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Predictors of Response to Physical Therapy Intervention for Plantar Heel Pain


Shane M. McClinton, Joshua A. Cleland and Timothy W. Flynn
Foot Ankle Int published online 3 November 2014
DOI: 10.1177/1071100714558508

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research-article2014
FAIXXX10.1177/1071100714558508Foot & Ankle InternationalMcClinton et al

(Original) Clinical Research Article


Foot & Ankle International®

Predictors of Response to Physical Therapy


1­–9
© The Author(s) 2014
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DOI: 10.1177/1071100714558508
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Shane M. McClinton, DPT, FAAOMPT1,2, Joshua A. Cleland, PT, PhD3,


and Timothy W. Flynn, PT, PhD4

Abstract
Background: Age, weight, and duration of symptoms have been associated with a poor response to treatment for plantar
heel pain (PHP), but no studies were identified that examined predictors of response to physical therapy intervention.
The purpose of this investigation was to examine the influence of age, body mass index (BMI), and symptom duration on
treatment response to physical therapy intervention.
Methods: Sixty participants received 6 visits over 4 weeks of physical therapy intervention that included manual therapy
and exercise or electrophysiological agents and exercise. Outcomes were assessed using the Foot and Ankle Ability
Measure (FAAM), Numeric Pain Rating Scale (NPRS), and Global Rating of Change Scale (GRC). Logistic regression
(P < .05) was used to analyze age, BMI, and symptom duration as potential predictors of a successful response based on
the minimal clinically important difference of the outcome measures. Sensitivity analysis was used to assess the influence
of success based on minimal clinically important changes in the FAAM, NPRS, and GRC or only the FAAM and NPRS.
Receiver operating curves were used to determine the cut point for the significant predictor.
Results: At the 6-month follow-up to physical therapy intervention, NPRS was improved by 3 points (95% CI, 2.4-3.6)
and FAAM improved by 22.5 points (95% CI, 16.8-28.2). Individuals with symptoms less than 7.2 months were 4.2 (95%
CI, 1.3-13.8; P = .016) and 8.5 (95% CI, 2.5-28.9; P = .001) times more likely to respond to treatment based on the NPRS/
FAAM/GRC and NPRS/FAAM success criteria, respectively. Age and BMI were not significant predictors (P ≥ .455 and
P ≥ .450, respectively).
Conclusion: Age and BMI were not associated with outcomes and obese individuals did achieve a successful outcome
with the physical therapy intervention used in the clinical trial. Individuals with PHP symptoms longer than 7 months
require additional consideration and further investigation of effective strategies to improve treatment response.
Level of Evidence: Prognosis, level 2b comparative study.

Keywords: plantar fasciitis, prognosis, obese, manual therapy, exercise

Introduction advocated initially to manage PHP and most patients


respond positively to treatment.14,44,50,63 Despite improve-
Plantar heel pain (PHP), commonly referred to as plantar ment in most who are treated conservatively for PHP,
fasciitis, is a frequently occurring foot condition that results approximately 18% to 50% of individuals continue to have
in disability and limited function in work, recreation, and
daily activities. While plantar fasciitis has been reported as 1
Physical Therapy Department, Des Moines University, Des Moines, IA,
the most common cause of plantar heel pain, the term plan-
USA
tar heel pain is inclusive of other pathological and painful 2
Orthopaedic and Sports Science Program, Rocky Mountain University
conditions of the plantar fascia and heel that are often dif- of Health Professions, Provo, UT, USA
3
ficult to discriminate via history and physical examina- Physical Therapy Department, Franklin Pierce University, Manchester,
tion.6,70 Individuals with PHP incur approximately 800 000 NH, USA
4
Physical Therapy Department, Rocky Mountain University of Health
to 1 million visits to physicians annually at an estimated
Professions, Provo, UT, USA
cost of $192 to $376 million.57,64 In addition to physician
visits, PHP was the most prevalent condition treated by Corresponding Author:
Shane M. McClinton, DPT, FAAOMPT, Physical Therapist/Assistant
podiatrists and the most common foot condition seen by
Professor, Physical Therapy Department, Des Moines University, 3200
physical therapists.2,54 Conservative (ie, nonsurgical and Grand Avenue, Des Moines, IA 50312, USA.
non-extracorporeal shock wave therapy) interventions are Email: shane.mcclinton@dmu.edu

