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Plantar heel pain
Accepted Manuscript Plantar heel pain Warrick McNeill, Dip.Phyty. (NZ) MCSP, Mark Silvester, Dip. Phty., Dip Manip. Ther., Adv Dip. Phty. (NZ) PII:
S1360-8592(16)30257-1
DOI:
10.1016/j.jbmt.2016.11.001
Reference:
YJBMT 1440
To appear in:
Journal of Bodywork & Movement Therapies
Please cite this article as: McNeill, W., Silvester, M., Plantar heel pain, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.11.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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PREVENTION & REHABILITATION: EDITORIAL Plantar heel pain First Steps
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A patients description of rising in the morning, placing their feet upon the floor, and taking their first step with the associated report of the pain elicited under the foot (see fig. 1), usually alerts the health professional to the likely possibility that the diagnosis will be related to the plantar fascia. The pain may subside and return later in the day particularly if the patient has been on their feet, but improves with rest. Heel pain can also present following an increase in weight bearing activity. (McPoil et al 2008, Martin et al 2014, Berbrayer and Fredericson 2014). The diagnosis of Plantar fasciopathies is made by assessing the clinical picture as there is not a gold standard test for the condition (Beeson 2014).
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Heel pain affects millions of people worldwide and is divided into two broad categories, posterior heel pain, and inferior (plantar) pain. Posterior heel pain most commonly is related to the Achilles tendon and its increasing prevalence can be associated with the continuation of exercise into older age (Dinneen et al 2016). This editorial focuses on inferior heel pain, of which Rosenbaum et al (2014) suggests that ‘plantar fasciitis is the most common culprit, accounting for 80% of patients with inferior heel pain,’ and is predicted to affect 1 in 10 people in their lifetime. They suggest that mechanical, rheumatologic or neurologic conditions can all present with plantar heel pain. Hossain and Makwana (2011) suggest that pain in the plantar heel area be initially named Heel pain syndrome (HPS) until clarification of the symptoms can establish a firm diagnosis.
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Plantar Fasciitis, Fasciosis or Fasciopathy?
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Berbayer and Fredericson (2014) differentiate acute plantar heel pain symptoms produced by inflammation, and, chronic pain in the same region, from degenerative causes. As the clinical course of plantar fasciopathy follows a predictable path they identify the acute phase as lasting 4 weeks, a sub-acute phase which persists from 4 weeks to 3 months and a chronic phase that goes beyond 3 months. Despite inflammation being cited as a primary cause there is little evidence to support the use of NSAID’s (nonsteroidal anti-inflammatory drugs) in the papers they quote. NSAID’s are typically prescribed in conjunction with other interventions as part of a trial of conservative measures, and 76% of patients report improvement with their use, (Wolgin et al 1994). Lemont et al’s (2003) view that ‘Plantar Fasciitis’ is a condition without signs of classic inflammation, swelling, erythema or macrophage infiltration and is characterised, on histological examination, by chronic degenerative tissue changes, and therefore should be renamed plantar fasciosis, is continuing to gain traction (Hossain and Makwana 2011) and reflects the sea-change reappraisal of the clinical nature of tendinopathies (Maffulli et al 2003, McNeill 2015). The use of the term plantar fasciopathy blends the inflammatory and degenerative elements to the condition. Insert fig.2 about here
Rosenbaum et al (2014) still state that NSAID’s are an appropriate treatment for HPS, which may reflect the view that there is an inflammatory pathway to plantar fasciopathy (see fig. 2) as well as a degenerative one. Rose and Singh (2016) appear to agree, they describe; acute events with a sudden onset of pain during sporting activities as possibly being ‘plantar fascia tears’ and best treated by ice, NSAID’s and immobilisation till symptoms reduce, and a stiff soled boot for 6 weeks, or, ‘peri-fascial oedema’ again best treated with oral NSAID’s or even an ultrasound guided steroid injection above the plantar fascia (see steroid injection discussion later). Table 1. Alternate diagnoses to Plantar fascia related causes of inferior heel pain Bone Calcaneal stress Fracture Calcaneal bone marrow oedema
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As HPS involves many different diagnoses (see Table 1.) that require quite different treatment approaches it is clear that an understanding of the structure of the inferior heel area, the biomechanics of the foot, the risk factors associated with injury and an assessment process is imperative if the path to recovery is to be maximised by the treating Clinician. Anatomy Biomechanics and Risk Factors
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The Plantar fascia is actually a broad fibrous triangular aponeurosis extending from the medial and anterior undersurface of the calcaneum to the base of the five proximal phalanges, it travels in a constantly present central band, though in some, the medial and/or lateral bands are missing (Hossain and Makwana 2011). The intrinsic muscles of the foot are compartmentalised by the Plantar fascia. Posteriorly it is contiguous with the Achilles tendon and when the calf musculature contracts, the plantar fascia is tightened by this connection. The structure of the stress dissipating fibrocartilage attachment to the medial calcaneal tubercle helps the aponeurosis to withstand significant loads.
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The inferior heel is protected by its fat pad, which acts as a shock absorber, the reinforced, fat globule filled honeycomb fat pad is known to degenerate beyond 40 years of age, losing thickness and height, while softening and reducing its protection of the heel (Rosenbaum 2014) , not surprising when the heel’s fat pad has to dissipate 250% of body weight while running (Rosenbaum 2014). Beeson (2014) describes an increasing thickness of the heel pad, but with the same effect of a loss of heel pad elasticity. The fat pad of symptomatic feet presents a significantly lower energy dissipation ratio when compared to asymptomatic feet (Wearing et al 2009). When a patient reports pain on prolonged standing, bilateral pain and night pain, but without first step pain, heel pad atrophy may well be implicated (Martin et al 2014).
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The role of the plantar fascia is to help support the arch of the foot via the skeletal truss formed by the hind foot and forefoot and held along the bottom by the aponeurotic structure. A pes planus foot is predicted to apply greater loads to the plantar fascia and this matches the risk factor of over-pronation in HPS. Beeson (2014) quotes 8 papers linking over pronation as a key risk factor in plantar fasciopathies, at odds with Hossain and Makwana’s (2011) view that over-pronation has not been verified as a risk factor, see Table 2. As it is, the gait cycle adds tension to the plantar fascia from heel strike to just before mid stance and the tightening fascia prevents excessive pronation, unless the foot is dysfunctional (Walden 2015A). The windlass tightening effect (see fig. 3) is used for propulsion. The intrinsic muscles of the foot assist in the creation of the desirably timed supinated and stiffened foot, and their loss of function, atrophy or over length reduces movement efficiencies.
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A high body mass index (BMI) is a significant risk factor in one major group of patients, the over 40, often female, non athletic individual, and this risk is amplified if there is an increase in weight bearing activity, such as occupational tasks with unsuitable footwear. Rosenbaum et al (2014) suggest heel spurs are associated with HPS but do not necessarily cause pain, they state that both heel spurs and pain ‘may develop from a common underlying pathologic condition.’ It is possible then that excess weight in mature individuals in modern man is an explanation for the increased incidence of calcaneal spurs, however, in the prehistoric record, hunter-gatherers who, in a specific population studied by Weiss (2012), died at significantly younger ages than modern humans, on average at 32.2 years if male and 37.2 years if female. Yet this prehistoric group still presented with 3x more calcaneal spurs than modern populations. This indicates that the increased activity likely required for survival in prehistory had an effect in generating the favourable conditions for the development of heel spurs in that population, a proportion of them possibly developing heel pain as well. This increased activity could represent the increased activity in the modern athlete who is the other major risk group for the development of HPS. Further research is required to determine if heel spurs are actually causal (Beeson 2014).
