Depression, Anxiety, and Stress in People With and Without Plantar Heel Pain

Is radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses more effective than advice plus customised foot orthoses alone in the treatment of plantar fasciopathy? A double-blind, randomised, sham-controlled trial

OBJECTIVES

To assess whether radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses is more effective than advice plus customised foot orthoses alone in alleviating heel pain in patients with plantar fasciopathy.

METHODS

200 patients with plantar fasciopathy were included in a four-arm, parallel-group, sham-controlled, observer-blinded, partly patient-blinded trial. At baseline, before randomisation, all patients received advice plus customised foot orthoses. Patients were randomised to rESWT (n=50), sham-rESWT (n=50), exercise (n=50) or advice plus customised foot orthoses alone (n=50). Patients in the rESWT and sham-rESWT groups received three treatments. The exercise programme comprised two exercises performed three times a week for 12 weeks, including eight supervised sessions with a physiotherapist. Patients allocated to advice plus customised foot orthoses did not receive additional treatment. The primary outcome was change in heel pain during activity in the previous week per Numeric Rating Scale (0-10) from baseline to 6-month follow-up. The outcome was collected at baseline, and 3, 6 and 12 months.

RESULTS

The primary analysis showed no statistically significant between-group differences in mean change in heel pain during activity for rESWT versus advice plus customised foot orthoses (-0.02, 95% CI -1.01 to 0.96), sham-rESWT versus advice plus customised foot orthoses (0.52, 95% CI -0.49 to 1.53) and exercise versus advice plus customised foot orthoses (-0.11, 95% CI -1.11 to 0.89) at 6 months.

CONCLUSION

In patients with plantar fasciopathy, there was no additional benefit of rESWT, sham-rESWT or a standardised exercise programme over advice plus customised foot orthoses in alleviating heel pain.

TRIAL REGISTRATION NUMBER

NCT03472989.

Differences in Baseline Physical Function and Mental Health PROM Scores in Patients With Foot and Ankle Conditions

BACKGROUND

This study sought to establish normative values for baseline physical and mental health by foot and ankle diagnosis using validated PROMIS scores and to compare the correlation between these 2 outcomes across common diagnoses. Additionally, it investigated the effects associated with chronic vs acute conditions and specific diagnoses on mental health.

METHODS

We reviewed baseline PROMIS Physical Function 10a (PF10a) and PROMIS Global-Mental (PGM) scores of 14,245 patients with one of the 10 most common foot and ankle diagnoses seen at our institution between 2016 and 2021. Pearson correlation coefficients were calculated to assess the relationship between PF10a and PGM by diagnosis. A multivariable regression model including age, sex, language, race, ethnicity, education level, income, and Charlson Comorbidity Index was used to determine the associated effect of diagnosis on PGM score.

RESULTS

On unadjusted analysis, patients diagnosed with an ankle fracture had the lowest mean physical function, whereas patients with hallux valgus had the highest (PF10a = 33.9 vs 46.7, P < .001). Patients with foot/ankle osteoarthritis had the lowest mean self-reported mental health, whereas patients with hallux rigidus had the highest (PGM = 49.9 vs 53.4, P < .001). PF10a and PGM scores were significantly positively correlated for all diagnoses; the correlation was strongest in patients diagnosed with foot/ankle osteoarthritis or hammertoes (r = 0.511) and weakest in patients with ankle fractures (r = 0.232) or sprains (r = 0.280). Chronic conditions, including hammertoes (β = -5.1, 95% CI [-5.8, -4.3], P < .001), foot/ankle osteoarthritis (β = -5.0, 95% CI [-5.7, -4.3], P < .001), and hallux valgus (β = -4.8, 95% CI [-5.5, -4.1], P < .001) were associated with the largest negative effects on patients' mental health.

CONCLUSION

Self-reported physical function and mental health varied across common foot and ankle diagnoses and were more tightly correlated in chronic conditions. The associations between diagnosis and mental health scores appear larger for more chronic diagnoses, including those that are generally associated with relatively unimpaired physical function.

Rasch analysis of the Depression, Anxiety, and Stress Scale in patients with chronic pain

OBJECTIVE

Questionnaires are commonly used to assess and screen pain-related, psychological symptoms in patients with chronic pain. In Germany, the "German pain questionnaire" provided by the German Pain Society used for this purpose includes the Depression, Anxiety, and Stress Scale (DASS). This study aims to analyze the DASS by fitting its data to the Rasch model to test the psychometric quality.

STUDY DESIGN AND SETTING

In this cross-sectional study, 932 patients with chronic pain answered the DASS. The 21-item short version was tested via Rasch analysis using the parameters threshold order, fit to the model, Differential Item Functioning, unidimensionality and reliability.

RESULTS

The Rasch analysis results showed a low reliability, misfitting items, Differential Item Functioning or multidimensionality. It was necessary to remove items from the subscales to improve fit to the Rasch model. A revised depression subscale of the DASS-21 was the only scale that achieved all the required psychometric parameters. The summation of all items to a total scale was not supported.

CONCLUSION

More research is required on somatic free measurement of psychological symptoms in patients with chronic pain. The results demonstrate that the development of a new instrument or a revision of existing instruments for screening of psychological symptoms in chronic pain are needed.

Predicting the outcome of plantar heel pain in adults: a systematic review of prognostic factors

BACKGROUND

Plantar Heel Pain (PHP) is a common disorder with many treatment pathways and is not self-limiting, hence prognostic information concerning recovery or recalcitrance is needed to guide practice. In this systematic review, we investigate which prognostic factors are associated with favourable or unfavourable PHP outcomes.