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2 Foot & Ankle International 

symptoms after conservative treatment and 30% have recur- sex, duration of symptoms, body mass index (BMI), and
rent symptoms.5,17,41,69 use of medications. In addition, the activities of daily living
Incomplete recovery or failure to respond to conservative subscale of the Foot and Ankle Ability Measure (FAAM),
treatment may be attributed to patient characteristics that the Lower Extremity Functional Scale (LEFS), the Beck
affect treatment response. Age, body mass, and duration of Anxiety Index (BAI), and the 3-item (current, best, worst
symptoms have been identified as characteristics associated pain) Numeric Pain Rating Scale (NPRS) were completed
with a reduced response to conservative treatment for plan- at baseline, 4 weeks, and 6 months after initiation of treat-
tar heel pain.23,32,41,53,69 Recently, a randomized clinical trial ment. Also, the Global Rating of Change Scale (GRC) was
demonstrated clinically meaningful improvement following completed at 4 weeks and 6 months after baseline. For the
multimodal physical therapy intervention for PHP,8 but did purpose of this secondary analysis, the variables selected
not analyze the influence of age, body mass, or duration of included age, duration of symptoms, BMI, FAAM, NPRS,
symptoms on treatment response. No other evidence was and GRC. The FAAM consisted of 21 questions about the
found to indicate factors associated with treatment response difficulty (range: 0 = unable to do, through 4 = no diffi-
to multimodal physical therapy intervention. Knowledge of culty) of daily tasks due to foot and ankle problems. The
factors that can potentially affect outcome can help identify total score was divided by the highest possible score and
individuals less likely to respond to physical therapy inter- multiplied by 100, where 0 = no functional ability and 100
vention. Once identified, additional research can focus on = highest state of functional ability. The FAAM has demon-
strategies that may be more effective for subgroups of non- strated content and context validity, an intraclass correlation
responders and help to reduce the incidence of persistent or coefficient (ICC) of 0.89, and a minimal clinically impor-
recurrent symptoms in individuals with PHP. Therefore, the tant difference (MCID) of 8 points.40 An 11-point NPRS,
purpose of this investigation was to identify if age, body where 0 = no pain and 10 = worst imaginable pain was used
mass, or symptom duration were predictors of outcome to to capture pain intensity. The NPRS with 3 items has dem-
physical therapy intervention in individuals with PHP. onstrated validity, a test-retest reliability of 0.61 to 0.88,
and an MCID of 2 points.7,20,33,34 The GRC was a single-
item questionnaire that ranked patient-perceived improve-
Methods ment between –7 (a very great deal worse) to 0 (about the
Participants same) to +7 (a very great deal better).31 Scores of +5 (quite
a bit better) have been used as an indicator of clinical
The study population included 60 individuals who partici- success.9,31,37
pated in a randomized clinical trial between October 2006
and January 2008.8 Participants included patients with PHP
between the ages of 27 and 63 years that presented at 1 of 2 Procedures
outpatient orthopaedic physical therapy clinics. The diag- Complete details of the clinical trial procedures are
nosis of PHP was based on pain localized to the medial cal- described by Cleland et al.8 Participants received 6 visits
caneal tubercle and pain worsened during the first steps over 4 weeks of physical therapy intervention that included
after awakening.11,16,44 Imaging was not used to further dis- manual therapy and exercise or electrophysiological agents
criminate the pathological conditions associated with the and exercise. Both groups received exercises that included
clinical presentation of PHP. Patients with precautions to stretching and self-mobilization of the plantar fascia, calf
manual therapy interventions (ie, tumor, fracture, rheuma- stretching with the knee flexed and extended, and ankle
toid arthritis, osteoporosis, prolonged history of steroid use, eversion self-mobilization. All patients were instructed to
severe vascular disease, etc); prior surgery to the distal perform all activities of daily living that did not increase
tibia, fibula, ankle joint, or rearfoot region (proximal to the symptoms and to avoid aggravating activities. In the group
base of the metatarsals); insufficient English proficiency to that received manual therapy, intervention was based on
complete questionnaires; or inability to comply with treat- patient-specific impairments in the hip, knee, lower leg,
ment and follow-up schedules were excluded. Prior to par- ankle, and foot regions. Manual therapy included joint
ticipating in the clinical trial, patients reviewed and signed mobilization or manipulation to the aforementioned areas
a consent form approved by the Human Investigations and soft tissue mobilization to the plantar fascia and flexor
Committee , Concord Hospital, Concord, NH and the Lower hallicus longus. In the group that received electrophysio-
South Regional Ethics Committee, Dunedin, New Zealand.8 logical agents, ultrasound (3 MHz, 1.5 W/cm2, 100-Hz,
20% duty cycle, 5 min duration) was performed to the
involved area followed by iontophoresis with dexametha-
Measures sone (40 mA.min dose). Thirteen patients were taking anti-
All participants in the clinical trial completed a standard- inflammatory medication at the start of the study and were
ized baseline examination at the outset that recorded age, instructed to continue usage as prescribed by their

