that pull the answers from the research Glasziou P., Del Mar C. and Salisbury J. (2007) Evidence-Based Practise Workbook 2 nd Ed.. BMJI Books Blackwell Publishing, Oxford.

8 What type of clinical question are we asking? When managing heel pain generally we are asking an intervention question e.g. taping/strapping/splinting, stretching, orthoses, activity/footwear modification, ECSWT, injection, acupuncture, casting, surgery, weight loss, platelet-rich plasma injections, MMC, etc. We could also ask questions about; aetiology/risk factors e.g. fascial thickening/loss of elasticity, quantity of ankle joint dorsiflexion, diabetes/fat pad thickening, R/A and O/A, oedema, cancer, infection, age, BMI*, time standing*, trauma (repetitive loading), physical inactivity* diagnosis e.g. site, structure, palpation/rom, history taking/assessment, medical imaging, force/pressure measurements, prognosis and prediction e.g. pain duration, time to functional restoration frequency and rate i.e. prevalence e.g. 1 in 8 people > 50 years will develop posterior heel pain* and incidence phenomena/thoughts i.e. more general questions *Chatterton B.D., Muller S. and Roddy E. Epidemiology of posterior heel pain in the general population: cross sectional findings from the Clinical Assessment Study of the Foot. Arthritis Care and Research (Hoboken) 2015 Jan 20. (Accepted Article) doi: /acr

9 Where do I look? If you are employed by an academic institution or the NHS you will probably have access to a large range of databases e.g. AMED, EMBASE, CINAHL, MEDLINE If not then you still access to powerful search engines and databases e.g. The Cochrane Collaboration and MedLine through PubMed

10 Where do I look? Cochrane Collaboration (Cochrane Database of Systematic Reviews) a database produced by John Wiley and Sons Ltd. (a medical publisher) containing approximately 5000 Cochrane Systematic Reviews of high quality controlled experimental trials in medicine and health care. Look here first for any systematic reviews

11 Where do I look? PubMed - a free internet search engine that is maintained by the National Center for Biotechnology Information (NCBI), at the U.S. National Library of Medicine (NLM) PubMed draws from MedLine (amongst others including U.K. based BioMed Central) the database of the U.S. National Library of Medicine consisting primarily of scholarly, peer reviewed journals (approximately 5600 worldwide from 1945 to present) and concentrating on biomedicine and health.

12 Let s form a focused intervention/management question - (P.I.C.O.) Glasziou et al. 2007, points out that to help us find the answer we what from the evidence (if it exists), then it is useful to think about and form your question by first breaking down what it is that you want to know P population and problem i.e who are the relevant people I intervention/indicator i.e the treatment you want to find out more about C comparator i.e. an alternative to the intervention you want to find out about O outcome i.e. what you or your patient want to happen (or not) Glasziou P., Del Mar C. and Salisbury J. (2007) Evidence-Based Practise Workbook 2nd Ed.. BMJI Books Blackwell Publishing, Oxford p.24

13 Question Mr. X attends your clinic c/o pain on the bottom his heel which has build up gradually over some months and is now painful following periods of rest. He would like to be without pain. You have heard that low dye taping provides initial pain relief and would like to find out if there is any evidence to support this

14 Using PICO Population adult/plantar heel pain/plantar fasciitis Intervention low dye taping Comparator nothing Outcome pain reduction

15 Further Help

16

17

18

19

20 What did we find? Authors/date Study design/n Findings Podolsky R, Kalichman L Van Lunen B. et al Abd El Salam MS, Abd Elhafz YN Radford JA et al Osbourne HR, Allison GT Lansdorf KB. et al Systematic review Cross over, (orthosis, l/d, control) n=17 Randomised clinical trial, l/d v. med.arch support ( U/S + stretching) n=30 Single blinded RCT (control=sham U/S) n=92 Double blinded RCT iontopheresis dexamethosone/acetic acid (l/d + stretching) n=31 (42f) Comparison study n=60 with and 45 without, 3-5 days Low dye and calcaneal taping best in short term, no long term studies Stat and clinically lower VAS scores short term mas.>l/d stat sig improvement in VAS short term L/d = stat sig. reduc. in VAS 1 st step 1/52 t/t Acetic acid>dexa in reducing stiffness symptoms over 4/52 L/d>without in reducing pain 31mm on VAS

21 Searching for an intervention e.g. most effective intervention in Sever s Disease Search terms - (child* OR adolescents) AND calcaneal apophysitis in PubMed (no results from Cochrane) (Google Scholar 97,700 results!) Search results 10 trials and 1 systematic review Systematic Review James AM. et al. (2013), results The limited evidence indicated that orthoses provided greater short-term pain relief than heel raises. 2 trials since SR 1. Wiegerinck JL et al. (2015) pragmatic trial wait and see/silicone heel cup/eccentric stretching over 10/52, all sig. reduced pain at 3/12 agree with parents on acceptable course 2. James et al. (2015) - early management focusing on the anthropometric differences (BMI, weight waist circ., foot posture, A/J ROM, and height) may minimize the intensity and duration of pain experienced.

