Okay, recording starting.
All right.
Well, hello, everybody.
My name is Dr. Trenton Raymond,
and I'll be hosting today's episode of the
Hands-On, Hands-Off podcast.
Today's guest is a pioneer in the space
of plantar heel pain, or PHP,
which we'll reference it.
And he has been published multiple times
on this topic.
Not only has he been a large advocate
for the use of manual therapy in the
treatment of PHP,
but he has also tackled the large task
of evaluating the cost-effectiveness of
physical therapy compared to other more
common management approaches.
Today we have the pleasure of speaking
with Dr. Shane McClinton.
Dr.
Shane McClinton is a fellowship-trained
physical therapist and is a professor in
the Department of Physical Therapy at Des
Moines University.
Thank you for joining us.
Thanks for having me.
Glad to be here.
Awesome.
Well,
can you just start by giving us a
little bit more about your background so
that the audience kind of knows who we're
talking with and maybe touch on just
briefly your career path and an overview
of what led you to this topic in
this research?
Great.
Yeah, thank you.
And I'm humbled to hear you say pioneer
in this area.
I'd probably refer to myself more as a
private if this were in the military and
just making some small contributions to an
area that there's lots of outstanding
individuals contributing to this area.
But anyway, thank you for that.
I obtained my initial physical therapy
degree from Des Moines University, which,
yes, I'm still there.
I did work elsewhere for a few years,
but I went on to get my DPT,
it's transitional degree again through Des
Moines University.
After that,
went through fellowship training at Regis
University in Colorado.
Then after that,
I got my PhD through Rocky Mountain
University in Provo, Utah.
and actually this um this study is was
part of my initial dissertation research
and kind of an extension thereof so it's
been something that i've been working on
for some time it's an area that i've
been interested in for quite some time and
actually just happy to get out the last
part of it which is the economic
evaluation following a follow-up that we
extended out to three years afterwards so
So I think your question along with that
was also what kind of prompted this study.
Being in clinical practice,
I work at a multi-specialty clinic.
So we work with family care physicians
that refer to us.
We work with podiatrists as well.
We also have osteopathic manual physicians
who are in our clinical practice.
And one of the observations I made when
working with plantar heel pain patients is
I would see the patients that would come
and be referred to me directly,
but I wouldn't see many patients that were
being referred from other providers,
even though
It was a condition that in my experience
and also the literature at the time,
and even since then has really supported
the fact that it's a very multidimensional
problem.
There's issues that extend proximally.
So we see a lot of neurogenic factors
that are contributing to their heel pain.
They have proximal impairments in the
lumbar spine and the hip and the knee.
They benefit from manual intervention.
It seemed like these patients were just
right down in our wheelhouse,
but the referral rate in our clinic and
across the board was very, very low.
So for example,
seven percent upwards of twenty percent
from other providers are referring those
patients to physical therapists.
So it just seemed to me like, well,
this is a population that we really should
have our hands on and we can really
help.
But we're not getting a lot of them
in our door.
And there's a lot of factors that we
can explore and discuss about why that is,
but regardless,
that was the facts of the healthcare
situation.
And so we embarked upon this study to
see if we could provide some evidence that
we can add value to these other providers.
We're not trying to take away from what
they do,
but we want to just show that we
can add some value to the things they're
currently doing.
And in our clinic situation,
eighty-some percent,
almost ninety percent of the patients,
when they were coming on their own,
they were going to see the podiatrist.
So by far, the majority of them,
and it makes sense.
If you have a foot problem,
you would want to go see the foot
doctor.
That makes a lot of sense.
And that's what most of them were doing.
So we felt like it was a,
you know,
the best approach was to start working
with them since that's where the majority
of the patients were coming.
So that's really was the premise behind
the study.
And we kind of knew that when you
added physical therapy,
it was probably going to add some costs.
And that's also the barrier to it because
patients,
it's going to take them a little more
time.
They have to participate.
They have to be more engaged.
So there are some upfront costs.
