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[Physio Explained] Strengthening for plantar heel pain: does It really work? with John Osborne

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In this episode with John Osborne we explore all things plantar heel pain. We discuss: 

  • Is a foot and ankle strengthening regime helpful for this patient population?
  • Current research in this realm
  • The short foot exercise: is it still relevant to use? 
  • Calf raises: are they helpful for this patient population? 
  • Discrepancies in morphology and capacity between people with plantar heel pain and those without

John is currently completing his PhD about the association of muscle strength and plantar heel pain. He has had a systematic review published in Journal of Orthopaedic Sports Physiotherapy in 2019 titled Muscle Function and Muscle Size Differences in People With and Without Plantar Heel Pain: A Systematic Review. The focus of John’s PhD includes exercise prescription for plantar heel pain, which muscles function during exercises for the foot and ankle and the association of foot muscle strength and size to plantar heel pain.

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Our host is @sarah.yule from Physio Network

SPEAKER_02:

There's a contingent of those with plantar heel pain that have got kinesiophobia. Exercise may actually address the fear of movement. as opposed to necessarily making them bigger and stronger. So again, the clinician probably needs to think about in what context am I doing this? If I've got somebody who wakes up in the morning and they've got heel pain and they've just got fear of walking to the bathroom as opposed to it only just being about them being not strong enough to walk to the bathroom, is it plausible to utilise some exercise intervention to try and reduce that fear around movement What

SPEAKER_00:

foot and ankle strengthening regime is helpful for our patients with plantar heel pain? And what does the evidence say? What footwear is recommended for those with plantar heel pain when exercising? John Osborne is an experienced sports podiatrist and the first podiatrist in Australia to successfully earn the Certified Sports Podiatrist credential awarded by the Australian Podiatry Association. He's currently completing his PhD at La Trobe University about the role of muscle strength in plantar heel pain, all of which has made him a fantastic guest for today's conversation. So lace up your shoes. There's going to be some great advice to inform your practice. I'm Sarah Yule, and this is Physio Explained. Well, thank you for joining us today, John, and welcome. No doubt we'll see how many puns I can fit into the discussion today. Well, let's kick off with the first question. What kind of a foot and ankle strengthening regime might be helpful for our patients with plantar heel pain?

SPEAKER_02:

I might actually rewind you a step and talk about maybe whether a foot and ankle strengthening regime is helpful. And that's probably the question that we can't answer. If we look at systematic review that we published way just before COVID, It certainly showed that there was no difference in calf capacity between those who have heel pain versus those that don't. So that's actually a sister of doing orthopedic sports physiotherapy, if you look it up. But you'll find that there's conflicting evidence for a range of reasons as to whether there's even a muscle or a size or a muscle strength deficit in those with heel pain compared to those without. So then to blanketly turn around and say well you know what is going to be or you know is there a particular regime that's going to be beneficial it's sort of it's it's difficult to really come out and say yes there is or no there isn't more recently there was the Delphi study that again we published it's sort of on the back of a number of other regimes that have been put out by Enric Riel and Mel Fratovich-Smith and a few others. It was more to try and get some consensus on what the experts would suggest for violating the foot and ankle strengthening regime. And you'll notice that everything that came up in the Delphi study is really looking around calf rises, some digital flexion, and then sort of the 2K and maybe the short foot exercise. There's sort of the 2 or 3K exercises that kept popping up. The other interesting sort of thing that for me that came out of the results of that study was that there was not much difference in across the three programs between an athlete, a middle-aged person and an elderly person. There was effectively, if I was doing three sets of 10 or 15, if again, we're looking at sort of best practice of what would be a strengthening regime to be helpful for those with heel pain, realistically for an athlete, three sets of 10 is probably not enough load. And I would probably even turn around and say the short foot's also not enough light as an exercise. So to answer your question more directly, I think the jury's still out. And I think we still have to probably, you know, go back to drawing board and do some more research. But I think that the building blocks are there and are beginning to be there to perhaps help us come up with some better protocols that we can apply now. to each individual patient as we see them, whether it's for plantar heel pain or whether it's for other foot and ankle pathology.

SPEAKER_00:

It's always challenging, isn't it? It's combining that sort of evidence-based practice with what the patient needs, with what we have seen starting to trend with working versus not working. So do you mind dissecting a little bit more that consensus study that you were involved with?