22 Searching for evidence of efficacy via intervention/treatment Extracorporeal shock wave therapy Stretching Orthosis therapy Weight Loss Radiofrequency microtenotomy Platelet-rich plasma injections Micromobile compression Kinesiotaping

23 Extracorporeal shock wave therapy Search term (extracorporeal shock wave therapy) AND (chronic plantar fasciitis) Results 29 clinical trails and 11 systematic reviews General agreement in reviews (Yin MC. et al. 2014), from good quality trails that ECSWT is efficacious and indicated in providing pain relief from 6 months + plantar fasciitis although long term effects are not clear as long term follow up studies are lacking Care; post 6 months may indicate fibroma should image to confirm

24 Stretching and plantar heel pain Search term; stretching AND (heel pain) Results 18 trials from and 9 systematic reviews General consensus that (eccentric) stretching relieves pain and improves function in the Achilles tendon and stretching relieves pain in the p/f in the short term; long term follow up is inconclusive

25 Orthosis therapy and plantar heel pain Search terms; (prefabricated orthoses) AND plantar OR lateral OR medial OR posterior (heel pain) Results 20 trials but only 10 were relevant and 6 systematic reviews but only 2 relevant Changing the search terms; (prefabricated orthoses) AND plantar fasciitis offered 9 trials and 2 systematic reviews Generally both prefabricated and custom made orthoses offer 1 st step relief and general pain relief and improved comfort on walking (but not specific on effect of sham devices

26 Weight Loss and plantar heel pain.search terms; (weight loss) AND (foot pain) Results 2 relevant trials and 1 relevant systematic review BMI of 25 (the target for decreased cardiovascular risk) represents a reasonable goal for weight loss that may reduce heel pain (Rano et al. 2001) there is currently limited evidence to support weight loss to reduce foot pain. (Butterworth et al. 2012) The evidence indicates that obesity is strongly associated with planus (low-arched) foot posture, pronated dynamic foot function and increased plantar pressures when walking. (Butterworth et al. 2014

27 Evidence for heel raises in shoe for retro-calcaneal bursitis Search terms; retrocalcaneal bursitis AND treatment Results; 13 trials (4 relevant to non surgical intervention in RB) no evidence could be found specifically for heel raises in PubMed. Google Scholar; retrocalcaneal bursitis and treatment 9,500 results! (1 relevant paper- Lee et al in Europe PubMed Central database), heel raises between 1.9 to 5.7 cm reduces the gastroc. activity and is therefore indicated in the t/t of RCB

28 Miller LE., Latt DL. Chronic Plantar Fasciitis is Mediated by Local Haemodynamics: Implications for Emerging Therapies. North American Journal of Medical Science. 2015; 7(1): 1-5 Emerging therapies for chronic plantar fasciitis Radiofrequency microtenotomy used to treat chronic tendinopathies, creates acute inflammatory response around tendon and encourages an extensive proliferation of vascular cells and new blood vessel formation within 28 days. Case series only/no comparative studies to date promising outcomes for chronic p/f Image from cosmanmedical.com

29 Emerging therapies for chronic plantar fasciitis Platelet-rich plasma injections not new but of increasing interest in chronic p/f treatment. Patient s own platelets are re-injected around site thought to enhance fibroblast migration and proliferation, increase local vascularisation and collagen deposition. Case series only, no comparative studies but satisfaction rates 45% at 6 months and 79-96% at 1 year follow up. Miller LE., Latt DL. Chronic Plantar Fasciitis is Mediated by Local Haemodynamics: Implications for Emerging Therapies. North American Journal of Medical Science. 2015; 7(1): 1-5

30 Emerging therapies for chronic plantar fasciitis Micromobile compression non-invasive and encourages deep vein circulation via pulsed pressure to the plantar venous plexus.theory - Increases perfusion through p/f microvasculature and promote healing 1 case study (2 year history of pain) to date led to increased activity over a 2 month period. Planned RCT this year. Image from footbeat.com Miller LE., Latt DL. Chronic Plantar Fasciitis is Mediated by Local Haemodynamics: Implications for Emerging Therapies. North American Journal of Medical Science. 2015; 7(1): 1-5

31 Kinesio Taping and Plantar Fasciitis Search term; kinesiotaping AND plantar fasciitis general search in PubMed as Clinical Queries search gave no result. 1 systematic review (Morris D. et al. 2013) featuring 1 RCT where kinesiotape combined with physiotherapy beneficial in the short term. Concluded insufficient evidence that kinesiotape can be used over other interventions

32 Summary Important to keep up to date with interventions for heel pain Form a search question Use the words from the question to enter into a database or search engine Decide what is relevant to your search Reflect on findings/inferences and use or shelve