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McClinton et al 3

Table 1.  Participant Characteristics and Outcome Measures at Baseline and the 6-Month Follow-up (mean ± SD or frequency [%];
n = 60).

Variable Baseline 6 Month Difference (95% CI)


Age in years (range) 48 ± 9 (27-63) — —
Female participants (%) 33 (55) — —
BMI in kg/m2 31.9 ± 7.5 — —
Duration of symptoms in days 271.6 ± 212.7 — —
NPRS 4.7 ± 1.7 1.7 ± 1.82 –3 (–2.4, –3.6)
 Change ≥ 2 points (%) — 42 (70) —
FAAM 57.5 ± 14.9 80 ± 16.5 22.5 (16.8, 28.2)
 Change ≥ 8 points (%) — 46 (77) —
GRC ≥ +5 (%) — 40 (67) —
Successful response (%)  
  NPRS/FAAM/GRC criteria — 29 (48) —
  NPRS/FAAM criteria — 38 (63) —

Abbreviations: BMI, body mass index; FAAM, Foot and Ankle Ability Measure; GRC, Global Rating of Change; NPRS, Numeric Pain Rating Scale.

physician. Patients were limited to intervention provided Standard logistic regression (P < .05) was used to ana-
within the clinical trial and did not receive any other inter- lyze age, BMI, and symptom duration as predictors of suc-
vention; for example, injections, night splints, anti-inflam- cessful treatment response based on the minimal clinically
matory medication (other than that taken prior to outset of important difference of the outcome measures. Predictor
the study), or immobilization were not utilized. The FAAM, variables were tested for multicollinearity and demonstrated
LEFS, BAI, NPRS, and GRC were administered at 4 weeks variance inflation factor values greater than 10 and toler-
and 6 months after the start of treatment. ance values less than 0.10 in all imputed data sets. A sensi-
tivity analysis was conducted using 2 criteria to define
successful response to physical therapy intervention. In the
Statistical Analysis first scenario, participants were defined as having a suc-
All data analyses and imputations were performed using cessful response if they exceeded MCID thresholds for 3
SPSS, Version 22.0 (SPSS Inc, Chicago, IL, USA). Despite outcome measures (NPRS, 2 points; FAAM, 8 points; and
significant difference in outcomes between the 2 physical GRC, +5 or greater) at the 6 month follow-up similar to
therapy intervention groups, significant, and clinically procedures used by Cleland et al.10 In the second scenario,
meaningful improvement was observed in both groups.8 successful response was defined only using the MCID of
Therefore, to provide the most comprehensive analysis that the NPRS and FAAM. Recent evidence has demonstrated
included all responders to physical therapy intervention, concerns regarding the validity and stability of the GRC,
participants from both treatment groups were included in and therefore both analyses were conducted to assess the
the analysis consistent with multivariate prognostic model- influence of a successful response criterion that does not
ing recommendations and procedures used by other include the GRC.24,59 Receiver operating curves were used
responder analyses of randomized clinical trials.22,26,27,35,48 to determine the cut point for the significant predictor, and
This type of analysis allows a detailed analysis of whether the Nagelkerke R2 was used to describe the amount of varia-
age, body mass, or symptom duration should alter the deci- tion explained by the significant predictor. The odds ratio
sion to manage PHP with physical therapy interventions. (95% CI) was reported to indicate the odds of a successful
Less than 12% of the original data was missing for the vari- response to treatment based on the determined cut point of
ables used in this investigation. Multiple imputation proce- the significant predictor. Sensitivity, specificity, and posi-
dures were used to handle missing values after analysis of tive and negative likelihood ratio values were calculated for
the missing data and observed absence of monotonicity. the predictor variable. In addition, MANCOVA and chi-
Five imputed data sets were generated using the Markov square tests were used to compare the FAAM, NPRS, and
Chain Monte Carlo method and pooled estimates from the GRC between individuals above and below the cut point for
multiple imputations were used when reporting data. Patient the significant predictor using baseline scores as the
characteristics and outcome variables were summarized covariate.
using the mean and standard deviation for continuous mea- Separate post hoc power analyses for logistic regression
sures and the frequency and percentages for categorical analyses were performed using G*Power 3.1.6 using the
measures (Table 1). observed odds ratio, Pr (y = 1 | x = 1) H0 calculated from