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Hossain and Makwana (2011) identify middle aged obese women as high risk though Beeson (2014) reports the gender literature inconsistent. An obese designation is a BMI of over 30. Rano et al (2001) suggest that decreasing an obese plantar heel pain patients BMI to a score of 25 or below (the same target for those with an identified cardiovascular risk) is a desirable goal. If the average height of a woman in England in 2012 was 164.5cm (Moody 2013), for her to have a BMI of over 30 she would need to weigh approximately 82kg’s. To drop to the target of a BMI of 25, she would need to lose approximately 15kg, which would need to be done primarily with diet control as weight bearing, shock loaded, cardiovascular exercise could easily aggravate the plantar heel pain. This weight loss goal without weight bearing exercise may well be very difficult to achieve but not reducing the BMI probably increases the risk of chronicity. Increasing age has a degenerative effect on the histopathology of the plantar fascia, and has led to the opinion that repetitive micro-trauma of the over strained plantar tissues are causative, and negatively affect the healing process increasing oedema and collagen degeneration (Beeson 2014).
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The lack of ankle dorsiflexion in plantar fasciopathies has stimulated debate as to whether it is an effect caused by the condition or indeed causal itself. Plantar equinus, a plantar flexed foot, is a position of rest when sleeping. Riddle et al’s (2003) view, after looking at single side plantar facsciopathies, is that the non involved side also exhibits a lack of dorsiflexion - not expected if the restriction was effect only. Relative flexibility as explained by Sahrmann (2002) indicates that tightened posterior lower leg musculature will be compensated for with overpronation at the foot. Riddle et al believe this to be the most important risk factor. Areas of interest for future research looking at risk in plantar heel pain include hamstring tightness, leg length discrepancy with the heel pain reported in the longer limb and decreased intrinsic muscle strength (Martin et al 2014). Insert Table 2. about here
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Table 2.
Risk Factors based on moderate evidence
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limited ankle dorsiflexion range of movement
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high body mass index in non athletic individuals
Other reported risk factors that have not yet been verified include: increased age
reduced metatarsophalangeal joint extension
running
supinated feet
work related weight bearing (associated with poor shock absorption)
over pronated feet
From Martin et al 2014
From Hossain and Makwana 2011
Examination Physical examination should include palpation of the proximal insertion of the plantar fascia and the windlass test - reproduction of the pain in the plantar fascia with passive MTP dorsiflexion which. The presence of both findings suggest a plantar fasciopathy (Martin et al 2014). A gap at the proximal end of the plantar fascia following a traumatic injury may indicate a rupture of the plantar fascia.
ACCEPTED MANUSCRIPT Silfverskiolds test is one recommended method to assess resistance to dorsiflexion at the ankle (Hossain and Makwana 2011), but limited dorsiflexion on its own does not only imply a plantar fasciopathy, it can indicate achilles, posterior heel, or calf muscle problems as well. The identification of exactly where the relevant pain is helps create the clinical picture to be interpreted.
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Eliciting Nerve symptoms using tinels test on the medial side of the foot below the medial maleolus for Tarsal tunnel syndrome, or a compression test of the medial calcaneal nerve posterior and inferior to the tarsal tunnel, or indeed a compression of the first branch of the lateral planter nerve (Baxter’s nerve) inferior to the tarsal tunnel is a useful exclusion from plantar fasciopathy (Hossain and Makwana 2011). Resisting great toe plantar flexion can indicate Flexor Hallucis Longus tendinopathy (Hossain and Makwana 2011). Assessing the foot for pronation or supination can be quantified by using the Foot Posture Index (Redmond et al 2006) but this might be relatively a non-specific test in plantar heel pain.
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Imaging
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Radiographic imaging in plantar fasciopathy is helpful to rule out other causes such as calcaneal bony injury, but the presence or absence of heel spurs is not clinically relevant. Diagnostic ultrasound looking at the thickness of the plantar fascia appears helpful, as a decreasing thickness of the plantar fascia occurs as plantar fascia pain resolves (Martin et al 2014). MRI (magnetic resonance imaging) is often recommended if conservative measures appear to be failing or the presentation is atypical (Hossain and Makwana 2011). How well are Plantar fasciopathies treated by physical therapists?
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A survey was undertaken of 285 UK based Physiotherapists questioning their management of plantar fasciopathies (Grieve and Palmer 2015), and reported to the World Confederation for Physical Therapy. The most common approach was reportedly a ‘hands off’ management approach consisting of advice (92%), plantar fasciopathy pathology education (81%), general stretching exercises (74%), more specific stretches to the calf muscles (69%) and plantar fascia (66%). Only 7% prescribed orthotics (custom or prefabricated) and only 1% of physiotherapists used night splints. ‘Hands on’ therapies including massage, myofascial release and trigger point therapy and were all used by less than a quarter of the respondents. The paper did not report on taping modalities. The authors suggested that that despite research evidence, best practice was not always ‘fully adopted’ by physiotherapists for the treatment of plantar fasciopathies in the UK.
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CONSERVATIVE TREATMENT GUIDELINES As Plantar fasciopathies are tissue overload related (increased BMI in the non athletic population and overuse in the athletic population) and probably combined with poor biomechanical alignment, inflexibility, and training errors (Beeson 2014), it is therefore thought that managing the over load is the mainstay of the conservative treatment approaches.
Support tape Taping to support the longitudinal arch can have positive effects on acute pain in the short term and, when combined with orthotics, can produce longer term improvement. Berbreyer and Fredericson (2014) cite a study by Lynch et al where 103 plantar fasciopathy patients were randomised into 3 groups including a mechanical treatment group who were treated with the low dye taping method that supports the longitudinal arch. (see Fig. 4.) The protocol was to low dye tape for 1 month followed by 2 months use of a rigid customised orthotic. This group rated their functional outcome significantly better than the other two groups treated with anti-inflammatory medication or with a visco-elastic heel cup.
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Berbreyer and Fredericson (2014) also cite a short term study by Hyland et al which compared calcaneal taping, sham taping, plantar fascia stretching and a control group who received no intervention. Significant improvements in pain levels were found in the calcaneal taping group compared with sham taping and calcaneal taping compared with a control group.
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Collectively this indicates that taping to support the longitudinal arch along with other therapies plays a role in plantar fasciosis management but is probably mainly useful in the early stages of the condition and useful for pain control. A drawback with rigid sports taping is that it is temporary, and with each strapping occasion it is advisable that the strapping should be removed before 24 hours have elapsed (McNeill and Pedersen 2016). There can be skin breakdown issues (Berbrayer and Fredericson 2014) although in the authors opinion these may possibly be less common in the foot than in other areas.
Orthotic support
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Dynamic tape, an elastic tape with biomechanical effects, has the advantage of being able to be worn for up to 5 days, according to Kendrick, its developer, and in uses associated with the plantar fascia the tape can assist in decelerating the navicular drop while the elastic recoil can help actively supinate the foot at the appropriate time. Kendrick suggests using a double layer, a powerband, of the original dynamic tape or the newer black Eco tape which hits a higher resistance sooner in its stretch phase, making its use applicable at the arch of the foot where there is less motion and a need to maintain the longitudinal arch (Kendrick 2016). For an example of the use of dynamic tape in pronation control, see Web source 1. The evidence for dynamic tape is primarily anecdotal at this point of its validation phase, but may prove its worth in the treatment of plantar fasciopathies.
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Analysis of biomechanics has shown that individuals with plantar fasciopathies have a greater range of available eversion compared with healthy controls, there is also some suggestion that they have a greater eversion velocity (Chang et al 2014). It is likely then that controlling excessive calcaneal eversion could help reduce pain and dysfunction in plantar fasciopathies. It is the authors view that control of calcaneal eversion is a clinical key and may account for the fact that plantar fasciosis can also occur in a supinated foot. Chang goes on to suggest that an arch support can significantly reduce the strain in the plantar fascia by shortening the distance between the rear and forefoot, changing the arch angle. Research suggests that an orthotic has short, medium and long term effects on reducing plantar fasciopathy pain and dysfunction, however different types of orthoses have also been shown to be effective including silicon pads and heel cups (Lee et al 2009) Berbrayer and Fredericson (2014) summarises opinion, ‘Good evidence exists that foot orthotics may be useful as a treatment for plantar fasciopathy. A prefabricated shoe insert is recommended for acute and subacute phases of that condition and customised devices can be considered if prefabricated inserts do not provide sufficient pain relief.’