METHODS

MEDLINE, Web of Science, EMBASE, Scopus and PubMed electronic bibliographic databases were searched for studies evaluating baseline patient characteristics associated with outcomes in prospective longitudinal cohorts or after specific interventions. Cohort, clinical prediction rule derivation and single arms of randomised controlled trials were included. Risk of bias was evaluated with method-specific tools and evidence certainty with GRADE.

RESULTS

The review included five studies which evaluated 98 variables in 811 participants. Prognostic factors could be categorised as demographics, pain, physical and activity-related. Three factors including sex and bilateral symptoms (HR: 0.49[0.30-0.80], 0.33[0.15-0.72], respectively) were associated with a poor outcome in a single cohort study. The remaining four studies reported twenty factors associated with a favourable outcome following shockwave therapy, anti-pronation taping and orthoses. Heel spur (AUC = 0.88[0.82-0.93]), ankle plantar-flexor strength (Likelihood ratio (LR): 2.17[1.20-3.95]) and response to taping (LR = 2.17[1.19-3.90]) were the strongest factors predicting medium-term improvement. Overall, the study quality was low. A gap map analysis revealed an absence of research that included psychosocial factors.

CONCLUSIONS

A limited number of biomedical factors predict favourable or unfavourable PHP outcomes. High quality, adequately powered, prospective studies are required to better understand PHP recovery and should evaluate the prognostic value of a wide range of variables, including psychosocial factors.

The struggle to stay physically active-A qualitative study exploring experiences of individuals with persistent plantar fasciopathy

BACKGROUND

Plantar fasciopathy is the most common cause of heel pain, and is associated with decreased physical activity level and quality of life. There has been limited research on the experiences of patients with plantar fasciopathy. This study seeks to gain more in-depth understanding and knowledge by exploring the lived experiences of people with persistent plantar fasciopathy.

METHODS

We included 15 participants with longstanding plantar fasciopathy. Face-to-face, semi-structured interviews were audio recorded, transcribed verbatim and analysed using Braun and Clark's reflexive thematic analysis. We used an inductive approach led by a phenomenological theoretical framework.

RESULTS

We identified three core themes and ten sub-themes. The first theme was 'Struggling to stay active' with sub-themes 'Struggling with pain and how to adjust it', ' Finding alternative activities' and 'Longing for the experience of walking'. The second main theme was 'Emotional challenges' with the sub-themes 'Feelings of frustration and self-blame' and 'Worries of weight gain and related consequences'. The third main theme was 'Relations to others' with the sub-themes 'Participation in family and social life', ' Visible in new ways', ' Striving to avoid sick leave' and 'Bothering others'.

CONCLUSIONS

Participants revealed how their heel pain led to inactivity and emotional and social challenges. Pain when walking and fear of aggravating it dominated the participants' lives. They emphasised the importance of finding alternative ways to stay active and avoiding sick leave. Treatment should focus on holistic and individually tailored approaches.

Activity and footwear characteristics in people with and without plantar heel pain: A matched cross-sectional observational study

BACKGROUND

Activity and footwear may be associated with plantar heel pain (PHP), however both factors have rarely been investigated. The aim of this study was to investigate activity and footwear characteristics in PHP while controlling for important confounders.

METHOD

This cross-sectional observational study compared 50 participants with PHP to 25 participants without PHP who were matched for age, sex and body mass index. Activity was measured using the Stanford Activity Questionnaire, as well as the number of hours per day participants stood for, and whether they stood on hard floors. Footwear characteristics were measured using the footwear domain of the Foot Health Status Questionnaire (FHSQ), as well as the style of shoe, heel height, and the Shore A hardness value of the heel of the shoe most used.

RESULTS

Participants with PHP stood for more than twice as long as participants without PHP (mean difference 3.4 hours, p < 0.001, large effect size). Participants with PHP also reported greater difficulty accessing suitable footwear (FHSQ footwear domain mean difference (MD) 22 points, p = 0.002, large effect size (ES), and they wore harder-heeled shoes (Shore A MD 6.9 units, p = 0.019, medium ES). There were no significant differences for physical activity, whether they stood on hard floors, the style of shoe they wore, or heel height.

CONCLUSIONS

Compared to people without PHP, people with PHP stand for more than twice the amount of time each day, have substantial difficulties accessing suitable footwear, and the primary shoes they wear are harder under the heel.

Surgical or non-surgical treatment of plantar fasciopathy (SOFT): study protocol for a randomized controlled trial

Background

Plantar fasciopathy is the most common reason for complaints of plantar heel pain and one of the most prevalent musculoskeletal conditions with a reported lifetime incidence of 10%. The condition is normally considered self-limiting with persistent symptoms that often last for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. Heavy-slow resistance training and radiofrequency microtenotomy for the treatment of plantar fasciopathy have shown potentially positive effects on short- and long-term outcomes (> 3 months). However, the effect of heavy-slow resistance training compared with a radiofrequency microtenotomy treatment is currently unknown. This trial compares the efficacy of heavy-slow resistance training and radiofrequency microtenotomy treatment with supplemental standardized patient education and heel inserts in improving the Foot Health Status Questionnaire pain score after 6 months in patients with plantar fasciopathy.

Methods

In this randomized superiority trial, we will recruit 70 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of two groups: (1) heavy-slow resistance training, patient education and a heel insert (n = 35), and (2) radiofrequency microtenotomy treatment, patient education and a heel insert (n = 35). All participants will be followed for 1 year, with the 6-month follow-up considered the primary endpoint. The primary outcome is the Foot Health Status Questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a Global Perceived Effect scale, the physical activity level, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment.