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4 Foot & Ankle International 

Table 2.  Odds Ratio, Sensitivity, Specificity, and Positive and Negative Likelihood Ratio Values of Symptom Duration Less Than 7.2
Months as a Predictor of Successful Response to Physical Therapy Intervention.

Successful Response Odds Ratio Sensitivity Specificity + LR – LR


Criteria (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
NPRS/FAAM/GRC 4.2 0.58 0.75 2.3 0.56
  (1.3, 13.8) (0.41, 0.74) (0.57, 0.87) (1.2, 4.7) (0.35, 0.89)
NPRS/FAAM 8.5 0.76 0.73 2.8 0.33
  (2.5, 28.9) (0.6, 0.87) (0.52, 0.87) (1.4, 5.6) (0.18, 0.62)

Abbreviations: FAAM, Foot and Ankle Ability Measure; GRC, Global Rating of Change; LR, likelihood ratio; NPRS, Numeric Pain Rating Scale.

Table 3.  Outcome Comparison of Individuals With Symptom Duration Above and Below the 7.2 Month Cut Point (mean ± SD or
frequency [%]; n = 60)a.

Symptoms < 7.2 Symptoms > 7.2 Difference


Outcome Variable Months (n = 35) Months (n = 25) (95% CI) P Value
FAAM
 Baseline 53.3 ± 15.4 63.2 ± 15 –9.9 (–1.9, –18) <.001
  6 month 82 ± 17.2b 77.2 ± 17.5b 4.8 (–4.3, 13.9)b >.19b
  Change score 24.5 ± 17.2b 19.6 ± 17.5b 4.4 (–4.7, 13.5)b >.19b
NPRS
 Baseline 5.5 ± 1.6 3.7 ± 1.5 1.8 (1, 2.6) <.001
  6 month 1.4 ± 2.2b 2.1 ± 2.1b –0.7 (–1.8, 0.4)b >.08b
  Change score –4 ± 2.2b –1.7 ± 2.1b –2.3 (–1.2, –3.4)b >.08b
GRC (%)
  6 month 25 (68.6) 16 (64) — >.36c
a
The P values indicate the lowest value from MANCOVA for all imputed data sets unless otherwise indicated. FAAM, Foot and Ankle Ability Measure;
GRC, Global Rating of Change; NPRS, Numeric Pain Rating Scale.
b
Adjusted for baseline score.
c
Calculated via chi-square test.