Calf length
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As the plantar fascia is directly contiguous with the fibres of the Achilles tendon the plantar fascia is placed under tensile stress during different phases of the gait cycle. During early stance the foot pronates, lowering the arch, and stretches the plantar fascia. As the heel starts to lift in late stance, the Achilles tendon is tensioned on the calcaneus, and this pull is resisted by the plantar fascia creating tensile force (Hossain and Makwana 2011). Excessive calf tension may increase this effect possibly contributing to the overload of the fascia.
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Multiple studies support the efficacy of stretching the calf muscles in plantar fasciopathies. (Berbrayer and Fredericson 2014, Martin et al 2014, Kamonseki et al 2015). Some studies have included intermittent stretch and sustained stretch but no particular method seems to be more beneficial (Berbrayer and Fredericson 2014, McPoil et al 2008). Some studies use the wall lean method to stretch gastrocnemius and soleus and others use the heel lowering over a step method, both seem to work (McPoil et al 2008, Kamonseki et al 2015). Recommendations from the orthopaedic section of the American Physical therapy association include stretching 2-3 times a day with either sustained (3 minutes) or intermittent (20 second) holding time. The aim is to improve ankle dorsiflexion range (Martin et al 2014).
Plantar fascia stretch
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In the authors opinion failing to maintain correct alignment of the femur on the lower leg and at the ankle and mid foot while stretching is a common mistake made by a patient while practicing their home stretch program. Therapists must ensure that as the calf is stretched the arch of the foot is maintained, initially teaching the patient to watch for any inappropriate calcaneal movement into a valgus alignment that would allow the arch to flatten, effectively lengthening the arch not stretching the calf. For further information see ‘Calf stretching in correct alignment’ (Silvester 2016) later in this Prevention and Rehabilitation Section of this edition of the JBMT.
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As the gait cycle progresses from stance towards toe off, the tension in the plantar fascia increases due to the windlass mechanism extending the MTP joints creating tension in the fascia and raising the arch. A good quality trial with long term follow up shows that plantar fascia stretching is effective in relieving pain and improving function in chronic plantar fasciopathy, with relief being maintained at a two-year followup. Technique is deemed to be important with the stretch performed in a non-weight bearing position with ankle dorsiflexed, the MTP joints passively extended and palpation of the fascia to feel it being stretched (DiGiovanni et al 2006) (see Fig. 5) insert fig 5. about here
A number of studies have used combined Achilles and plantar fascia stretching and found this to be effective (McPoil et al 2008, Kamonseki et al 2015, Martin et al 2014). Hamstring stretches with combined stretching were also found to be effective (Kamonseki et al 2015).
Manual Therapy Since there is general agreement that lack of dorsiflexion is a risk factor in plantar fasciosis it is appropriate to assess whether the reduced range is myofascial i.e. gastrocnemius–soleus in origin or if it is articular, usually reduced dorsiflexion at the talocrural joint. If the ankle is stiff, there will be a hard end feel in dorsiflexion and, when stretching, the patient may feel the restriction anteriorly in the joint rather than
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posteriorly in the muscle. This may be accompanied with a reduced posterior glide of the talus. If this is the case the talocrural joint could be mobilised in an anterior-posterior direction to regain dorsiflexion (Landrum et al 2008, Vicenzino et al 2006). Self massage in the form of ‘foam rolling’ or ‘roller massage’ may be used if extrapolation on the findings reported in Rios Monteiro et al (2016), published in this section of the JBMT, can be made.
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There is some limited evidence that a manual therapy approach including ankle joint mobilisation and calf soft tissue release with deep massage and myofascial trigger point release to increase calf flexibility is helpful in improving function and reducing pain in plantar fasciosis patients, at least in the short term (Martin et al, 2014, Santos et al 2016, Saban and Deutscher 2014). In practice, manual therapy to assist the effects of exercise would be commonplace and, in the authors opinion, appropriate.
Alignment control and hip strength
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As overpronation is a risk factor in fasciopathies (Beeson 2014) it follows that alignment correction at the foot is an appropriate intervention, hence the use of orthotics and the justification for their efficacy, but as the foot does not work in isolation and is at the end of the kinetic chain, it is the authors view that foot alignment should be considered as part of that hip down kinetic chain. The relationship between lower limb injury and leg alignment has been explored in a number of studies. Barton et al (2012) looked at the positive relationship between increased rearfoot eversion, increased medial tibial rotation and increased hip adduction in a patellofemoral pain group. Similarly in his clinical commentary Powers (2010) argues that some injuries in the lateral thigh and knee could benefit from proximal stability rehabilitation at the hip and trunk and that the analysis of biomechanics should be incorporated into knee rehabilitation programs.
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Kamonseki et al (2015) looked at the effect of stretching exercises with and without strengthening of the foot intrinsic muscles and the hip lateral rotators and abductors. All conditions improved with stretching but no additional improvements from strengthening were reported. In the authors opinion while isolated strengthening of the hip lateral rotators and abductors may appear to be a rational strategy in a malalignment based pathology, it is more important for that strengthening to come from integrative exercise manifesting the strength as alignment improvements during gait and movement. The isolated hip muscle strengthening strategy employed by Kamonseki et al, was therefore unlikely to produce a more positive response. A strategy of this type that relates directly to overpronation has been put forward by Wallden (2015B). Overall there is no current direct evidence that links alignment improvements at the hip and knee to improved alignment at the foot and therefore less pain and dysfunction in plantar heel related pathologies, however it remains fertile ground for thought. The authors contend that future research into mal-alignment based pathology of the lower limb using an integrative hip strengthening strategy may produce different results in the treatment of heel fasciopathies. Martin et al (2014) do recommend therapeutic exercise and neuromuscular re-education, though grade the advice at the lowest strength of evidence - ‘expert opinion.’
Intrinsic foot muscle training Despite the Authors view that the foot should be incorporated in whole lower limb exercise strategies, there are researchers addressing the importance of the intrinsic foot muscles. Huffer et al (2016) have conducted a systematic review on strength training for plantar fasciitis and the intrinsic foot musculature, they concluded that there was, ‘limited external validity that foot exercises, toe flexion against resistance
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and minimalist running shoes may contribute to improved intrinsic foot musculature function.’ A 2014 systematic review found that there is a significant association between intrinsic foot muscle weakness and painful foot pathologies such as plantar fasciitis (Latey et al 2014). Intrinsic foot muscle strengthening may fall into Martin et al’s (2014) expert opinion category and still be a recommended treatment strategy.
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‘Short foot’ exercises that aims to strengthen the foot intrinsics and maintain the longitudinal and transverse arches have been studied. The exercise action is described as drawing the metatarsal heads back to towards the heel without curling the toes with the long toe flexors. (Mulligan and Cook 2013) A paper by Lee et al (2016), published in this section of this edition of the JBMT, looking at foot exercise and kinesio taping in patients with patellofemoral pain and a pronated foot, found the short foot exercise to be significantly better at increasing the Abductor Hallucis muscle activity over kinesio taping applied to the rear foot in a supinated position.
Eccentric exercise
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As eccentric exercise is useful in tendinopathies evidence is starting to be published that suggests that eccentric loading of the calf musculature, along with conventional physical therapy treatment is useful in the treatment of plantar fasciopathies. (Rupareliya et al 2015).
Night Splints
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There is ample evidence that night splinting reduces the pain and disability associated with plantar fasciosis especially first step pain (McPoil et al 2008). One research team randomised the allocation of orthotics against orthotics and night splints. At the 8 week follow up the night splint group reported less pain and improved function (Martin et al 2014). Another group randomly assigned two groups. One group tested NSAID’s, corticosteriod injection and orthotics, the other group had the same but with the inclusion of night splinting. There was a significant positive difference in the night splinting group (Martin et al 2014).