SPEAKER_02:

What we rolled out is we rolled out the three different Exercise regimes. Yeah, three different sort of exercise regimes. So we had an athlete and we had a middle-aged person and we had an older person. The premise behind that was to sort of cover the breadth of the different people that could otherwise have unhealed pain. And I suppose as the clinician doing the research, I want to make sure that if I've got an athlete and I'm providing them with an exercise program that's more structured around where their needs are, you can't necessarily achieve that again in Adelphi because you're making a lot of assumptions about what the patient presenting looks like. So as a clinician, if you're trying to translate this out, if you've got somebody that's got great absolute strength, in their digits or grand absolute strength in the inversion or aversion in the ankle or dorsal plantar flexion in the ankle, wherever it is, then you probably use that as your guide to begin with. So that's probably the best place to start thinking about it. But the application of, say, some of these three different programs, so there's a stage one, stage two, and stage three, and then each of them has exercises in each of those stages. The objective was to sort of say, okay, well, let's start everybody at stage one. So in this way, it provides some progression. So one of the criticisms of our programs that are outlined in the research is that their capacity for progression is limited. And that was a criticism that came from the experts. So we wanted to try and make sure. So when getting this out for the experts, we wanted to give them the option to be able to progress these things. So there's the capacity to then start with a sort of in the younger athletic adult, hallux plantar flexion against a band, digital plantar flexion against a band, the heel rise and the short foot exercise. And then once they sort of get through their four sets of between six to 12 using an eight repetition maximum as the weight, then they can sort of start to do that more frequently. Then it steps into that stage two where they're applying the toe spread out and the heel rise, but in the standing position and the short exercise in the standing position and then to a heel rise. This is what the experts agreed to. So they got 70% agreement to do these particular exercises. And then if they didn't agree on one of the exercises, it was sort of put back to them to say, okay, well, if you don't agree on the exercise, what are you going to replace it with? So then we can take it back to the experts and say, okay, so you didn't get 70% consensus on this exercise. You provided these as your options. Which do you think it should be replaced with? Or do you think it should stay the same? Interestingly, from the researcher's perspective, more times an exercise wasn't counted. It was often replaced with either a short foot or a heel rise. So it seems to be that the researchers coming up with these ideas seem to be really stuck on those two exercises as the options going forward. A narrative review I've just finished writing. Interestingly, I've put out all 300 of the exercises from foot and ankle that have been provided in the research and tried to sort of categorize them. And again, those two exercises just constantly come up in the literature. Just for interest's sake, when I went back and sort of trying to find where these exercises actually come from, the short foot was just random suggestion by an orthopaedic surgeon way back when, and everybody's just piled on and taken it with them. Another paper that's yet to come out looks at the talk production of all these different exercises and how much talk production occurs. about the MTPJs to sort of see, well, are they, how much are they achieving as an exercise individually? But that sort of just seems to be the common thing. So if you were to apply it as a clinician, you can apply this just directly and pull the, it's all there in the paper and the paper is free to access on Journal of Foot Make and Research. So there's no need to go looking through third parties to go find it. It's pretty easy to access. And you can sort of jump on and you can see the exercises and the programs because they're all out there and they're out there for you. But their effectiveness, we don't know.

SPEAKER_01:

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SPEAKER_00:

free today. Fantastic. It sounds like, obviously, the heel rise and short foot are your two that remain to be consistent. You mentioned earlier that short foot is difficult to progress. Where would you see its progression going?

SPEAKER_02:

So, me as a clinician, I would probably only use it at the very, very beginning, just maybe to get some... neuromuscular activation going on, I probably wouldn't even use it, if I'm honest. My clinician hat on says it barely represents anything that we actually do. And my researcher hat on turns around and says it doesn't, like it's contracting over such a small space and such a short length that it's not going to generate much force either. So I would probably be shifting my attention towards other exercises. Not to say that it should be completely discounted and discredited because I know a lot of people still like to use it and still use it for some of their certain circumstances and pathologies, but I would have it right down the end of it. For the amount of teaching time it takes, it produces a small amount of return.

SPEAKER_00:

And then on the other end of that spectrum, what do you think are the exercises that you've seen that do produce a great return and a great output?

SPEAKER_02:

Yeah, so I've got a paper about to come out which probably answers that question for you. So we're just in the final stages of writing that paper up, which is the one I was talking about before about talk production at MTVJ. So we've ranked exercises from quiet standing and squatting and then we've taken all the way through to variations on heel rises. So I'm going to save my answer to that question so that when the paper comes out, it has some value. But I think you'll find that if your aim is to try and get people stronger, then utilise that. One of the things that is a common theme in the research around from the exercise is that everyone's doing sort of three sets of 10, which is great for a beginner, okay? And it's not to say that that can't be successful, but successful to a point. So I think if we're trying to engage our patients in getting bigger and stronger, then we need to think about how can we add and how can we increase the loads that they're trying to carry from their feet. At the end of the day, if they can walk in your door, then they're probably already starting to carry their body weight in terms of load. So are we then also providing that as a capacity for rehab?