So that's why we wanted to study this
at least a year and why we even
extended out to two and three years,
because we wanted to see if there were
downstream savings that we could then
provide evidence to say, yes,
there might be a little more upfront,
but in the long run,
it's gonna be worth it.
You're gonna have better outcomes,
hopefully less likely to have these
problems again.
And by the way, in the long run,
we're gonna have a lot of cost savings.
from managing other conditions,
from managing that condition,
from missing work,
a lot of the other factors that are
the economic burden of suffering from
plantar heel pain.
I mean, that's awesome.
Thank you for sharing that background.
And I mean,
the thing that jumps out to me is
that seven to twenty percent just seems so
low for an area that, you know,
I think most of us feel very comfortable
evaluating trading.
And like you said,
there's some research to support what we
do works.
But this is awesome to see this like
this lens and this side of it.
For the viewers and listeners who haven't
read your work yet,
could you just orient us a little bit
to the idea of your primary study and
the subsequent studies?
Then when you get to the cost evaluation,
maybe just discuss the design so that we
know what that looked like.
Yeah, absolutely.
So we do have a couple of,
as you mentioned,
we have a couple of publications from the
same study.
So from the start of this study,
we were planning to collect the pain
function, quality of life,
and all of the costs related outcomes.
So I think that's an important factor is
that the design did include not just the,
you know,
I guess what I'm getting at is the
economic evaluation wasn't an
afterthought.
We were planning that from the inception
and quite a bit of planning went into
designing that aspect of it particularly.
So the study was a two-arm study.
We had a group and it was a
randomized clinical trial and it was also
a very pragmatic trial.
So when we talked about intervention,
it wasn't
I mean, it was structured,
but it wasn't scripted.
So it's important to kind of understand
that the individuals involved in the
treatment,
both the podiatrist and the physical
therapist,
were allowed to treat the patients,
for the most part,
how they normally would.
So because the patients were coming to see
the podiatrist first,
that's where they entered the study.
So when they were seen by the podiatrist
at our clinic,
at the Des Moines University Clinic,
they were then asked to enroll in the
study.
And so every patient started with at least
one visit from a podiatrist.
Then from there,
we randomized them into the two different
groups.
One group would just continue with the
podiatrist based on their recommendations.
For the most part, they did follow suit.
Their referral rate didn't increase much.
For the most part,
they managed them the way that they
normally did.
In the other group,
they started with a physical therapist
right away.
Again,
the physical therapist still would
collaborate with the podiatrist,
but for the most part,
the physical therapist provided the
treatment that they felt was warranted for
that patient.
We collected our outcomes at six weeks to
capture what was going on early on after
that first visit, and then six months,
and then every year thereafter up to three
years.
So that's the design.
And so the outcomes were the numeric pain
rating scale,
but an ankle ability measure was our
functional scale.
And then the,
we use the EQ five D to get
their quality of life,
which was used in the economic evaluation.
And then we used our billing records to
get costs.
So we knew all the charges in all
of the departments that they were seen in.
And then anything, any,
treatments that they had outside of our
clinic,
there was a questionnaire that we
developed that was modeled off of other
questionnaires that have been validated in
order to capture all of the costs.
So if they went to an acupuncturist,
they were documenting that.
If they had to travel to those
appointments, they were documenting that.
If they missed time from work,
they were documenting that.
So we captured as best we could all
the costs that we related to treatment,
either directly or indirectly.
And yeah,
I think that was the general design that,
oh, uh, as far as the studies,
then we had our initial publication was
in, uh,
and that was just the one year follow-up
and just the outcomes.
So our outcomes with regards to pain and
function between the two groups.
And of course we described the study
methodology there.
We followed up with that in the next
year with a case series.
And in that case series,
what our intent was,
was really to describe the details of the
treatment provided,
particularly in the
podiatry plus physical therapy group.
So we went through our decision-making,
the process, the details,
how we prioritized what treatments,
how we decided what treatments.