classification tables and R2 obtained from both response cri- successful treatment response. Analysis of the receiver
teria analyses, and α = .05.21 operating curves for symptom duration identified a cut
point of 218 days (ie, 7.2 months) for both successful
response criteria. Individuals with symptoms less than 7.2
Results months were 4.2 (P = .016) and 8.5 (P = .001) times more
The characteristics of the sample included middle-aged par- likely to respond to treatment based on the NPRS/FAAM/
ticipants who were, on average, obese (Table 1).47 Mean GRC, and NPRS/FAAM success criteria, respectively
changes in NPRS and FAAM scores in response to physical (Table 2). Sensitivity, specificity, and positive and negative
therapy intervention at the 6-month follow-up exceeded the likelihood ratio values for the accuracy of symptoms less
MCID of 2 and 8 points, respectively (Table 1). Also, the than 7.2 months to predict a positive response to physical
lower confidence interval of the FAAM and NPRS change therapy intervention are listed in Table 2. Using the response
score exceeded the MCID. In addition, 67% of participants rate of the sample and calculated likelihood ratios (Tables 1
reported a GRC of +5 (quite a bit better) or greater. and 2), the probability of successful response to physical
The sensitivity analysis demonstrated different frequen- therapy intervention if symptoms were present less than 7.2
cies of successful response between the 2 criteria used. The months increased from 48% to 68% (95% CI, 52-81) using
NPRS/FAAM/GRC criteria resulted in 29 cases deemed a the NPRS/FAAM/GRC criteria and from 63% to 83% (95%
successful response and the NPRS/FAAM criteria defined a CI, 70-91) using the NPRS/FAAM criteria. Differences in
successful response in 38 cases (Table 1). Duration of the FAAM, NPRS, and GRC between individuals with
symptoms was the only significant predictor in logistic symptoms less than, and greater than, 7.2 months are pro-
regression analyses using the NPRS/FAAM/GRC and the vided in Table 3.
NPRS/FAAM criteria. Age and BMI were not significant For the logistic regression analysis using the NPRS/
predictors (P ≥ .455 and P ≥ .450, respectively) of FAAM/GRC criteria, the Nagelkerke R2 ranged from 0.117

