Chronic plantar heel pain modifies associations of ankle plantarflexor strength and body mass index with calcaneal bone density and microarchitecture

Chronic plantar heel pain (CPHP) is associated with calcaneal bone spurs, but its associations with other calcaneal bone features are unknown. This study therefore aimed to determine associations between having CPHP and bone density and microarchitecture of the calcaneus. We assessed 220 participants with CPHP and 100 age- and sex-matched population-based controls. Trabecular bone density, thickness, separation and number, BV/TV, and cortical density, thickness and area were measured using a Scanco Xtreme1 HR-pQCT scanner at a plantar and mid-calcaneal site. Clinical, physical activity and disease history data were also collected. Associations with bone outcomes were assessed using multivariable linear regression adjusting for age, sex, physical activity, BMI and ankle plantarflexor strength. We assessed for potential effect modification of CPHP on these covariates using interaction terms. There were univariable associations at the plantar calcaneus where higher trabecular bone density, BV/TV and thickness and lower trabecular separation were associated with CPHP. In multivariable models, having CPHP was not independently associated with any bone outcome, but modified associations of BMI and ankle plantarflexor strength with mid-calcaneal and plantar bone outcomes respectively. Beneficial associations of BMI with mid-calcaneal trabecular density (BMI-case interaction standardised X/unstandardised Y beta -10.8(mgHA/cm3) (se 4.6), thickness -0.002(mm) (se 0.001) and BV/TV -0.009(%) (se 0.004) were reduced in people with CPHP. Beneficial associations of ankle plantarflexor strength with plantar trabecular density (ankle plantarflexor strength -case interaction -11.9(mgHA/cm3) (se 4.4)), thickness -0.003(mm) (se 0.001), separation -0.003(mm) (se 0.001) and BV/TV -0.010(%) (se 0.004) were also reduced. CPHP may have consequences for calcaneal bone density and microarchitecture by modifying associations of BMI and ankle plantarflexor strength with calcaneal bone outcomes. The reasons for these case-control differences are uncertain but could include a bone response to entheseal stress, altered loading habits and/or pain mechanisms. Confirmation with longitudinal study is required.

Effect of a Toe-Walking Protocol in Plantar Heel Pain: A Proof of Concept

Background: Plantar heel pain (PHP) is one of most common disorders of the foot treated in primary care. It affects athletic and sedentary populations, with patient reports of activity-limiting pain and reduced quality of life. Recently, atrophy of the forefoot plantar intrinsic musculature was identified in patients with PHP. Therefore, the purpose of this study was to assess whether loading the plantar fascia strengthens the intrinsic foot musculature (IFM) and decreases symptoms in subjects with PHP Methods: A within-subjects experimental design assessed foot function, foot pain, disability, and activity limitation in 12 subjects with PHP prior to and at the end of a six-week toe-walking program. The primary outcome measure was the Foot Function Index (FFI). IFM strength (both hallux flexion and lesser toe flexion) was measured as a secondary outcome. Results: After six weeks of treatment, the mean (SD) FFI score significantly decreased from 73.2 (32.4) to 43.3 (22.8) points (p = 0.010, ES=1.1). HHD measures: Both great toe flexion and lesser toes flexion strength measures demonstrated significant force increases from 21.8N to 29.6N (+7.8N) 95%CI [1.3, 14.4] (p=0.024, ES=1.0) and from 21.4N to 28.4N (+6.6N) 95%CI [1.8, 11.4] (p=0.010, ES=0.9), respectively. Conclusion: Results suggest that toe-walking may reduce PHP symptoms and increase IFM strength. There was no identified correlation between the IFM and FFI changes. Symptom reduction may be due to a reduction in cortical inhibition rather than IFM strength changes. Findings provide foundation for future larger and more controlled studies, to further validate the effectiveness of toe-walking in reducing symptoms of PHP patients. Trial registration: Bond University Ethics Committee (BUHREC Protocol No. 1908)

