Podiatrist vs GP management of plantar heel pain

NewsBot · Sep 23, 2020

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Custom insoles versus sham and GP-led usual care in patients with plantar heel pain: results of the STAP-study - a randomised controlled trial
Nadine Rasenberg et al
British Journal of Sports Medicine Published Online First: 02 September 2020

Objectives To compare custom-made insoles to sham insoles and general practice (GP)-led usual care in terms of pain at rest and during activity at 12 weeks follow-up in individuals with plantar heel pain.

Methods In this randomised clinical trial 185 patients aged 18 to 65 years, with a clinical diagnosis of plantar heel pain for at least 2 weeks, but no longer than 2 years were recruited. Patients were randomly allocated into three groups: (1) GP-led treatment, plus an information booklet with exercises (usual care; n=46), (2) referral to a podiatrist for treatment with a custom-made insole plus an information booklet with exercises (custom-made insole; n=70) and (3) referral to a podiatrist and treatment with a sham insole plus an information booklet with exercises (sham insole; n=69). As well as the primary outcome of pain severity (11-point Numerical Rating Scale) we used the Foot Function Index (0 to 100) as a secondary outcome.

Results Of 185 randomised participants, 176 completed the 12-week follow-up. There was no difference in pain or function between the insole and the sham groups at 12 weeks. Participants in the GP-led usual care group reported less pain during activity at 12 weeks, (mean difference (MD) 0.94, 95% CI 0.23 to 1.65), less first step pain (MD 1.48, 95% CI 0.65 to 2.31), better function (MD 7.37, 95% CI 1.27 to 13.46) and higher recovery rates (RR 0.48, 95% CI 0.24 to 0.96) compared with participants in the custom insole group.

Conclusions Referral to a podiatrist for a custom-made insole does not lead to a better outcome compared to sham insoles or compared to GP-led usual care.
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NewsBot · Sep 23, 2020

Editorial
Plantar heel pain: should you consult a general practitioner or a podiatrist?

NewsBot · Sep 23, 2020

PodCast:
The Physio Matters Podcast was live.
#007 - Chewing It Over - 10th September 2020

scotfoot · Sep 23, 2020

In the Podcast referenced above a well know podiatrists called Ian Griffiths gives some feedback on Rasenberg et al 2020 .

During the broadcast , Ian informs us that he is part of a group who have put together a study into the treatment of plantar heel pain , and which is presently going through the review process .

He also states " strengthening work does not feature " in this paper under review . I don't understand that and here is why .

We know that heel pain is associated with weakened intrinsic foot muscles but don't know which comes first .

If the pain causes the weakness then surely this should be addressed by the treatment since intrinsic weakness is associated with poorer balance and even deformity in the long term .

So although there may be little formal evidence at present ( see Australian ballet info on injury prevention on internet ) that strengthening helps treat the pain it does, by definition , treat the weakness .

Any thoughts Ian .

Ps I enjoy your broadcasting .

scotfoot · Sep 26, 2020

Re the above , some might make the assumption that if plantar heel pain is successfully treated the intrinsics will regain their former levels of strength in due course and without any specific strengthening .

In my opinion this is not a sound treatment plan for people involved in sports who want to return to their sports as soon as possible and in the best condition , nor is it a sound plan for those older patients with sarcopenia .

Heel pain can be viewed as an injury which is associated with intrinsic muscle weakness ,so how can a rehab program for the condition not involve strengthening ???

Sorry if I have picked you up wrongly Ian but, if not , I believe your " paper under review " is seriously flawed .

Brian A. Rothbart · Oct 8, 2020

Another outcome that demonstrates that using any type of insole without first diagnosing the foot structure present in the patient is a misfeasance at best, and malpractice at worst.

NewsBot · Apr 26, 2021

Management of planter heel pain in general practice in Australia
Glen A. Whittaker Hylton B. Menz Karl B. Landorf Shannon E. Munteanu Christopher Harrison
17 April 2021

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.
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NewsBot · Nov 5, 2021

Cost-effectiveness of custom-made insoles versus usual care in patients with plantar heel pain in primary care: cost-effectiveness analysis of a randomised controlled trial
Nadine Rasenberg et al
BMJ Open. 2021 Nov 3;11(11)

Objectives: To evaluate the cost-effectiveness of custom-made insoles compared with general practitioner (GP)-led usual care after 26 weeks of follow-up in individuals with plantar heel pain (PHP) from a societal perspective.

Design: Cost-effectiveness analysis of a double-blinded randomised controlled trial.

Setting: General practice in the Netherlands.

Participants: 116 participants with PHP for at least 2 weeks, aged 18-65 years and presenting to the GP.

Interventions: Participants were randomised to GP-led usual care (n=46) or referral to a podiatrist for treatment with a custom-made insole (n=70). Participant randomised to a sham insole (n=69) were excluded from this analysis.

Primary and secondary outcomes: Outcomes comprised pain during rest and activity, and quality of life. Costs included healthcare and lost productivity costs. Statistical uncertainty was estimated using bootstrapping and presented using cost-effectiveness acceptability curves.

Results: Participants in the custom-made insole group experienced statistically significant more pain during activity at 26 weeks than participants in the usual care group (overall effect 1.06; 95% CI 0.36 to 1.75). There were no significant differences between groups in other outcomes. Total societal costs in the custom-made insole group were non-significantly higher than in the usual care group (mean difference €376; 95% CI -€1775 to €2038). The intervention with custom-made insoles was dominated by usual care by the GP (ie, more expensive and less effective) for pain during activity and quality of life outcomes. For the outcome pain at rest, the intervention was more expensive and more effective than usual care. However, the maximum probability of cost-effectiveness was only 0.59 at very high ceiling ratios.

Conclusions: These findings show that that custom-made insoles are not cost-effective in comparison with GP-led usual care. Clinicians should be reserved in prescribing custom-made insoles for PHP as a primary intervention.
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scotfoot Well-Known Member

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Brian A. Rothbart Well-Known Member

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