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The issue with night splinting for plantar fasciopathies appears to be the tolerance to the intervention. This issue was addressed by Attard and Singh (2012) by testing an anterior and a posterior night splint. They found that both night splints were effective in reducing pain but the anterior night splint was more effective. They postulate that this may be because it was more comfortable and therefore the patients were more compliant to the treatment.
Steroid injection
There is evidence of short term pain relief following steroid injection into the proximal plantar fascia (Berbrayer and Fredericson 2014). A thickened fascia is associated with plantar fasciosis and imaging studies have shown a decrease in the thickness of the fascia post injection. However, in vitro studies have shown that tendon and fascia failing loads decrease by approximately 35%, showing an increased risk of plantar fascia rupture. It is likely that the risk is higher in the foot than in other areas of the body because of weight bearing stresses. Martin et al (2014) identifies that there is limited evidence for corticosteroid injections for ‘heel pain / plantar fasciitis’ as the potential harm is not offset by the benefits. If a patient is prescribed a steroid injection they may be able to mitigate a percentage of risk if they are instructed to reduce activity for 2-3 weeks. Other complications of steroid injections into this area include injection site
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pain, infection, plantar fat pad atrophy, lateral plantar nerve injury, calcaneal osteomyelitis, skin pigmentation changes and muscle damage (Berbrayer and Fredericson 2014, Martin et al 2014).
Extracorporeal shock wave therapy
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This is a form of sound wave therapy applied to the heel which produces micro trauma to the damaged tissue and subsequent regeneration. Complications include pain in the calcaneal area and calcaneal erythema. A number of trials have shown that it is effective and a meta-analysis of 11 high quality trials concluded that it should be used to treat chronic plantar fasciopathy and should be strongly considered before surgery as a treatment option (Berbrayer and Fredericson 2014).
When do conservative measures require reassessment?
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Thomas et al (2010) advise that patients should have chronic symptoms and have been treated conservatively for six months before being referred for extracorporeal shockwave therapy or surgical interventions such as fasciotomies or nerve releases.
Summary
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The clinical treatment of plantar fasciopathies involves taping the arch of the foot usually producing immediate pain relief. Providing the patient then with orthotics usually means they can then be weaned off taping. Assessment of dorsiflexion restriction helps determine manual therapy intervention. Usually calf stretching is begun early and this is done with any lower limb valgus corrected. Manual therapy should be targeted to the structure which is limiting dorsiflexion. If this is, say, soleus then trigger point therapy and deep massage into soleus to assist stretching can be chosen. Contract/relax stretching by the therapist may be included. If the ankle is stiff it can be mobilised. Plantar fascia specific stretching should also be commenced early in treatment. Assessing lower limb valgus alignment and strength in the hip lateral rotator abductors is important at this point. If the patient has a valgus alignment in the lower limb and weakness in the ipsilateral hip then a strengthening and alignment strategy to correct this alignment and integrate it into normal gait is recommended. Night splinting is recommended if progress is deemed to be slow but as tolerance to wearing a night splint may prove difficult it might not be instituted early in the treatment process.
Warrick McNeill, Dip.Phyty. (NZ) MCSP * Physioworks, 53 Wimpole Street, London W1G 8YH, UK *Corresponding author. Tel.: +44 7973122996. E-mail address: [email protected] (W. McNeill) Mark Silvester, Dip. Phty., Dip Manip. Ther., Adv Dip. Phty. (NZ)
Back for the Future. 366G Huia Road, Titirangi, Auckland 0604, New Zealand
______________________________________________________________________________ References
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Barton, C.J., Levinger, P., Crossley, K.M., Hylton, B.M. 2012. The relationship between rearfoot, tibial and hip kinematics in individuals with patellofemoral pain syndrome. Clinical Biomechanics 27 702 – 705. Beeson P 2014 Plantar fasciopathy: revisiting the risk factors. Foot and ankle surgery 20(2014)160-165 Berbrayer, D., Fredericson, M. 2014. Update on Evidence-Based Treatments for Plantar Fasciopathy. Physical Medicine and Rehabilitation. 6 159-169
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Chang, R., Rodrigues, P.A., Van Emmerik, R.E.A.,Hamill, J. 2014. Multi-segment foot kinematics and ground reaction forces during gait of individuals with plantar fasciitis Journal of Biomechanics 47 2571–2577
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DiGiovanni, B.F., Nawoczenski, D.A., Malay, D.P., Graci, P.A., Williams, T.T., Wilding, G.E., Baumhauer, J.F. 2006. Plantar Fascia specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. The Journal of Bone and Joint Surgery. Vol 88-A Number 8 1775-1781
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Dinneen, A.J., Shafafy,R., Carne, A., Solan, M.C. 2016. Posterior Heel Pain. Orthopaedics and Trauma. 30(1):8-17 Greive, R.,Palmer, S. 2015 Physiotherapy for plantar fasciitis: A UK-wide survey of current practice. WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 S427–S632 Hossain, M., Makwana, N. 2011. “Not Plantar Fasciitis”; the differential diagnosis and management of heel pain syndrome. Orthopaedics and Trauma. 25(3): 198-206 Huffer, D., Hing, W., Newton, R., Clair, M., Strength training for plantar fasciitis and the intrinsic foot musculature: A systematic review, Physical Therapy in Sports (2016), doi: 10.1016/ j.ptsp.2016.08.008.
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Kamonseki, D.H., Concalves, G.A., Yee, L.C. 2015. Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: a randomised controlled single blind clinical trial. Manual Therapy. http;DX.DOI.ORG/10.1016/j.math.2015.10.006 Kendrick, R. 2016. Personal correspondence
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Landrum E.L., Kelln C.B., Parente, W.R., Ingersoll, C.D., Hertel, J. 2008. Immediate Effects of Anterior-toPosterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study. Journal of Manual and Manipulative Therapy. 16(2): 100–105 Latey, P. J., Burns, J., Hiller, C., & Nightingale, E. J. (2014). Relationship between intrinsic foot muscle weakness and pain: a systematic review. Journal of Foot and Ankle Research, 7(1): A51 Lee, J. Yoon, J., Cynn H. 2016. Foot exercise and taping in patients with patellofemoral pain and pronated foot. Journal of Bodywork and Movement Therapies. http://dx.doi.org/10.1016/j.jbmt.2016.07.010
Lee, S. Y., McKeon, P., Hertel, J. 2009. Does the use of orthoses improve self-reported pain and function measures in plantar fasciitis? A meta-analysis. Physical Therapy in Sport 10 12-18 Lemont, H., Ammirati, K.M., Usen, N. 2003. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association. 93: 234-237. Maffulli, N., Wong, J., Almekinders, L.C., 2003. Types and epidemiology of tendinopathy. Clin. Sports Med. 22, 675-692.
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Martin, R.L., Davenport, T.E., Reischl, S.R., McPoil, T.G., Matheson, J.W., Wukich, D.K., McDonough,C.M. 2014. Heel Pain - Plantar fasciitis: Revision 2014. Journal of Orthopaedic and Sports Physical Therapy 44:11, A1-A33 McNeill, W. 2015. About eccentric exercise (editorial). Journal of Bodywork & Movement Therapies. 19, 553-557
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McNeill, W., Pedersen, C. 2016. Dynamic Tape. Is it all about controlling the Load (editorial). Journal of Bodywork and Movement Therapies. 20, 179-188 McPoil, T., Martin, R., Cornwall, M., Wukich, D., Irrgang, J., Godges J. 2008. Heel pain- plantar fasciitis. Journal of Orthopaedic and Sports Physical Therapy 38: A1-18.