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McClinton et al 5

to 0.181 in the 5 imputed data sets and indicated that dura- analysis resulted in an increased success rate and a higher
tion of symptoms predicted 18.1% of the variation, at best. odds ratio associated with the predictor variable. The
The Nagelkerke R2 using the NPRS/FAAM criteria range increased success rate and odds ratio is likely attributed to
between 0.258 to 0.326 and therefore duration of symptoms the lower standards to achieve success in the NPRS/FAAM
explained 32.6% of the variation, at best. criteria; namely, 2 versus 3 measures used as the cut point
Results of post hoc power analysis indicated a power of for successful response. Despite evidence that the GRC
0.97 for the analysis including the NPRS/FAAM/GRC cri- lacked correlation with functional change measures, GRC
teria and a power of 0.99 using the NPRS/FAAM criteria. may represent an important treatment response construct
worthy of consideration when determining treatment suc-
cess.24,59 In this study, a more conservative estimate of suc-
Discussion cessful response to treatment was obtained when the GRC
In the clinical trial, 48% to 63% of individuals with PHP was added to the pain and function measures compared to
demonstrated a successful response to 6 sessions of multi- the pain and function measures alone. Further consensus is
modal physical therapy intervention conducted over 4 needed to improve consistency in reporting of response to
weeks. If PHP symptoms were present for less than 7.2 PHP conservative treatment so that better comparisons can
months, the probability of a successful response increased be made between investigations.
to 68% and 83% for the NPRS/FAAM/GRC and NPRS/ A successful response to physical therapy intervention
FAAM criteria, respectively. There were no other investiga- was found in this analysis despite a sample that included
tions found that examined success to intervention for PHP individuals who, on average, were obese (Table 1).47
based on the 2 criteria used in this investigation. The criteria Furthermore, high BMI was not a predictor of poor response
and rate of success to conservative intervention for PHP to treatment in the logistic regression analysis. Previously,
varies widely between studies making direct comparison increased weight or obesity had been associated with an
difficult. Some investigations have reported success rates increased risk of PHP.25,29,30,56 In addition, individuals who
ranging from 44% to 89% based on patient reports of are overweight or obese were reportedly less responsive to
improvement of symptoms, no pain, total/100% relief, reso- conservative treatment for PHP.23,32,69 Because PHP often
lution of symptoms, good to excellent results, or 80% relief limits weightbearing exercise, individuals with PHP are less
of symptoms.4,15,23,41,46,49,58,61,69 Other investigations have able to use exercise to manage their weight.50 The results of
used outcome instruments to define success that included this analysis are promising in that individuals who are over-
an 11-point visual analog scale (VAS) less than 5, GRC weight or obese can have a successful response to physical
greater than +4, GRC greater than +5, or FAAM change therapy intervention for PHP allowing them to reap the ben-
greater than 8 points and have reported success rates rang- efits of weightbearing exercise.
ing from 45% to 80%.18,37,39 When looking at the success Increased age is another factor that has been associated
rates of individual measures from the clinical trial (Table 1), with PHP and decreased response to conservative treat-
rates of success were similar to other investigations that ment.29,53 In this analysis, age was not a significant factor
demonstrated 80% success based on FAAM change greater that predicted successful response to treatment, but this
than or equal to 8 and 70% success based on GRC greater sample was limited to individuals between the ages of 27 to
than or equal to +5.18,37 63. Because of the limited age range of this sample, it is
While no responder criteria was found to determine the unclear if individuals greater than 63 years of age have a
cut point for successful response in individuals with PHP, different rate of success than individuals less than 63 years
responder criteria based on multiple measurement domains old. Approximately 15% of individuals with PHP are greater
including pain, function, and patient’s global rating of 65 years or older, and therefore it is important to identify
change has been developed and used in other popula- successful interventions for PHP in older adults.57
tions.10,51,52 The successful response criteria used in this The results of this analysis indicated that individuals with
investigation was chosen to minimize the possibility of PHP symptom duration less than 7 months were more likely
deeming a response successful based on only 1 domain of to respond to the physical therapy intervention included in
response to treatment where unsuccessful responses may the clinical trial. Two other studies were found that reported
still be observed in other domains. As a result, the success a reduced response to conservative intervention for PHP if
rates observed in this investigation may be lower than symptoms were present for a longer duration, namely, 12 or
investigations using only 1 measure to determine success. more months.41,69 In a telephone survey of 100 patients
In addition to using criteria involving 3 measures of treated conservatively by 3 orthopaedic surgeons, a good
response to treatment, a parallel analysis was conducted result (defined as no symptoms) was achieved in 14 of 22
only using the NPRS and FAAM criteria. While the NPRS/ (64%) with symptoms for 12 or more months compared to
FAAM/GRC and NPRS/FAAM criteria produced similar 68 of 78 (87%) with symptoms less than 12 months (P <
results in logistic regression analysis, the NPRS/FAAM .003).69 Conservative treatment was case-specific and

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6 Foot & Ankle International 