Discussion

By comparing the two treatment options, we should be able to answer if radiofrequency microtenotomy compared with heavy-slow resistance training is superior in patients with plantar fasciopathy.

Trial registration

ClinicalTrials.gov NCT03854682. Prospectively registered on February 26, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06785-w.

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

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

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials

OBJECTIVE

To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors.

STUDY SELECTION

Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation.

DATA SYNTHESIS

We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field.

RESULTS

Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct.

CONCLUSION

There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

"Psychometric properties of the Norwegian foot function index revised short form"

Background

Foot disorders affect up to one quarter of the adult population. Plantar fasciopathy is a common cause of foot pain associated with decreased activity level and quality of life. Patient-reported outcome measures are important in assessing the burden of a condition as well as in research on the effects of interventions. The Foot Function Index revised short form (FFI-RS) is a region specific questionnaire frequently used in research. This study aimed to cross-culturally adapt the FFI-RS into Norwegian and to test its psychometric properties.

Methods

The FFI-RS was translated into Norwegian (FFI-RSN) following international guidelines. 139 patients with foot disorders (88% with plantar fasciopathy) were included at baseline to measure internal consistency, explorative factor analysis, construct validity and floor and ceiling effects. 54 patients were included after 1 week for test-retest reliability and smallest detectable change analyses. 100 patients were included for responsiveness and minimal important change at 3 months.

Results

Cronbach’s alpha for internal consistency was 0.97 and factor analysis supported the use of the total score of the FFI-RSN. Two out of three predefined hypotheses were confirmed by assessing the construct validity with Spearman’s correlation coefficient. Quadratic weighted Kappa for test-retest reliability showed 0.91 (95% CI 0.86–0.96) and the smallest detectable change was 6.5%. The minimal important change was 8.4% and the area under the receiver operating characteristic curve for responsiveness was 0.78 (95% CI 0.69–0.87). We found no floor or ceiling effects on the total score of the FFI-RSN.

Conclusions

The present study showed excellent reliability of the FFI-RSN and supports the use of the total score of the questionnaire. Furthermore, we found the FFI-RSN to have acceptable responsiveness in relation to change in general health. Smallest detectable change, minimal important change and responsiveness were presented as novel results of the total score of the FFI-RS. FFI-RSN can be used to evaluate global foot health in clinical or research settings with Norwegian patients suffering from plantar fasciopathy.

Trial registration

Clinical Trials.gov NCT04207164. Initial release 01.11.19.

Case report: Baxter's nerve radiofrequency in patient with plantar fasciitis nonresponsive to conventional treatment

Plantar fasciitis is recognized as the leading cause of talalgia worldwide. In the vast majority of cases it can be controlled with the use of appropriate footwear, stretching exercises and changes in the sport activity, while a few cases require infiltrations or surgical interventions. The latter puts the patient at greater risk, and is reserved for the most severe cases. We propose using pulsed radiofrequency ablation of Baxter's nerve to treat this painful symptom in patients who do not respond adequately to conventional treatment. We present the case of a patient with refractory plantar fasciitis in whom surgery had been ruled out. The patient underwent pulsed radiofrequency treatment with satisfactory results in the short and medium term.

Psychological factors associated with foot and ankle pain: a mixed methods systematic review

Background

Foot and ankle pain is common, and generally viewed through a biomedical lens rather than applying a biopsychosocial model. The objectives of this review were to evaluate: (1) the psychosocial characteristics of participants with foot/ankle pain compared to participants without foot/ankle pain; (2) the association between psychosocial factors with pain and function in people with foot/ankle pain; and (3) understand the psychosocial factors associated with the lived experience of foot/ankle pain.

Methods

A mixed methods systematic review was conducted according to the PRISMA guidelines and guided by the Joanna Briggs Institute methodology for mixed methods systematic reviews. The databases MEDLINE, Embase, CINAHL, SPORTDiscus, PsychInfo, and Scopus were searched. The Mixed Methods Assessment Tool was used to evaluate study quality. A convergent segregated approach was used to synthesise and integrate quantitative and qualitative data.

Results

Eighteen studies were included, consisting of 13 quantitative, 4 qualitative and 1 mixed methods study. The overall quality of the studies was considered high. Integration of the quantitative and qualitative data were not possible due to the disparate nature of the included studies. A narrative synthesis of the quantitative data revealed that negative emotional and cognitive factors were more common in people with foot/ankle pain compared to those without foot/ankle pain. A significant association was also found between emotional distress with foot pain and foot function in some people with plantar heel pain. In addition, kinesiophobia and pain catastrophising were significantly associated with impaired foot function, and pain catastrophising was significantly associated with first step pain in people with plantar heel pain. The qualitative data revealed emotional impacts, physical challenges, and a loss of self which was individual and unpredictable.

Conclusions

This review provides evidence that negative psychological constructs are greater in participants with foot/ankle pain compared to those without foot/ankle pain, although the cross-sectional nature of the study designs included in this review reduces the certainty of the evidence. These findings indicate that psychological constructs are associated with foot/ankle pain. Further research should evaluate the predictive ability of multidimensional screening tools to identify patients at risk of developing persistent foot/ankle pain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00506-3.