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Moody, A. 2013. Adult anthropometric measures, overweight and obesity. In Craig, R., Mindell, J. Health Survey for England – 2012. Volume 1: Health, social care and lifestyles. Health and Social Care Information Centre. p. 20 Mulligan, E.P. Cook, P.G. 2013. Effect of plantar intrinsic muscle training on medial longitudinal arch morphology and dynamic function. Manual Therapy 18 425-430
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Powers. C.M. The influence of abnormal hip mechanics on knee injury: A biomechanical perspective. Journal of Orthopaedic Sports Physical Therapy. 40(2) 42-51. Rano, J.A., Fallat, L.M., Savoy-Moore, R.T. 2001. Correlation of Heel Pain with Body Mass Index and Other Characteristics of Heel Pain. The Journal of Foot & Ankle Surgery 40(6):351-356 Redmond, A.C., Crosbie,J., Ouvrier, R.A. 2006. Development and validation of a novel rating system for scoring standing foot posture: The Foot Posture Index. Clinical Biomechanics 21 89–98
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Riddle, D.L., Pulisic, M., Pidcoe, P., Johnson, R.E. 2003. Risk factors for plantar fasciitis: a match controlled study. J Bone Joint Surg 85A:872–7.
Rios Monteiro, E., Cavanaugh, M.T., Frost, D.M., ds Silva Novaes, J. 2016. Is self-massage an
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effective joint range-of-motion strategy? A pilot study. Journal of Bodyworks and Movement Therapies. http://dx.doi.org/10.1016/j.jbmt.2016.10.003
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Rosenbaum, A.J., DiPreta, J.A., Misener, D. 2014. Plantar heel pain. The Medical clinics of North America. 98(2):339-52 Rose, B., Singh, D. 2016. Inferior heel pain. Orthopaedics and Trauma. 30(1): 18-23 D. Rupareliya, D., Shukla, Y., Bhise, A., Prabhakar M. 2015. To study the effect of eccentric loading exercises of calf muscles in plantar fasciitis. An interventional study. WCPT Congress / Physiotherapy; Volume 101, Supplement 1 S1238–S1642 Saban B, Deutscher D, Ziv T. 2014. Deep massage to posterior calf muscles in combination with neural mobilisation exercises as a treatment for heel pain: a pilot randomised clinical trial. Manual Therapy 19, 102-108.
Sahrmann, S., 2002. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby.
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Santos, B.D., Correa, L.A., Santos, L.T., Filho, N.A.M., Lemos, T., Nogueira, L.A.C. 2016 .Combination of Hip Strengthening and Manipulative Therapy for the treatment of plantar fasciitis: A case report. Journal of Chiropractic Medicine March (In Press) http://dx.doi.org/10.1016/j.jcm.2016.08.001 Silvester, M. 2016. Calf stretching and incorrect alignment. Journal of Bodyworks and Movement Therapies.
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Thomas, J.L., Christensen, J.C., Kravitz, S.R., Mendicino, R.W., Schuberth, J.M., Vanore, J.V., Weil, L.S., Zlotoff, H.J., Bouché, R., Baker, J. 2010 ,The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision The Journal of Foot and Ankle Surgery , Volume 49 , Issue 3 , S1 - S19 Walden, M. 2015A. Don’t get caught flat footed - How over- pronation may just be a dysfunctional model. Journal of Bodywork & Movement Therapies 19, 357-361
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Vicenzino, B., Branjerdporn, M, Teys, P., Jordan, K. 2006. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. Journal of Orthopaedic Sports Physical Therapy. 36(7):464-71.
Wallden M. 2015B. The over-pronated foot – a new paradigm. Journal of Bodywork and Movement therapies 19, 712-716. Wearing, S.C., Smeathers J.E., Yates, B., Urry, S. R., Dubois, P. 2009. Bulk compressive properties of the heel fat pad during walking: A pilot investigation in plantar heel pain. Clinical Biomechanics. 24(4):397-402 Web source 1:
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https://www.youtube.com/watch?v=3w3RQevwcUc&index=22&list=PL7VopBXj_mKff7gxPkKMb0OJKnmrONTAq
Weiss, E. 2012. Calcaneal spurs: Examining etiology using prehistoric skeletal remains to understand present day heel pain The Foot 22 125–129
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Wolgin, M., Cook, C., Graham, C., Maudlin, D. 1994. Conservative treatment of plantar heel pain: long-term follow-up. Foot and Ankle International.15(3):97–102
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Figure 2. Nomenclature. (Note; the size of the circle does not represent incidence)
Low dye taping
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Figure. 4A. 4B. 4C.
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Figure. 5. Plantar fascia stretch technique
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Hi Caroline the editorial figures are attached below see the word doc for legends after the reference list
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Best Warrick Warrick McNeill
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MCSP Director Physioworks
Physioworks Chartered Physiotherapy and Pilates Clinic 53 Wimpole Street London W1G 8YH United Kingdom
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E: [email protected] W: +44 (0) 845 331 6116 M: +44 (0) 7973 122 996 www.physioworks.co.uk
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tough on the causes of pain
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S1360-8592(16)30257-1
DOI:
10.1016/j.jbmt.2016.11.001
Reference:
YJBMT 1440
To appear in:
Journal of Bodywork & Movement Therapies
Please cite this article as: McNeill, W., Silvester, M., Plantar heel pain, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.11.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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PREVENTION & REHABILITATION: EDITORIAL Plantar heel pain First Steps
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A patients description of rising in the morning, placing their feet upon the floor, and taking their first step with the associated report of the pain elicited under the foot (see fig. 1), usually alerts the health professional to the likely possibility that the diagnosis will be related to the plantar fascia. The pain may subside and return later in the day particularly if the patient has been on their feet, but improves with rest. Heel pain can also present following an increase in weight bearing activity. (McPoil et al 2008, Martin et al 2014, Berbrayer and Fredericson 2014). The diagnosis of Plantar fasciopathies is made by assessing the clinical picture as there is not a gold standard test for the condition (Beeson 2014).
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Heel pain affects millions of people worldwide and is divided into two broad categories, posterior heel pain, and inferior (plantar) pain. Posterior heel pain most commonly is related to the Achilles tendon and its increasing prevalence can be associated with the continuation of exercise into older age (Dinneen et al 2016). This editorial focuses on inferior heel pain, of which Rosenbaum et al (2014) suggests that ‘plantar fasciitis is the most common culprit, accounting for 80% of patients with inferior heel pain,’ and is predicted to affect 1 in 10 people in their lifetime. They suggest that mechanical, rheumatologic or neurologic conditions can all present with plantar heel pain. Hossain and Makwana (2011) suggest that pain in the plantar heel area be initially named Heel pain syndrome (HPS) until clarification of the symptoms can establish a firm diagnosis.
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Plantar Fasciitis, Fasciosis or Fasciopathy?
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Berbayer and Fredericson (2014) differentiate acute plantar heel pain symptoms produced by inflammation, and, chronic pain in the same region, from degenerative causes. As the clinical course of plantar fasciopathy follows a predictable path they identify the acute phase as lasting 4 weeks, a sub-acute phase which persists from 4 weeks to 3 months and a chronic phase that goes beyond 3 months. Despite inflammation being cited as a primary cause there is little evidence to support the use of NSAID’s (nonsteroidal anti-inflammatory drugs) in the papers they quote. NSAID’s are typically prescribed in conjunction with other interventions as part of a trial of conservative measures, and 76% of patients report improvement with their use, (Wolgin et al 1994). Lemont et al’s (2003) view that ‘Plantar Fasciitis’ is a condition without signs of classic inflammation, swelling, erythema or macrophage infiltration and is characterised, on histological examination, by chronic degenerative tissue changes, and therefore should be renamed plantar fasciosis, is continuing to gain traction (Hossain and Makwana 2011) and reflects the sea-change reappraisal of the clinical nature of tendinopathies (Maffulli et al 2003, McNeill 2015). The use of the term plantar fasciopathy blends the inflammatory and degenerative elements to the condition. Insert fig.2 about here
Rosenbaum et al (2014) still state that NSAID’s are an appropriate treatment for HPS, which may reflect the view that there is an inflammatory pathway to plantar fasciopathy (see fig. 2) as well as a degenerative one. Rose and Singh (2016) appear to agree, they describe; acute events with a sudden onset of pain during sporting activities as possibly being ‘plantar fascia tears’ and best treated by ice, NSAID’s and immobilisation till symptoms reduce, and a stiff soled boot for 6 weeks, or, ‘peri-fascial oedema’ again best treated with oral NSAID’s or even an ultrasound guided steroid injection above the plantar fascia (see steroid injection discussion later). Table 1. Alternate diagnoses to Plantar fascia related causes of inferior heel pain Bone Calcaneal stress Fracture Calcaneal bone marrow oedema
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As HPS involves many different diagnoses (see Table 1.) that require quite different treatment approaches it is clear that an understanding of the structure of the inferior heel area, the biomechanics of the foot, the risk factors associated with injury and an assessment process is imperative if the path to recovery is to be maximised by the treating Clinician. Anatomy Biomechanics and Risk Factors
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The Plantar fascia is actually a broad fibrous triangular aponeurosis extending from the medial and anterior undersurface of the calcaneum to the base of the five proximal phalanges, it travels in a constantly present central band, though in some, the medial and/or lateral bands are missing (Hossain and Makwana 2011). The intrinsic muscles of the foot are compartmentalised by the Plantar fascia. Posteriorly it is contiguous with the Achilles tendon and when the calf musculature contracts, the plantar fascia is tightened by this connection. The structure of the stress dissipating fibrocartilage attachment to the medial calcaneal tubercle helps the aponeurosis to withstand significant loads.