included stretching, cushion or hard shoe inserts, anti- neuroscience education and myofascial trigger point inter-
inflammatory medication or injections, ice or heat, heel cup, vention on chronic PHP.
night splint, or foot strapping. Similarly, in a mailed follow- The results of this analysis indicated that symptom dura-
up survey to 157 PHP patients who received conservative tion was a significant predictor of response to physical ther-
treatment from 1 orthopaedic surgeon, patients with symp- apy intervention for PHP. While the results of this analysis
toms greater than 12 months were less likely to have a good provide evidence of an improved response with a shorter
outcome defined as no pain (P < .04).41 Conservative treat- duration of symptoms and a lesser response with a longer
ment included anti-inflammatory medication or injection, duration of symptoms, caution is warranted in generalizing
night splint, at least 1 session of exercise instruction pro- the results. As indicated in Table 3, individuals with symp-
vided by a physical therapist, and a custom orthosis or heel toms longer than 7 months had higher functional scores on
cup. In the clinical trial that provided the sample for this the FAAM and lower pain on the NPRS at baseline that may
analysis, patients received physical therapy intervention that have limited potential for improvement. Conversely, indi-
included stretching and self-mobilization exercises to the viduals with a lower duration of symptoms had lower func-
lower leg, ankle, and foot in addition to manual therapy or tional scores and higher pain scores at baseline, which may
electrophysiological modalities. Despite the different con- have contributed to greater potential for improvement.
servative treatments provided to the participants that formed Therefore, because the responder criteria were based on the
the sample for this analysis and in other studies that demon- magnitude of response, namely, the MCID of outcome mea-
strated reduced response with longer symptom duration, sures, the effect of duration determined from logistic regres-
symptom duration appears to be a significant prognostic fac- sion may have been affected by the baseline differences
tor to consider in the conservative management of individu- between individuals above and below the 7-month duration
als with PHP. cut point. Despite the statistical significance that demon-
Individuals with longer symptom duration may develop strated greater odds of successful outcome in individuals
different pain mechanisms that contribute to their PHP with symptoms less than 7 months, clinically meaningful
experience and response to treatment. Individuals with a changes were also observed in individuals with symptoms
longer duration of pain demonstrated maladaptive psycho- greater than 7 months based on the MCID of the NPRS and
social factors consistent with a central sensitization versus FAAM (Table 3). In addition, an equal proportion of indi-
nociceptive pain mechanism.62 The reduced treatment viduals with symptoms greater and less than 7 months dem-
response associated with longer duration of PHP symptoms onstrated GRC of +5 or greater (Table 3). While further
and evidence of lower foot function in PHP patients with research is warranted to examine effective solutions in indi-
higher stress and depression indicates the potential for cen- viduals with a longer duration of symptoms, the physical
tral sensitization mechanisms in patients with a longer dura- therapy intervention provided in this clinical trial resulted
tion of PHP.13 Therefore, clinical reasoning models that in clinically meaningful changes regardless of symptom
integrate intervention with consideration of pain mecha- duration and was still effective in individuals with symp-
nism and clinical presentation may benefit individuals with toms greater than 7 months.
longer PHP symptoms. Therapeutic pain neuroscience edu- In addition to duration of symptoms, there may be other
cation is one intervention that is recommended in the pres- factors that were not recorded during the clinical trial or
ence of central sensitization and has demonstrated positive considered in this analysis that may predict successful treat-
effects on pain, disability, anxiety, and stress in chronic ment response. Symptom duration explained 11.7% to
musculoskeletal pain conditions.38 No evidence was found 32.6% of the variation in the data, and therefore other fac-
on the effects of therapeutic pain neuroscience education in tors are likely to contribute to the remaining variability in
individuals with PHP although a clinical trial is underway treatment response. Few studies were found that investi-
that includes this as one part of the conservative manage- gated factors related to response to conservative treatment
ment plan.42 In addition to therapeutic pain neuroscience other than age, BMI, and symptom duration. Several other
education, other interventions directed at proximal inputs to factors derived from the history and physical examination
PHP through central or peripheral neurodynamic mecha- including foot posture/mobility, ankle or hallux dorsiflex-
nisms, for example, myofasicial trigger points, may be of ion, daily weightbearing duration, lower leg/foot strength,
additional benefit. Myofascial trigger point manual and dry neurodynamic dysfunction, stress, depression, and low
needling intervention has demonstrated significant improve- back pain have demonstrated an association with PHP or
ment of PHP, pain pressure thresholds, and foot-related foot function and may contribute to the response to physical
function.1,12,55 In investigations of myofascial trigger point therapy intervention.3,13,28,30,36,45,56,60,66 Additional informa-
therapy on PHP, only Cotchett et al12 included a sample of tion derived from imaging including heel pad energy dissi-
participants with an average duration greater than 7 months. pation ratio, hyperemia, thickened plantar fascia, and heel
Further research is needed to identify factors related to lon- spurs may also contribute to prediction of response to treat-
ger duration of PHP and to test the effects of pain ment.29,43,65,67,68 While the historical, physical examination,