Again, even though it was pragmatic,
there was an impairment-based logic behind
it that we tried to outline as best
we could in that article.
We also have a nice appendix that
describes the exercise interventions done,
the manual interventions that are done.
It gives you a little bit of a
depiction of the frequency of some of
those interventions as well.
And that's also described in the initial
paper too,
the frequency of which interventions.
So you kind of get a snapshot of
what was done.
And then lastly,
and recently published was our economic
evaluation because that included the three
year outcomes.
So in that study,
the focus was obviously looking at the
cost effectiveness between the two groups.
So can we improve their health related
quality of life at a lower cost across
a three year time span?
Uh, and,
You know,
I'll let the cat out of the bag.
Hopefully everybody's read the article
anyway.
But the good news is,
is we were able to demonstrate cost
effectiveness in economic valuation
language
the usual podiatry plus physical therapy
treatment dominated the usual podiatry
treatment, meaning it was more effective.
You got a better outcome and it was
less costly, meaning it costs less.
It's kind of a no brainer.
When you go to the store and you
find something that's a better value and
it actually costs less,
you're buying that every time.
So that was the good news.
And again,
fairly robust across the different
replicates that we we tried to utilize to
to demonstrate some of the potential
variability.
And pretty consistently,
things fell into that category of being
cost effective.
That's awesome.
And thank you for lining that out because
that'll be nice as we're going through our
discussion to have that orientation to
kind of like the three tiers of the
publication and especially referencing
that case series,
which was illustrating the interventions
for the different heel pain presentations.
I find that one,
I find all of it interesting.
I just love diving into the actual
interventions you chose and why.
I thought that was awesome.
So let's start.
And you already prefaced some of this,
but let's just start with talking a little
bit about the cost effectiveness study.
Can you just talk a little bit about
the two branches that you chose and maybe
just give another overview of kind of the
results and the biggest kind of takeaway
that you found from that one?
Yeah,
so the two branches of the study or
the two arms of the study would have
been usual podiatry care.
So again,
following the care that the podiatrist
recommended,
primarily it was a handout on certain
exercises, you know, your calf stretching,
some banded plantar flexion exercises.
They would almost always prescribe a foot
orthosis in most cases,
typically over the counter.
typically are getting some
anti-inflammatory medications with that.
On lesser occasions,
they might have injections into the heel
that are performed.
And in even fewer circumstances,
there were a few cases that did end
up having a surgery on the plantar fascia.
compared to the group that had that
initial visit with the podiatrist and then
they saw a physical therapist.
We were typically assessing for
impairments anywhere from the lumbar spine
down to the ankle and foot,
generally prioritizing a little bit of the
ankle and foot.
So limited dorsiflexion is a common
impairment.
We were using joint mobilization
techniques,
manual techniques to the calf and the
plantar fascia.
to address those impairments,
both medial and lateral gliding of the
calcaneus,
addressing issues in the forefoot as well.
So again,
any impairment that we commonly find
we were managing that using manual
intervention and then typically
complementing it with or augmenting it
with an exercise that would kind of match
that impairment.
So I would suggest a very impairment-based
approach that was taken,
but also very pragmatic in the sense that
some patients might have almost exclusive
ankle and foot intervention.
Other patients,
the priority might have been more in the
lumbopelvic area where they had
more impairments up there that we felt
were contributing to their symptoms,
of which we typically tried to confirm
with a pre-post-test kind of assessment.
So we might do some manual intervention to
the lumbar spine.
And if we measured their asterisk or
comparable sign and they got better,
then we would say, hey,
that's probably something we need to
prioritize in their treatment,
in addition to whatever else we might be
doing.
I'm probably missing some things that we
did treatment-wise,
but off the top of my head,
those were the primary things that we were
working on with those patients.
So they definitely got a heavy dose of
manual therapy, heavy dose of exercise.
They were doing a home program.
And we were following up typically a
couple of times a week at first,
but then we would decrease to once a
week.
And I think on average,
somewhere around six visits or so per
patient in that group.