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The inferior heel is protected by its fat pad, which acts as a shock absorber, the reinforced, fat globule filled honeycomb fat pad is known to degenerate beyond 40 years of age, losing thickness and height, while softening and reducing its protection of the heel (Rosenbaum 2014) , not surprising when the heel’s fat pad has to dissipate 250% of body weight while running (Rosenbaum 2014). Beeson (2014) describes an increasing thickness of the heel pad, but with the same effect of a loss of heel pad elasticity. The fat pad of symptomatic feet presents a significantly lower energy dissipation ratio when compared to asymptomatic feet (Wearing et al 2009). When a patient reports pain on prolonged standing, bilateral pain and night pain, but without first step pain, heel pad atrophy may well be implicated (Martin et al 2014).
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The role of the plantar fascia is to help support the arch of the foot via the skeletal truss formed by the hind foot and forefoot and held along the bottom by the aponeurotic structure. A pes planus foot is predicted to apply greater loads to the plantar fascia and this matches the risk factor of over-pronation in HPS. Beeson (2014) quotes 8 papers linking over pronation as a key risk factor in plantar fasciopathies, at odds with Hossain and Makwana’s (2011) view that over-pronation has not been verified as a risk factor, see Table 2. As it is, the gait cycle adds tension to the plantar fascia from heel strike to just before mid stance and the tightening fascia prevents excessive pronation, unless the foot is dysfunctional (Walden 2015A). The windlass tightening effect (see fig. 3) is used for propulsion. The intrinsic muscles of the foot assist in the creation of the desirably timed supinated and stiffened foot, and their loss of function, atrophy or over length reduces movement efficiencies.
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A high body mass index (BMI) is a significant risk factor in one major group of patients, the over 40, often female, non athletic individual, and this risk is amplified if there is an increase in weight bearing activity, such as occupational tasks with unsuitable footwear. Rosenbaum et al (2014) suggest heel spurs are associated with HPS but do not necessarily cause pain, they state that both heel spurs and pain ‘may develop from a common underlying pathologic condition.’ It is possible then that excess weight in mature individuals in modern man is an explanation for the increased incidence of calcaneal spurs, however, in the prehistoric record, hunter-gatherers who, in a specific population studied by Weiss (2012), died at significantly younger ages than modern humans, on average at 32.2 years if male and 37.2 years if female. Yet this prehistoric group still presented with 3x more calcaneal spurs than modern populations. This indicates that the increased activity likely required for survival in prehistory had an effect in generating the favourable conditions for the development of heel spurs in that population, a proportion of them possibly developing heel pain as well. This increased activity could represent the increased activity in the modern athlete who is the other major risk group for the development of HPS. Further research is required to determine if heel spurs are actually causal (Beeson 2014).
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Hossain and Makwana (2011) identify middle aged obese women as high risk though Beeson (2014) reports the gender literature inconsistent. An obese designation is a BMI of over 30. Rano et al (2001) suggest that decreasing an obese plantar heel pain patients BMI to a score of 25 or below (the same target for those with an identified cardiovascular risk) is a desirable goal. If the average height of a woman in England in 2012 was 164.5cm (Moody 2013), for her to have a BMI of over 30 she would need to weigh approximately 82kg’s. To drop to the target of a BMI of 25, she would need to lose approximately 15kg, which would need to be done primarily with diet control as weight bearing, shock loaded, cardiovascular exercise could easily aggravate the plantar heel pain. This weight loss goal without weight bearing exercise may well be very difficult to achieve but not reducing the BMI probably increases the risk of chronicity. Increasing age has a degenerative effect on the histopathology of the plantar fascia, and has led to the opinion that repetitive micro-trauma of the over strained plantar tissues are causative, and negatively affect the healing process increasing oedema and collagen degeneration (Beeson 2014).
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The lack of ankle dorsiflexion in plantar fasciopathies has stimulated debate as to whether it is an effect caused by the condition or indeed causal itself. Plantar equinus, a plantar flexed foot, is a position of rest when sleeping. Riddle et al’s (2003) view, after looking at single side plantar facsciopathies, is that the non involved side also exhibits a lack of dorsiflexion - not expected if the restriction was effect only. Relative flexibility as explained by Sahrmann (2002) indicates that tightened posterior lower leg musculature will be compensated for with overpronation at the foot. Riddle et al believe this to be the most important risk factor. Areas of interest for future research looking at risk in plantar heel pain include hamstring tightness, leg length discrepancy with the heel pain reported in the longer limb and decreased intrinsic muscle strength (Martin et al 2014). Insert Table 2. about here
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Table 2.
Risk Factors based on moderate evidence
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limited ankle dorsiflexion range of movement
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high body mass index in non athletic individuals
Other reported risk factors that have not yet been verified include: increased age
reduced metatarsophalangeal joint extension
running
supinated feet
work related weight bearing (associated with poor shock absorption)
over pronated feet
From Martin et al 2014
From Hossain and Makwana 2011
Examination Physical examination should include palpation of the proximal insertion of the plantar fascia and the windlass test - reproduction of the pain in the plantar fascia with passive MTP dorsiflexion which. The presence of both findings suggest a plantar fasciopathy (Martin et al 2014). A gap at the proximal end of the plantar fascia following a traumatic injury may indicate a rupture of the plantar fascia.
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Eliciting Nerve symptoms using tinels test on the medial side of the foot below the medial maleolus for Tarsal tunnel syndrome, or a compression test of the medial calcaneal nerve posterior and inferior to the tarsal tunnel, or indeed a compression of the first branch of the lateral planter nerve (Baxter’s nerve) inferior to the tarsal tunnel is a useful exclusion from plantar fasciopathy (Hossain and Makwana 2011). Resisting great toe plantar flexion can indicate Flexor Hallucis Longus tendinopathy (Hossain and Makwana 2011). Assessing the foot for pronation or supination can be quantified by using the Foot Posture Index (Redmond et al 2006) but this might be relatively a non-specific test in plantar heel pain.
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Imaging
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Radiographic imaging in plantar fasciopathy is helpful to rule out other causes such as calcaneal bony injury, but the presence or absence of heel spurs is not clinically relevant. Diagnostic ultrasound looking at the thickness of the plantar fascia appears helpful, as a decreasing thickness of the plantar fascia occurs as plantar fascia pain resolves (Martin et al 2014). MRI (magnetic resonance imaging) is often recommended if conservative measures appear to be failing or the presentation is atypical (Hossain and Makwana 2011). How well are Plantar fasciopathies treated by physical therapists?