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McClinton et al 7

and imaging factors listed previously may occur more com- 3. Allen RH, Gross MT. Toe flexors strength and passive exten-
monly in some populations of PHP, they are also present in sion range of motion of the first metatarsophalangeal joint in
asymptomatic individuals and the impact of these factors on individuals with plantar fasciitis. J Orthop Sports Phys Ther.
clinical management including prediction of successful 2003;33:468-478.
4. Amis J, Jennings L, Graham D, Graham CE. Painful heel syn-
response requires further investigation.19
drome: radiographic and treatment assessment. Foot Ankle.
1988;9:91-95.
Conclusion 5. Beyzadeoglu T, Gokce A, Bekler H. The effectiveness of
dorsiflexion night splint added to conservative treatment for
Individuals with PHP for less than 7 months were more plantar fasciitis. Acta Orthop Traumatol Turc. 2007;41:220-
likely to respond to the physical therapy interventions pro- 224.
vided in the clinical trial, but age and BMI were not predic- 6. Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J
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of individuals with symptoms less than 7 months, some 7. Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric
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able to demonstrate clinically meaningful changes in Pa 1976). 2005;30:1331-1334.
8. Cleland JA, Abbott JH, Kidd MO, et al. Manual physical ther-
response to physical therapy intervention. Participants in
apy and exercise versus electrophysical agents and exercise
this trial were obese based on the average BMI yet were
in the management of plantar heel pain: a multicenter ran-
responsive to physical therapy intervention despite previous domized clinical trial. J Orthop Sports Phys Ther. 2009;39:
reports of the associations of obesity with PHP and a poor 573-585.
treatment response. The upper age range in this sample was 9. Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL.
limited, and further analysis is needed to assess the influ- Development of a clinical prediction rule for guiding treat-
ence of age on treatment response in individuals greater ment of a subgroup of patients with neck pain: use of thoracic
than 63 years old. Further research is needed to elucidate spine manipulation, exercise, and patient education. Phys
additional strategies effective for PHP lasting longer than 7 Ther. 2007;87:9-23.
months and matched to individual patient characteristics 10. Cleland JA, Fritz JM, Whitman JM, Heath R. Predictors of
and preferences. short-term outcome in people with a clinical diagnosis of cer-
vical radiculopathy. Phys Ther. 2007;87:1619-1632.
11. Cornwall MW, McPoil TG. Plantar fasciitis: etiology and
Acknowledgments
treatment. J Orthop Sports Phys Ther. 1999;29:756-760.
Thanks to Tom Cappaert, PhD, ATC, Rocky Mountain University 12. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of
of Health Professions, Provo, UT; Joanne Totten, PT, and Sue trigger point dry needling for plantar heel pain: a randomized
Kennedy, School of Physiotherapy, University of Otago, Dunedin, controlled trial. Phys Ther. 2014;94(8):1083-1094.
New Zealand, for their essential contributions. 13. Cotchett MP, Whittaker G, Erbas B. Psychological variables
associated with foot function and foot pain in patients with
Declaration of Conflicting Interests plantar heel pain [published online March 20, 2014]. Clin
Rheumatol. 2014. doi:10.1007/s10067-014-2565.
The author(s) declared no potential conflicts of interest with
14. Covey CJ, Mulder MD. Plantar fasciitis: how best to treat? J
respect to the research, authorship, and/or publication of this
Fam Pract. 2013;62:466-471.
article.
15. Davis PF, Severud E, Baxter DE. Painful heel syn-

drome: results of nonoperative treatment. Foot Ankle Int.
Funding 1994;15:531-535.
The author(s) disclosed receipt of the following financial support 16. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-
for the research, authorship, and/or publication of this article: This specific plantar fascia-stretching exercise enhances outcomes
work was supported by the American Academy of Orthopaedic in patients with chronic heel pain. A prospective, randomized
Manual Physical Therapists, Cardon Rehabilitation Products study. J Bone Joint Surg Am. 2003;85-A:1270-1277.
Grant. In addition, Empi Inc. (St. Paul, MN) kindly provided ion- 17. DiGiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar
tophoresis units and supplies to one clinical site. These organiza- fascia-specific stretching exercise improves outcomes in
tions played no role in the study design, conduct and reporting, or patients with chronic plantar fasciitis. A prospective clini-
manuscript publication decisions. cal trial with two-year follow-up. J Bone Joint Surg Am.
2006;88:1775-1781.
18. Drake M, Bittenbender C, Boyles RE. The short-term effects
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