Assessing the Quality and Readability of Online Resources for Plantar Fasciitis

The Internet is utilized now more than ever to research medical conditions and treatments by patients and physicians alike. The aim of this study was to evaluate the quality and readability of information available online for plantar fasciitis. Web sites were identified using the search term "plantar fasciitis." The first 25 Web sites from 5 different search engines gave a total of 125 being evaluated. Readability of each Web site was assessed using the Flesch Reading Ease score, the Flesch-Kincaid grade level, and the Gunning Fog Index. Quality was assessed using the DISCERN instrument (www.discern.org.uk) and the Journal of the American Medical Association (JAMA) benchmark criteria. The presence of Health on the Net (HON) code certification was also assessed. The authorship of each Web site was categorized into 1 of 5 categories (Physician, Academic, Commercial, Allied health or Other eg, blogs). A total of 83 Web site pages were evaluated with the majority of the web sites being authored by physicians (32.53%) and blogs (25.30%). Only 24 Web sites were HON certified (28.91%). Physician and Academic Web sites were the most credible sources, with the highest mean DISCERN (p = .00001) and JAMA (p = .0278.) scores, respectively. These Web sites were also the most difficult to read according to the readability score testing. The information available on the Internet pertaining to plantar fasciitis is highly variable and provides moderate quality information about treatment choices. Given this variability in quality, health care providers should direct patients to known sources of reliable, readable online information.

Case report: Baxteŕs nerve radiofrequency in patient with plantar fasciitis nonresponsive to conventional treatment

Plantar fasciitis is recognized as the leading cause of talalgia worldwide. In the vast majority of cases it can be controlled with the use of appropriate footwear, stretching exercises and changes in the sport activity, while a few cases require infiltrations or surgical interventions. The latter puts the patient at greater risk, and is reserved for the most severe cases. We propose using pulsed radiofrequency ablation of Baxter's nerve to treat this painful symptom in patients who do not respond adequately to conventional treatment. We present the case of a patient with refractory plantar fasciitis in whom surgery had been ruled out. The patient underwent pulsed radiofrequency treatment with satisfactory results in the short and medium term.

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.

Management of plantar heel pain in general practice in Australia

BACKGROUND

Studies have described general practitioner (GP) management of plantar heel pain from some countries; however, there is limited information from Australian general practice.

OBJECTIVES

To describe patient and GP characteristics, and management actions for plantar heel pain in Australian general practice.

DESIGN

Secondary analysis of data from the Bettering the Evaluation and Care of Health (BEACH) dataset.

METHODS

Data were summarised using descriptive analysis and robust 95% confidence intervals (CIs) were calculated around point estimates. Multivariate logistic regression identified predictors of plantar heel pain management.

RESULTS

From 1,568,100 encounters between April 2000 and March 2016, plantar heel pain was managed at 3007 encounters. GPs manage plantar heel pain approximately once every 500 encounters, which extrapolates to 271,100 encounters in 2015-2016. Patient factors independently associated with plantar heel pain encounters included female sex (OR 1.27, 95% CI 1.17-1.34 cf. males), being aged 45-64 (OR 3.44, 95% CI 2.94-4.01 cf. aged 75+) and patients from a non-English speaking background (OR 1.22, 95% CI 1.07-1.39). Plantar heel pain was frequently managed using medication (45.1 per 100), with non-steroidal anti-inflammatory drugs the most common (22.8 per 100). GPs also commonly provided counselling/advice/education (32.4 per 100), and referrals for diagnostic imaging (19.1 per 100) and to podiatrists (12.0 per 100).

CONCLUSIONS

Plantar heel pain is a frequently managed foot condition in Australian general practice. GPs use medication, counselling and education, diagnostic imaging and referral to podiatrists for management. Further research is required to understand the drivers of these management actions and whether they are effective.

The role of video-based multimedia information in reduction of anxiety before dilatation and curettage

OBJECTIVE

Considerable amount of women undergoing dilatation and curettage (D&C) are subject to preoperative anxiety. We hypothesized that the implementation of video-based multimedia information (MMI) before the D&C might facilitate patients' education and provide clear information regarding the procedure. This study aimed to compare the impact of video-based MMI and conventional written information on anxiety, pain severity, and satisfaction in patients undergoing D&C.

METHODS

Seventy four women scheduled for D&C for abnormal uterine bleeding were enrolled in this prospective randomized study. Subjects were assigned to receive a video-based MMI or conventional written information (controls). The trait and state anxiety were assessed using the State and Trait Anxiety Inventory (STAI) before the MMI or written information. STAI-state (STAI-S) was repeated after the application of the MMI or written information. All patients underwent D&C by the same gynecologist. Following D&C, patient satisfaction and procedural pain were ranked using a Likert scale and Visual Analogue Scale.

RESULTS

Post-informational STAI-S score was significantly lower than the pre-informational STAI-S score in the video group (p<0.001), whereas no significant change occurred in STAI-S score in the control group (p=0.210). The satisfaction rate of the patients receiving MMI before the D&C was significantly higher than the satisfaction rate of the controls (75% vs. 50%, p=0.027).

CONCLUSION

Implementation of MMI before the D&C procedure is associated with less anxiety, less severe postoperative pain and improved patients satisfaction, compared to the conventional written information.

Long-term effect and prognostic factors of a low-dose radiotherapy of painful plantar calcaneal spurs : A retrospective unicenter study

PURPOSE

To estimate the long-term effect of low-dose radiotherapy of painful plantar calcaneal spurs, and to verify possible prognostic factors.