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A survey was undertaken of 285 UK based Physiotherapists questioning their management of plantar fasciopathies (Grieve and Palmer 2015), and reported to the World Confederation for Physical Therapy. The most common approach was reportedly a ‘hands off’ management approach consisting of advice (92%), plantar fasciopathy pathology education (81%), general stretching exercises (74%), more specific stretches to the calf muscles (69%) and plantar fascia (66%). Only 7% prescribed orthotics (custom or prefabricated) and only 1% of physiotherapists used night splints. ‘Hands on’ therapies including massage, myofascial release and trigger point therapy and were all used by less than a quarter of the respondents. The paper did not report on taping modalities. The authors suggested that that despite research evidence, best practice was not always ‘fully adopted’ by physiotherapists for the treatment of plantar fasciopathies in the UK.
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CONSERVATIVE TREATMENT GUIDELINES As Plantar fasciopathies are tissue overload related (increased BMI in the non athletic population and overuse in the athletic population) and probably combined with poor biomechanical alignment, inflexibility, and training errors (Beeson 2014), it is therefore thought that managing the over load is the mainstay of the conservative treatment approaches.
Support tape Taping to support the longitudinal arch can have positive effects on acute pain in the short term and, when combined with orthotics, can produce longer term improvement. Berbreyer and Fredericson (2014) cite a study by Lynch et al where 103 plantar fasciopathy patients were randomised into 3 groups including a mechanical treatment group who were treated with the low dye taping method that supports the longitudinal arch. (see Fig. 4.) The protocol was to low dye tape for 1 month followed by 2 months use of a rigid customised orthotic. This group rated their functional outcome significantly better than the other two groups treated with anti-inflammatory medication or with a visco-elastic heel cup.
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Berbreyer and Fredericson (2014) also cite a short term study by Hyland et al which compared calcaneal taping, sham taping, plantar fascia stretching and a control group who received no intervention. Significant improvements in pain levels were found in the calcaneal taping group compared with sham taping and calcaneal taping compared with a control group.
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Collectively this indicates that taping to support the longitudinal arch along with other therapies plays a role in plantar fasciosis management but is probably mainly useful in the early stages of the condition and useful for pain control. A drawback with rigid sports taping is that it is temporary, and with each strapping occasion it is advisable that the strapping should be removed before 24 hours have elapsed (McNeill and Pedersen 2016). There can be skin breakdown issues (Berbrayer and Fredericson 2014) although in the authors opinion these may possibly be less common in the foot than in other areas.
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Dynamic tape, an elastic tape with biomechanical effects, has the advantage of being able to be worn for up to 5 days, according to Kendrick, its developer, and in uses associated with the plantar fascia the tape can assist in decelerating the navicular drop while the elastic recoil can help actively supinate the foot at the appropriate time. Kendrick suggests using a double layer, a powerband, of the original dynamic tape or the newer black Eco tape which hits a higher resistance sooner in its stretch phase, making its use applicable at the arch of the foot where there is less motion and a need to maintain the longitudinal arch (Kendrick 2016). For an example of the use of dynamic tape in pronation control, see Web source 1. The evidence for dynamic tape is primarily anecdotal at this point of its validation phase, but may prove its worth in the treatment of plantar fasciopathies.
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Analysis of biomechanics has shown that individuals with plantar fasciopathies have a greater range of available eversion compared with healthy controls, there is also some suggestion that they have a greater eversion velocity (Chang et al 2014). It is likely then that controlling excessive calcaneal eversion could help reduce pain and dysfunction in plantar fasciopathies. It is the authors view that control of calcaneal eversion is a clinical key and may account for the fact that plantar fasciosis can also occur in a supinated foot. Chang goes on to suggest that an arch support can significantly reduce the strain in the plantar fascia by shortening the distance between the rear and forefoot, changing the arch angle. Research suggests that an orthotic has short, medium and long term effects on reducing plantar fasciopathy pain and dysfunction, however different types of orthoses have also been shown to be effective including silicon pads and heel cups (Lee et al 2009) Berbrayer and Fredericson (2014) summarises opinion, ‘Good evidence exists that foot orthotics may be useful as a treatment for plantar fasciopathy. A prefabricated shoe insert is recommended for acute and subacute phases of that condition and customised devices can be considered if prefabricated inserts do not provide sufficient pain relief.’
Calf length
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As the plantar fascia is directly contiguous with the fibres of the Achilles tendon the plantar fascia is placed under tensile stress during different phases of the gait cycle. During early stance the foot pronates, lowering the arch, and stretches the plantar fascia. As the heel starts to lift in late stance, the Achilles tendon is tensioned on the calcaneus, and this pull is resisted by the plantar fascia creating tensile force (Hossain and Makwana 2011). Excessive calf tension may increase this effect possibly contributing to the overload of the fascia.
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Multiple studies support the efficacy of stretching the calf muscles in plantar fasciopathies. (Berbrayer and Fredericson 2014, Martin et al 2014, Kamonseki et al 2015). Some studies have included intermittent stretch and sustained stretch but no particular method seems to be more beneficial (Berbrayer and Fredericson 2014, McPoil et al 2008). Some studies use the wall lean method to stretch gastrocnemius and soleus and others use the heel lowering over a step method, both seem to work (McPoil et al 2008, Kamonseki et al 2015). Recommendations from the orthopaedic section of the American Physical therapy association include stretching 2-3 times a day with either sustained (3 minutes) or intermittent (20 second) holding time. The aim is to improve ankle dorsiflexion range (Martin et al 2014).
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In the authors opinion failing to maintain correct alignment of the femur on the lower leg and at the ankle and mid foot while stretching is a common mistake made by a patient while practicing their home stretch program. Therapists must ensure that as the calf is stretched the arch of the foot is maintained, initially teaching the patient to watch for any inappropriate calcaneal movement into a valgus alignment that would allow the arch to flatten, effectively lengthening the arch not stretching the calf. For further information see ‘Calf stretching in correct alignment’ (Silvester 2016) later in this Prevention and Rehabilitation Section of this edition of the JBMT.
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As the gait cycle progresses from stance towards toe off, the tension in the plantar fascia increases due to the windlass mechanism extending the MTP joints creating tension in the fascia and raising the arch. A good quality trial with long term follow up shows that plantar fascia stretching is effective in relieving pain and improving function in chronic plantar fasciopathy, with relief being maintained at a two-year followup. Technique is deemed to be important with the stretch performed in a non-weight bearing position with ankle dorsiflexed, the MTP joints passively extended and palpation of the fascia to feel it being stretched (DiGiovanni et al 2006) (see Fig. 5) insert fig 5. about here
A number of studies have used combined Achilles and plantar fascia stretching and found this to be effective (McPoil et al 2008, Kamonseki et al 2015, Martin et al 2014). Hamstring stretches with combined stretching were also found to be effective (Kamonseki et al 2015).
Manual Therapy Since there is general agreement that lack of dorsiflexion is a risk factor in plantar fasciosis it is appropriate to assess whether the reduced range is myofascial i.e. gastrocnemius–soleus in origin or if it is articular, usually reduced dorsiflexion at the talocrural joint. If the ankle is stiff, there will be a hard end feel in dorsiflexion and, when stretching, the patient may feel the restriction anteriorly in the joint rather than
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posteriorly in the muscle. This may be accompanied with a reduced posterior glide of the talus. If this is the case the talocrural joint could be mobilised in an anterior-posterior direction to regain dorsiflexion (Landrum et al 2008, Vicenzino et al 2006). Self massage in the form of ‘foam rolling’ or ‘roller massage’ may be used if extrapolation on the findings reported in Rios Monteiro et al (2016), published in this section of the JBMT, can be made.
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There is some limited evidence that a manual therapy approach including ankle joint mobilisation and calf soft tissue release with deep massage and myofascial trigger point release to increase calf flexibility is helpful in improving function and reducing pain in plantar fasciosis patients, at least in the short term (Martin et al, 2014, Santos et al 2016, Saban and Deutscher 2014). In practice, manual therapy to assist the effects of exercise would be commonplace and, in the authors opinion, appropriate.