Effect of a toe-walking protocol in plantar heel pain: A pilot study

Introduction/Purpose: Plantar heel pain (PHP) is one of most common disorders of the foot treated in primary care. It affects athletic and sedentary populations, with patient reports of activity-limiting pain and reduced quality of life. Recently, atrophy of the forefoot plantar intrinsic musculature was identified in patients with PHP.Therefore, the purpose of this study was to assess whether loading the plantar fascia strengthens the intrinsic foot musculature (IFM) and decreases PHP sufferers’ symptoms.Methods: A within-subjects experimental design assessed Foot Function Index (FFI) and IFM strength via hand-held dynamometry (HHD) in 12 patients with PHP prior to and at the end of a six-week toe-walking program.Results: After six weeks of treatment, the mean (SD) FFI score significantly decreased from 73.2 (32.4) to 43.3 (22.8) points (p = 0.010, ES = 1.1). HHD measures: Both great toe flexion and lesser toes flexion strength measures demonstrated significant force increase of 7.8N 95%CI [1.3, 14.4] (p = 0.024, ES = 1.0) and 6.6N 95%CI [1.8, 11.4] (p = 0.010, ES = 0.9), respectively.Conclusion: Results suggest toe-walking reduces PHP symptoms and increases IFM strength. There was no identified correlation between the IFM and FFI changes. Symptom reduction may potentially be due to a reduction in cortical inhibition rather than IFM strength changes. Findings provide foundation for future studies, employing imaging, to further validate the effectiveness of toe-walking in reducing symptoms of PHP patients.Trial registration: PROSPERO 2016 CRD42016036302 Registered 10 March 2016, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016036302

Incidence of plantar fasciitis in overweight patients of government hospitals of Faisalabad city.

Objective: To determine relationships of body mass index with plantar fasciitis and foot functions index and how many activities of daily living were limited with plantar heel pain due to overweight in population of Government Hospitals of Faisalabad City. Study Design: Cross-sectional study. Setting: Government Hospitals of Faisalabad City (Allied Hospital & District Headquarter Hospital). Period: March to May 2018. Material & Methods: 140 patients included both males and females. Convenient sampling technique was used in selection of study sample. Calculate BMI (kg/m2) and FFI questionnaire used in this study to find how many activities of daily living was limited with plantar heel pain due to overweight. Data was analyzed by using statistical package for social sciences (SPSS) version 20. Chi square test was applied. Results: There were 70 males and 70 females. Data was collected to overweight population (mean age, 42.15; mean BMI, 29.52 kg/m2; and mean height, 1.68m). Out of 140 overweight population was (66.4%) and obese population (33.6%). The windlass test showed (87.9%) positive and (12.1%) negative. Chi-square test revealed no significant relation between rise in BMI and plantar heel pain (p = 0.105). However it shows significant relation between rise in BMI and FFI (p = 0.000). Conclusion: There is no statistical significant relation between body mass index and plantar fasciitis. According to foot function index patients significantly limit activities of daily living with plantar heel pain due to overweight.

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

Background Plantar heel pain (PHP) accounts for 11–15% of foot symptoms requiring professional care in adults. Recovery is variable, with no robust prognostic guides for sufferers, clinicians or researchers. Therefore, we aimed to determine the validity, reliability and feasibility of questionnaire, clinical and biomechanical measures selected to generate a prognostic model in a subsequent cohort study. Methods Thirty-six people (19 females & 17 males; 20–63 years) were recruited with equal numbers in each of three groups: people with PHP (PwPHP), other foot pain (PwOP) and healthy (H) controls. Eighteen people performed a questionnaire battery twice in a randomised order to determine online and face-to-face agreement. The remaining 18 completed the online questionnaire once, plus clinical measurements including strength and range of motion, mid-foot mobility, palpation and ultrasound assessment of plantar fascia. Nine of the same people underwent biomechanical assessment in the form of a graded loaded challenge augmenting walking with added external weight and amended step length on two occasions. Outcome measures were (1) feasibility of the data collection procedure, measurement time and other feedback; (2) establishing equivalence to usual procedures for the questionnaire battery; known-group validity for clinical and imaging measures; and initial validation and reliability of biomechanical measures. Results There were no systematic differences between online and face-to-face administration of questionnaires (p-values all > .05) nor an administration order effect (d = − 0.31–0.25). Questionnaire reliability was good or excellent (ICC2,1_absolute)(ICC 0.86–0.99), except for two subscales. Full completion of the survey took 29 ± 14 min. Clinically, PwPHP had significantly less ankle-dorsiflexion and hip internal-rotation compared to healthy controls [mean (±SD) for PwPHP-PwOP-H = 14°(±6)-18°(±8)-28°(±10); 43°(±4)- 45°(±9)-57°(±12) respectively; p < .02 for both]. Plantar fascia thickness was significantly higher in PwPHP (3.6(0.4) mm vs 2.9(0.4) mm, p = .01) than the other groups. The graded loading challenge demonstrated progressively increasing ground reaction forces. Conclusion Online questionnaire administration was valid therefore facilitating large cohort recruitment and being relevant to remote service evaluation and research. The physical and ultrasound examination revealed the expected differences between groups, while the graded loaded challenge progressively increases load and warrants future research. Clinician and researchers can be confident about these methodological approaches and the cohort study, from which useful clinical tools should result, is feasible. Level of evidence IV