PATIENTS AND METHODS

In this retrospective unicenter study, electronic patient files of patients with painful plantar calcaneal spurs treated with low-dose radiotherapy between July 2009 and February 2020 were reviewed. The low-dose radiotherapy consisted of a total dose of 3.0 Gy given with a fraction dose of 0.5 Gy three times a week. The pain reduction was estimated using a patient questionnaire with a visual analogue scale. Kaplan-Meier statistics and Cox regression analysis were used for the statistical analysis.

RESULTS

Altogether, 864 heels of 666 patients were reviewed. The probability of an insufficient pain control 10 years after low-dose radiotherapy was 45.9% (95% confidence interval 39.4-52.4%) in the subset of patients with a minimum follow-up of 3 months (582 heels of 467 patients). Patients with an unsatisfactory pain reduction 3 months after low-dose radiotherapy were offered a re-irradiation. Forty percent of the patients who received a re-irradiation developed good pain reduction. Occurrence of an initial aggravation of pain during or within 3 months after low-dose radiotherapy (p = 0.005), and treatment of bilateral painful plantar calcaneal spurs (p = 0.008) were identified as significant unfavorable prognostic factors on univariate analysis. On multivariate analysis, the initial aggravation of pain remained as independent significant prognostic factor (p = 0.01). No clear radiation toxicity was observed.

CONCLUSIONS

Low-dose radiotherapy is a safe and effective treatment option for patients with painful plantar calcaneal spurs. An initial aggravation of pain during or within 3 months after radiotherapy was identified as unfavorable prognostic factor for the treatment outcome. Re-irradiation of patients with an unsatisfactory pain reduction after low-dose radiotherapy is effective and should be offered to patients.

Embedding pain neuroscience education in the physical therapy management of patients with chronic plantar fasciitis: a prospective case series

OBJECTIVES

The purpose of this case series was to describe the effects of a biopsychosocial approach that embeds pain neuroscience education (PNE) within physical therapy for improving foot and ankle function, pain, and psychosocial factors in patients with chronic plantar fasciitis.

METHODS

Seven female patients (mean [SD] age = 49.0 [11.4] years) receiving physical therapy for chronic plantar fasciitis were enrolled. Along with formal physical therapy, patients received six 15-minute PNE sessions. Knowledge of pain neuroscience was assessed before and after PNE with the Revised Neurophysiology of Pain Questionnaire. Patients completed questionnaires for foot and ankle function (Activities of Daily Living subscale of the Foot and Ankle Ability Measure), pain intensity (Numeric Rating Scale), pain catastrophizing (Pain Catastrophizing Scale), and fear of movement (Tampa Scale for Kinesiophobia) at baseline (before treatment) and 6 and 12 weeks. Local and remote pain sensitivity was assessed using a pressure algometer at baseline and 6 weeks.

RESULTS

Patients attended a mean (range) of 8.7 (7 to 12) physical therapy sessions over a mean (range) of 46.7 (42 to 56) days. After PNE, six (86%) patients demonstrated increased knowledge of pain neuroscience. At 12 weeks, six (86%) patients met or exceeded minimally clinically important difference (MCID) for foot and ankle function and pain. Five (71%) patients met or exceeded MCID for pain catastrophizing and fear of movement. Local pain sensitivity was reduced in six (86%) patients.

CONCLUSIONS

Physical therapy integrating PNE is potentially beneficial for patients with chronic plantar fasciitis. Future studies should examine the efficacy of PNE in randomized trials with larger representative samples.

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

Background

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

Methods

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

Discussion

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

Trial registration

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Corticosteroid injection plus exercise versus exercise, beyond advice and a heel cup for patients with plantar fasciopathy: protocol for a randomised clinical superiority trial (the FIX-Heel trial)

Background

Plantar fasciopathy has a lifetime prevalence of 10%. Patients experience sharp pain under the heel, often for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. A corticosteroid injection offers short-term pain relief but is no better than placebo in the longer term (> 8 weeks). Heavy-slow resistance training has shown potentially positive effects on long-term outcomes (> 3 months), and combining exercises with an injection may prove to be superior to exercises alone. However, the effect of heavy-slow resistance training compared with a simpler approach of patient advice (e.g., load management) and insoles is currently unknown. This trial compares the efficacy of patient advice with patient advice plus heavy-slow resistance training and with patient advice plus heavy-slow resistance training plus a corticosteroid injection in improving the Foot Health Status Questionnaire pain score after 12 weeks in patients with plantar fasciopathy.

Methods

In this randomised superiority trial, we will recruit 180 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of three groups: (1) patient advice and an insole (n = 60); (2) patient advice, an insole, and self-dosed heavy-slow resistance training consisting of heel raises (n = 60); or (3) patient advice, an insole, heavy-slow resistance training, and an ultrasound-guided corticosteroid injection (n = 60). All participants will be followed for 1 year, with the 12-week follow-up considered the primary endpoint. The primary outcome is the Foot Health Status questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a 7-point Global Rating of Change, the Pain Self-Efficacy Questionnaire, physical activity level, health-related quality of life measured by the EQ-5D-5L, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment. Additionally, a health economic evaluation of the treatments will be carried out.

Discussion

This trial will test if adding heavy-slow resistance training to fundamental patient advice and an insole improves outcomes and if a corticosteroid injection adds even further to that effect in patients with plantar fasciopathy.

Trial registration

ClinicalTrials.gov, NCT03804008. Prospectively registered on January 15, 2019.

Muscle Function and Muscle Size Differences in People With and Without Plantar Heel Pain: A Systematic Review

BACKGROUND

Plantar heel pain is a common condition, but little is known about the relationship between muscle strength and plantar heel pain.