Alignment control and hip strength
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As overpronation is a risk factor in fasciopathies (Beeson 2014) it follows that alignment correction at the foot is an appropriate intervention, hence the use of orthotics and the justification for their efficacy, but as the foot does not work in isolation and is at the end of the kinetic chain, it is the authors view that foot alignment should be considered as part of that hip down kinetic chain. The relationship between lower limb injury and leg alignment has been explored in a number of studies. Barton et al (2012) looked at the positive relationship between increased rearfoot eversion, increased medial tibial rotation and increased hip adduction in a patellofemoral pain group. Similarly in his clinical commentary Powers (2010) argues that some injuries in the lateral thigh and knee could benefit from proximal stability rehabilitation at the hip and trunk and that the analysis of biomechanics should be incorporated into knee rehabilitation programs.
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Kamonseki et al (2015) looked at the effect of stretching exercises with and without strengthening of the foot intrinsic muscles and the hip lateral rotators and abductors. All conditions improved with stretching but no additional improvements from strengthening were reported. In the authors opinion while isolated strengthening of the hip lateral rotators and abductors may appear to be a rational strategy in a malalignment based pathology, it is more important for that strengthening to come from integrative exercise manifesting the strength as alignment improvements during gait and movement. The isolated hip muscle strengthening strategy employed by Kamonseki et al, was therefore unlikely to produce a more positive response. A strategy of this type that relates directly to overpronation has been put forward by Wallden (2015B). Overall there is no current direct evidence that links alignment improvements at the hip and knee to improved alignment at the foot and therefore less pain and dysfunction in plantar heel related pathologies, however it remains fertile ground for thought. The authors contend that future research into mal-alignment based pathology of the lower limb using an integrative hip strengthening strategy may produce different results in the treatment of heel fasciopathies. Martin et al (2014) do recommend therapeutic exercise and neuromuscular re-education, though grade the advice at the lowest strength of evidence - ‘expert opinion.’
Intrinsic foot muscle training Despite the Authors view that the foot should be incorporated in whole lower limb exercise strategies, there are researchers addressing the importance of the intrinsic foot muscles. Huffer et al (2016) have conducted a systematic review on strength training for plantar fasciitis and the intrinsic foot musculature, they concluded that there was, ‘limited external validity that foot exercises, toe flexion against resistance
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and minimalist running shoes may contribute to improved intrinsic foot musculature function.’ A 2014 systematic review found that there is a significant association between intrinsic foot muscle weakness and painful foot pathologies such as plantar fasciitis (Latey et al 2014). Intrinsic foot muscle strengthening may fall into Martin et al’s (2014) expert opinion category and still be a recommended treatment strategy.
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‘Short foot’ exercises that aims to strengthen the foot intrinsics and maintain the longitudinal and transverse arches have been studied. The exercise action is described as drawing the metatarsal heads back to towards the heel without curling the toes with the long toe flexors. (Mulligan and Cook 2013) A paper by Lee et al (2016), published in this section of this edition of the JBMT, looking at foot exercise and kinesio taping in patients with patellofemoral pain and a pronated foot, found the short foot exercise to be significantly better at increasing the Abductor Hallucis muscle activity over kinesio taping applied to the rear foot in a supinated position.
Eccentric exercise
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As eccentric exercise is useful in tendinopathies evidence is starting to be published that suggests that eccentric loading of the calf musculature, along with conventional physical therapy treatment is useful in the treatment of plantar fasciopathies. (Rupareliya et al 2015).
Night Splints
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There is ample evidence that night splinting reduces the pain and disability associated with plantar fasciosis especially first step pain (McPoil et al 2008). One research team randomised the allocation of orthotics against orthotics and night splints. At the 8 week follow up the night splint group reported less pain and improved function (Martin et al 2014). Another group randomly assigned two groups. One group tested NSAID’s, corticosteriod injection and orthotics, the other group had the same but with the inclusion of night splinting. There was a significant positive difference in the night splinting group (Martin et al 2014).
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The issue with night splinting for plantar fasciopathies appears to be the tolerance to the intervention. This issue was addressed by Attard and Singh (2012) by testing an anterior and a posterior night splint. They found that both night splints were effective in reducing pain but the anterior night splint was more effective. They postulate that this may be because it was more comfortable and therefore the patients were more compliant to the treatment.
Steroid injection
There is evidence of short term pain relief following steroid injection into the proximal plantar fascia (Berbrayer and Fredericson 2014). A thickened fascia is associated with plantar fasciosis and imaging studies have shown a decrease in the thickness of the fascia post injection. However, in vitro studies have shown that tendon and fascia failing loads decrease by approximately 35%, showing an increased risk of plantar fascia rupture. It is likely that the risk is higher in the foot than in other areas of the body because of weight bearing stresses. Martin et al (2014) identifies that there is limited evidence for corticosteroid injections for ‘heel pain / plantar fasciitis’ as the potential harm is not offset by the benefits. If a patient is prescribed a steroid injection they may be able to mitigate a percentage of risk if they are instructed to reduce activity for 2-3 weeks. Other complications of steroid injections into this area include injection site
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pain, infection, plantar fat pad atrophy, lateral plantar nerve injury, calcaneal osteomyelitis, skin pigmentation changes and muscle damage (Berbrayer and Fredericson 2014, Martin et al 2014).
Extracorporeal shock wave therapy
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This is a form of sound wave therapy applied to the heel which produces micro trauma to the damaged tissue and subsequent regeneration. Complications include pain in the calcaneal area and calcaneal erythema. A number of trials have shown that it is effective and a meta-analysis of 11 high quality trials concluded that it should be used to treat chronic plantar fasciopathy and should be strongly considered before surgery as a treatment option (Berbrayer and Fredericson 2014).
When do conservative measures require reassessment?
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Thomas et al (2010) advise that patients should have chronic symptoms and have been treated conservatively for six months before being referred for extracorporeal shockwave therapy or surgical interventions such as fasciotomies or nerve releases.
Summary
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The clinical treatment of plantar fasciopathies involves taping the arch of the foot usually producing immediate pain relief. Providing the patient then with orthotics usually means they can then be weaned off taping. Assessment of dorsiflexion restriction helps determine manual therapy intervention. Usually calf stretching is begun early and this is done with any lower limb valgus corrected. Manual therapy should be targeted to the structure which is limiting dorsiflexion. If this is, say, soleus then trigger point therapy and deep massage into soleus to assist stretching can be chosen. Contract/relax stretching by the therapist may be included. If the ankle is stiff it can be mobilised. Plantar fascia specific stretching should also be commenced early in treatment. Assessing lower limb valgus alignment and strength in the hip lateral rotator abductors is important at this point. If the patient has a valgus alignment in the lower limb and weakness in the ipsilateral hip then a strengthening and alignment strategy to correct this alignment and integrate it into normal gait is recommended. Night splinting is recommended if progress is deemed to be slow but as tolerance to wearing a night splint may prove difficult it might not be instituted early in the treatment process.
Warrick McNeill, Dip.Phyty. (NZ) MCSP * Physioworks, 53 Wimpole Street, London W1G 8YH, UK *Corresponding author. Tel.: +44 7973122996. E-mail address: [email protected] (W. McNeill) Mark Silvester, Dip. Phty., Dip Manip. Ther., Adv Dip. Phty. (NZ)
Back for the Future. 366G Huia Road, Titirangi, Auckland 0604, New Zealand
______________________________________________________________________________ References
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Chang, R., Rodrigues, P.A., Van Emmerik, R.E.A.,Hamill, J. 2014. Multi-segment foot kinematics and ground reaction forces during gait of individuals with plantar fasciitis Journal of Biomechanics 47 2571–2577
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Figure 2. Nomenclature. (Note; the size of the circle does not represent incidence)
Low dye taping
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Figure. 4A. 4B. 4C.
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Figure. 5. Plantar fascia stretch technique
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Hi Caroline the editorial figures are attached below see the word doc for legends after the reference list
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Best Warrick Warrick McNeill
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MCSP Director Physioworks
Physioworks Chartered Physiotherapy and Pilates Clinic 53 Wimpole Street London W1G 8YH United Kingdom
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E: [email protected] W: +44 (0) 845 331 6116 M: +44 (0) 7973 122 996 www.physioworks.co.uk
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tough on the causes of pain
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