SPEAKER_00:

Fantastic point. And presumably, and I noticed it written in the study, those progressions were based around weight-based as a preference rather than repetition-based increases in terms of increasing loads.

SPEAKER_02:

Yeah, so in that paper, it was all around increasing the weight or the load in that sense, which I think is a nice thing. The other thing that I quite like about the way those programs are laid out in the study, although you can argue it's a criticism, is that we've got the repetition maximum as the weight. So rather than turning around and trying to say, well, everyone needs to lift three kilos or five kilos or a hundred kilos, it's working within the participant's current repetition maximum. So if clinicians are able to say, all right, well, we're getting everybody to target six repetition maximum or eight repetition maximum, I think that they're going to be better targeting the sort of weights that they need to be getting these patients to try and achieve. And I think you'll find that there'll be some insight for the clinician about what is so where the capacity is for the patient that they've got in front of them. Where the criticism comes in is that, yeah, the broad range of repetitions is provided, say, 6 to 12 or 1.8 repetition maximum. Well, if they're repetition maximum is 8, they can't really do 12. Another way to perhaps conceptualize that if you were to try and apply it clinically is that if, yes, a person is sitting at eight, they may not be sitting at eight forever and that eight may change day to day. So you try to sit between that six to 12 mark and you're aiming for failure within that is probably a nicer way to try and conceptualize it as a clinician.

SPEAKER_00:

That makes sense. I know from there's studies in years gone back that we sort of have benchmarks around what the age-related norms are for single leg heel raises and those sorts of things. What consistencies have you noticed potentially if there are any between either strength or morphology or whatever it may be between those with plantar heel pain and those without it?

SPEAKER_02:

There's not a huge difference in morphology between And there's almost no difference in calf rise capacity in those with heel pain compared to those without. One of the calf rise capacity, if we were to put everyone on those wonderful looking box plots, the box basically sits squarely right on the zero and the little whiskers that go outside to find your outliers are really tiny. So as far as calf rise capacity is, there really wasn't much. There's not a huge amount of studies done, So that may change. But similarly, well, not quite similarly, when it comes to muscle morphology, there's far more variance. And depending on the study, depending on the way they've done the study, they'll either say that there is some difference or there is not. It does vary. tend in muscle morphology to look like. There is smaller muscle mass in those with heel pain compared to those without, but in some ways it can depend on which study you want to pick out. And it's hard to pull all that data because they've all done them all differently. So I think that there's more things to watch when it comes to that space. But I think we also need to maybe think about strength that may not just address muscle morphology and muscle strength. If there's a contingent of those with plantar heel pain that have got carnetophobia, exercise may actually address the fear of movement as opposed to necessarily making them bigger and stronger. So again, the clinician probably needs to think about in what context am I doing this? If I've got somebody who wakes up in the morning and they've got heel pain and they've just got fear of walking to the bathroom as opposed to it only just being about them being not strong enough to walk to the bathroom, Is it plausible to utilise some exercise intervention to try and reduce that fear around movement in order to try and get them moving? How you measure that, I don't know. But I think that movement and exercise has its place and that may be another reason as to why it can be effective. We don't know how effective it is in heel pain and I keep on reiterating that point, but that's because we really don't know. But if you're going to apply for a patient more broadly or for those with plantar heel pain, that might be a plausible reason as to why you'd apply.

SPEAKER_00:

Great point. And I suppose my final question, with your clinician hat on and possibly seeing how physios and podiatrists and osteos and how we all might treat plantar heel pain, what do you think are the low-hanging fruits that we should all be looking out for in practice to treat plantar heel pain?

SPEAKER_02:

The big one for low-hanging fruit is for wear chases. It's a really easy one. There's a nice paper that came out by Karl Landau and some others where they looked at hard surfaces and footwear and how they have an impact. The other big low-hanging fruit, which is related to exercise, is looking at the person and their health in front of you. So if they have a high BMI, which inevitably a lot of them will, we probably need to find a way to address that as well. Because if they're not going to do the exercise and those sorts of things to look after their general health, are they going to do the rehabilitation plan that is in your brain and not theirs? So you still need to look and view the person as a holistic thing and sort of try and find interventions and ways that work with the person. A lot of the interventions in plantar heel pain seem to be mildly effective depending on where you are, which provided a nice general clinical overview on how to manage plantar heel pain. It's a great paper to go back to and use as a reference point for starting, but you do need to just consider who the person is in front of you. If you can do that, then you can apply the intervention that seems to have best for the two of you and perhaps addresses some of the other questions that they might need addressed holistically.

SPEAKER_00:

All fantastic advice, John. So a very big thank you for sharing your valuable insights on managing plantar heel pain today. My

SPEAKER_02:

pleasure. Thanks for having me.