OBJECTIVES

To review the evidence relating to muscle strength in those with and without plantar heel pain.

METHODS

We systematically reviewed the literature by searching key databases. Included studies assessed muscle strength (or endurance or size as proxies) in those with and without plantar heel pain. A modified Downs-Black quality index was used to assess study quality and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was used to evaluate the strength of the evidence. Meta-analysis was performed where possible.

RESULTS

Seven studies met the eligibility criteria. Hallux plantar flexion, lesser toe plantar flexion, ankle dorsiflexion, ankle inversion, and ankle eversion strength values were reduced in those with heel pain compared to those without; however, there was inconsistency in the findings between studies. No difference was found in calf muscle endurance between those with and without plantar heel pain (standardized mean difference, 0.01; 95% confidence interval: -0.56, 0.59). Generally, foot muscle volume was smaller in people with plantar heel pain compared to those without. The quality of individual studies was generally high (score range, 11-16/17 on the modified Downs-Black quality index); however, the GRADE ratings suggest the strength of this evidence to be very low.

CONCLUSION

People with plantar heel pain have reduced strength and volume of the foot muscles, but there is no discernible difference in calf muscle endurance. These findings should be interpreted with respect to the very low GRADE ratings and are likely to change with further research. Accordingly, the role of muscle strength in plantar heel pain is worthy of further investigation. J Orthop Sports Phys Ther 2019;49(12):925-933. Epub 9 Oct 2019. doi:10.2519/jospt.2019.8588.

Coexistence of plantar calcaneal spurs and plantar fascial thickening in individuals with plantar heel pain

Objectives

To examine associations between plantar calcaneal spurs, plantar fascia thickening and plantar heel pain (PHP), and to determine whether tenderness on palpation of the heel differentiates between these presentations.

Methods

Adults aged ⩾50 years registered with four general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months underwent a detailed clinical assessment. PHP in the past month was documented using a foot manikin. Plantar calcaneal spurs were identified from weight-bearing lateral radiographs and plantar fascia thickening (defined as >4 mm) from ultrasound. Tenderness on palpation of the plantar fascia insertion was documented. Associations between these factors and PHP were explored using generalized estimating equations.

Results

Clinical and radiographic data were available from 530 participants (296 women, mean [s.d.] age 64.9 [8.4] years), 117 (22.1%) of whom reported PHP. Plantar calcaneal spurs and plantar fascia thickening were identified in 281 (26.5%) and 501 (47.3%) feet, respectively, but frequently coexisted (n = 217, 20.4%). Isolated plantar calcaneal spurs were rare (n = 64, 6.0%). Participants with PHP were more likely to have a combination of these features compared with those without PHP (odds ratio 2.16, 95% CI 1.24, 3.77, P = 0.007). Tenderness on palpation of the heel was not associated with plantar calcaneal spurs or plantar fascia thickening, either in isolation or in combination, in those with PHP.

Conclusion

Plantar calcaneal spurs and plantar fascial thickening are associated with PHP, but frequently coexist. Tenderness on palpation of the heel does not appear to differentiate between clinical presentations of PHP.

Heavy-slow resistance training in addition to an ultrasound-guided corticosteroid injection for individuals with plantar fasciopathy: a feasibility study

Introduction

Plantar fasciopathy, characterised by plantar heel pain, affects one in ten in a lifetime. Heavy-slow resistance training (HSR) is an emerging treatment, but it often takes considerable time before the effect starts to manifest. Combining HSR with a corticosteroid injection (known for its short-term pain relief) could potentially improve outcomes in both short and long term. As this combination is yet to be investigated, we aimed to evaluate the feasibility of combining HSR with a corticosteroid injection for individuals with plantar fasciopathy before investigating the efficacy in a clinical trial.

Materials and methods

We recruited 20 participants with plantar fasciopathy for this prospectively registered feasibility study (ClinicalTrials.gov: NCT03535896). Participants received an ultrasound-guided injection and performed heel raises on a step every second day for 8 weeks. To assess participant acceptability of the combined interventions and exercise compliance, we used a 7-point Likert scale dichotomised to “unacceptable” (categories 1–2) or “acceptable” (categories 3–7) and training diaries. Greater than or equal to 10/20 had to rate the combination “acceptable”, ≥ 15/20 had to perform ≥ 20 training sessions, and ≥ 15/20 had to start exercising ≤ 7 days after injection to confirm feasibility.

Results

Eighteen out of 20 rated the combination acceptable. Five training diaries could not be retrieved. Ten out of 15 participants performed ≥ 20 training sessions, and 15/15 started exercising ≤ 7 days after injection.

Conclusions

Based on participant acceptability and time to exercise start, combining HSR with corticosteroid injection is feasible and the efficacy should be investigated in a future trial. Due to loss of 5/20 training diaries, firm conclusions regarding exercise compliance could not be drawn.

Trial registration

ClinicalTrials.gov, NCT03535896

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0489-3) contains supplementary material, which is available to authorized users.

Plantar heel pain in middle-aged and older adults: population prevalence, associations with health status and lifestyle factors, and frequency of healthcare use

Background

The objectives of this study were to estimate the population prevalence and distribution of plantar heel pain in mid-to-older age groups, examine associations with selected health status and lifestyle factors, and report the frequency of healthcare use.

Methods

Adults aged ≥50 years registered with four general practices were mailed a health survey (n = 5109 responders). Plantar heel pain in the last month was defined by self-reported shading on a foot manikin, and was defined as disabling if at least one of the function items of the Manchester Foot Pain and Disability Index were also reported. Population prevalence estimates and associations between plantar heel pain and demographic characteristics, health status measures and lifestyle factors were estimated using multiple imputation and weighted logistic regression. Healthcare professional consultation was summarised as the 12-month period prevalence of foot pain-related consultation.

Results

The population prevalence of plantar heel pain was 9.6% (95% CI: 8.8, 10.5) and 7.9% (7.1, 8.7) for disabling plantar heel pain. Occurrence was slightly higher in females, comparable across age-groups, and significantly higher in those with intermediate/routine and manual occupations. Plantar heel pain was associated with physical and mental impairment, more anxiety and depression, being overweight, a low previous use of high-heeled footwear, and lower levels of physical activity and participation. The 12-month period prevalence of foot pain-related consultation with a general practitioner, physiotherapist or podiatrist/chiropodist was 43.0, 15.1 and 32.8%, respectively.

Conclusions

Plantar heel pain is a common, disabling symptom among adults aged 50 years and over. Observed patterns of association indicate that in addition to focused foot-specific management, primary care interventions should also target more general physical and psychological factors that could potentially act as barriers to treatment adherence and recovery.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2718-6) contains supplementary material, which is available to authorized users.

Self-dosed and pre-determined progressive heavy-slow resistance training have similar effects in people with plantar fasciopathy: a randomised trial

QUESTION

For people with plantar fasciopathy, is a 12-week self-dosed heavy-slow resistance training program more beneficial than a 12-week pre-determined heavy-slow resistance training program?

DESIGN

A randomised trial with concealed allocation, partial blinding, and intention-to-treat analysis.

PARTICIPANTS

Seventy people with plantar fasciopathy confirmed on ultrasonography.

INTERVENTION

Both groups performed a repeated heel raise exercise in standing for 12 weeks. Participants in the experimental group were self-dosed (ie, they performed as many sets as possible with as heavy a load as possible, but no heavier than 8 repetition maximum). The exercise regimen for the control group was pre-determined (ie, it followed a standardised progressive protocol).

OUTCOME MEASURES

The primary outcome was the Foot Health Status Questionnaire pain domain. Secondary outcomes included: a 7-point Likert scale of Global Rating of Change dichotomised to 'improved' or 'not improved'; Patient Acceptable Symptom State defined as when participants felt no further need for treatment; and number of training sessions performed.

RESULTS

There was no significant between-group difference in the improvement of Foot Health Status Questionnaire pain after 12 weeks (adjusted MD -6.9 points, 95% CI -15.5 to 1.7). According to the Global Rating of Change, 24 of 33 in the experimental group and 20 of 32 in the control group were improved (RR = 1.16, 95% CI 0.83 to 1.64). Only four participants achieved Patient Acceptable Symptom State: three of 35 in the experimental group and one of 35 in the control group. No significant between-group difference was found in the number of training sessions that were performed (MD -2 sessions, 95% CI -8 to 3).

CONCLUSION

Self-dosed and pre-determined heavy-slow resistance exercise programs are associated with similar effects on plantar fasciopathy pain and other outcomes over 12 weeks. Advising people with plantar fasciopathy to self-dose their slow-heavy resistance training regimen did not substantially increase the achieved dose compared with a pre-determined regimen. These regimens are not sufficient to achieve acceptable symptom state in the majority of people with plantar fasciopathy.

REGISTRATION

ClinicalTrials.govNCT03304353.

Psychosocial variables and presence, severity and prognosis of plantar heel pain: A systematic review of cross-sectional and prognostic associations

OBJECTIVE

Plantar heel pain (PHP) is often disabling, and persistent symptoms are common. Psychosocial variables are known to affect pain and disability but the association of these factors with PHP has yet to be established. The purpose of the present systematic review was to determine if psychosocial variables are associated with the presence, severity and prognosis of PHP.

METHODS

A systematic review of the literature and qualitative synthesis was carried out. Electronic searches of MEDLINE, CINAHL, SPORTDiscus, PsycINFO and EMBASE were undertaken from the inception of the respective databases up to November 2017. Any study design incorporating measurements of psychosocial variables with participants with plantar heel pain were included. The quality of included articles was appraised using the Newcastle Ottawa Scale.

RESULTS

Five articles from four studies were included in the review, with a total of 422 participants. Moderate-level evidence suggested a clinically unimportant association with the incidence of PHP and depression, anxiety and stress, and limited evidence suggested a clinically unimportant association with job dissatisfaction. Moderate-level evidence suggested that there may also be an association between depression, anxiety, stress and catastrophization and PHP pain, and between depression, anxiety, stress, catastrophization and kinesiophobia and PHP function. We also found moderate-level evidence that a psychological disorder may be associated with a poorer outcome to shockwave therapy.

CONCLUSION

In light of this review, the association of psychosocial variables and plantar heel pain cannot be ruled out. Given recommendations to adopt an individualized and stratified approach to other musculoskeletal conditions, clinicians should remain vigilant to their presence.

Physical therapist decision-making in managing plantar heel pain: cases from a pragmatic randomized clinical trial

INTRODUCTION

Plantar heel pain (PHP) is a common condition managed by physical therapists that can, at times, be difficult to treat. Management of PHP is complicated by a variety of pathoanatomic features associated with PHP in addition to several treatment approaches with varying efficacy. Although clinical guidelines and clinical trial data support a general approach to management, the current literature is limited in case-specific descriptions of PHP management that addresses unique combinations of pathoanatomical, physical, and psychosocial factors that are associated with PHP. Purpose: The purpose of this case series is to describe physical therapist decision-making of individualized multimodal treatment for PHP cases presenting with varied clinical presentations. Treatment incorporated clinical guidelines and recent evidence including a combination of manual therapy, patient education, stretching, resistance training, and neurodynamic interventions. A common clinical decision-making framework was used to progress individualized treatment from a focus on symptom modulation initially to increased load tolerance of involved tissues and graded activity. In each case, patients met their individual goals and demonstrated clinically meaningful improvements in pain, function, and global rating of change that were maintained at the 1-2-year follow-up. Implications: This case series provides details of physical therapist management of a variety of PHP clinical presentations that can be used to complement clinical practice guidelines in the management of PHP.

Association of Anxiety and Depression With Pain and Quality of Life in Patients With Chronic Foot and Ankle Diseases

BACKGROUND

The purposes of this study were to clarify the incidence of anxiety and depression among patients with chronic foot and ankle diseases and to examine the independent association of anxiety and depression with pain and quality of life.

METHODS

Patients who visited the foot and ankle clinic from April 2015 to November 2016 were recruited. Anxiety and depression in patients were assessed using the Hospital Anxiety and Depression Scale. Pain and quality of life were evaluated using the visual analog scale (VAS) and Self-Administered Foot Evaluation Questionnaire (SAFE-Q), respectively. Furthermore, patient characteristics, including age, sex, body mass index, pain in other body areas, social support, employment, and household income, were surveyed. A multiple regression analysis was performed to examine the independent association of anxiety and depression with pain and quality of life. A total of 250 patients were included in the analysis.

RESULTS

The prevalence of anxiety and depression was 30% and 27%, respectively. The VAS and all SAFE-Q subscale scores were significantly worse in patients with anxiety or depression than in patients without the same (median VAS 63 vs 49 for anxiety, P = .005; 68 vs 47 for depression, P < .001). Furthermore, the multiple regression analyses showed that the presence of anxiety ( P = .02) and depression ( P < .001) was independently associated with increased pain, and it led to low scores on all SAFE-Q subscales ( P < .001 for all subscales).

CONCLUSION

About 30% of patients with chronic foot and ankle disease had anxiety or depression. The presence of these psychological symptoms was independently associated with worse pain and impaired quality of life after controlling for patient characteristics. Clinicians need to recognize the possibility of concurrent anxiety and depression to provide a more holistic treatment for chronic foot and ankle disease.

LEVEL OF EVIDENCE

Level IV, case series.

The association between pain catastrophising and kinesiophobia with pain and function in people with plantar heel pain

BACKGROUND

Psychological variables, including catastrophic thoughts and kinesiophobia, are common in people with chronic musculoskeletal pain and are associated with pain and function. However, the role of each factor has not been evaluated in people with plantar heel pain (plantar fasciitis).

METHODS

Thirty-six participants diagnosed with plantar heel pain were recruited. Main outcome measures included the Pain Catastrophising Scale, Tampa Scale of Kinesiophobia, the Foot Health Status Questionnaire and a Visual Analogue Scale. Hierarchical regression models were developed to evaluate the association between each psychological variable with variations in foot pain, first step pain and foot function.

RESULTS

In a full model with age, sex and BMI, kinesiophobia contributed to 21% of the variability in foot function and was a significant predictor in this model (Beta=-0.49, P=0.006). In a separate model, catastrophising explained 39% of the variability in foot function and was a significant predictor in this model (Beta=-0.65, P<0.001). Finally, pain catastrophising accounted for 18% of the variability in first step pain and was a significant predictor in a model that also included age, sex and BMI (Beta=0.44, P=0.008).

CONCLUSIONS

After controlling for age, sex and BMI, kinesiophobia and catastrophising were significantly associated with foot function, while catastrophising was associated with first step pain in people with plantar heel pain. In addition to addressing biological factors in the management of plantar heel pain, clinicians should consider the potential role of pain catastrophising and kinesiophobia in this population.

Foot pain severity is associated with the ratio of visceral to subcutaneous fat mass, fat-mass index and depression in women

Body composition and poor mental health are risk factors for developing foot pain, but the role of different fat deposits and psychological features related to chronic pain are not well understood. The aim of this study was to investigate the association between body composition, psychological health and foot pain. Eighty-eight women participated in this study: 44 with chronic, disabling foot pain (mean age 55.3 SD 7.0 years, BMI 29.5 SD 6.7 kg/m²), and 44 age and BMI matched controls. Disabling foot pain was determined from the functional limitation domain of the Manchester Foot Pain and Disability Index. Body composition was measured using dual X-ray absorptiometry and psychological health (catastrophisation, central sensitisation and depression) was measured using three validated questionnaires. Between-group analyses found that foot pain was not significantly associated with body composition variables, but was significantly associated with all psychological health measures (P < 0.001-0.047). Within-group analyses found that the severity of foot pain was significantly correlated with body composition measures: fat mass (total, android, gynoid, and visceral), fat-mass ratios [visceral/subcutaneous (VAT/SAT), visceral/android], fat-mass index (FMI), and depression. In multivariable analysis, VAT/SAT (β 1.27, 95% CI 0.28-2.27), FMI (β 0.14, 95% CI 0.02-0.25) and depression (β 0.06, 95% CI 0.00-0.12) were independently associated with foot pain severity. Psychological health, not body composition, was associated with prevalent foot pain. For women with foot pain, VAT/SAT, FMI and depression were associated with severity. Further work is needed to determine if a reduction in fat mass reduces the severity of foot pain.