So, um, those, those were the two arms,
um, of the study there.
Um,
and then what was the next follow-up you
wanted?
Well,
I just had a quick question on the
arms.
Was there any discussion of a PT like
only arm, you know,
just to see how that would compare with
the other two?
Yeah.
And it would have been nice to, yeah,
it would have been really nice to have
that.
And, and, um,
So a couple of issues with that,
obviously it increased our sample size
significantly if we're adding another
group in there, you know,
that makes it kind of difficult to get
the enrollment.
The second thing was, is again,
the problem at the time that we were
trying to address is the fact that we
weren't really getting patients referred
to us from these other providers.
So I do feel like we can treat
these patients off the street or in direct
access quite well,
but
But at this point in time,
we really wanted to provide some evidence
to other providers that if they're seeing
them,
then we can provide an added benefit.
So I would say that would be the
main reason why we didn't go that route.
But you're right,
it makes a lot of sense.
I think that's a great answer, though,
because as we'll talk about later,
some of the takeaways from this is working
with clinicians and working in teams is
usually a multidisciplinary approach.
So I actually kind of like that idea
of having the two arms,
both including the referral source.
So then when we go into looking at
that case series of those eight
treatments, can you talk a little bit,
well, I guess this is for both studies,
but can you talk a little bit about
the inclusion criteria that was referenced
in the article,
just so we kind of understand the
population that was being treated?
Yeah,
so the patients had to have symptoms for
long enough, not for too long,
but long enough that it wasn't just an
acute kind of situation.
So I'm actually gonna go.
The...
The diagnosis was made clinically as it
normally is.
So they need to have palpatory pain at
the medial aspect of the calcaneus near
the proximal attachment of the plantar
fascia.
And it needs to be worse with the
initial steps,
typically first thing in the morning,
but it could be after they've been sitting
for a long time.
typical patterns,
it dissipates and actually move a little
bit,
but then gets worse the more that they're
on their feet.
So if they're meeting kind of that
criteria,
they did need to have enough of a
disability on the FAM in order for us
to make a meaningful change.
So, you know,
that was another part of the criteria.
It is the FAM had to be low
enough that we could make enough
improvement in their case.
So they couldn't just have
a little bit of plantar fasciitis symptoms
affecting and barely affecting their
disability.
Similarly,
we had to have enough sufficient pain to
be included.
We did try to exclude other factors that
wouldn't be considered plantar fasciitis.
So radiculopathy is one of the exclusion
criteria,
and that would be hard signs of
radiculopathy.
So definitely seeing motor loss,
sensory loss,
that is something that we can measure with
our clinical tests.
And I say that because a lot of
these patients seem to have something
neurogenically going on when you test
their neurodynamics, and again,
when we treat the lumbar spine.
So obviously there is something going on
there that's the relationship between the
lumbar spine, not just the nerves,
but the structures of the lumbar spine are
influencing their pain experience and
their heal,
which again is why I feel like physical
therapists should be included in this
population,
at least just a screen for that.
If we can't find any impairments in lumbar
spine or with our neurodynamic testing,
then very well some of the excellent
treatment that our podiatrists and other
providers provide might be all that they
need.
But in some cases that could be,
I would suggest it could be the reason
why many of these patients go on to
have persisting symptoms and continued
pain.
So we also want to exclude anybody with,
you know, tumor or fracture,
rheumatic inflammatory disease,
so rheumatoid or reactive or psoriatic
arthritis, inflammatory bowel disease,
some of these conditions that might mimic
plantar heel pain.
We wanted to also make sure they were
clean from any treatment in the past six
weeks.
So if they'd seen other providers,
we wanted to have kind of a washout
period and would exclude those that have
had more recent treatment.
Yeah, that's great.
Thank you for that background.
And I thought it was a thorough and
thoughtful inclusion criteria based on
what you were just discussing.
And I thought it was interesting to talk
about timeline,
patients with greater than a year of heel
pain,
given that this is often a diagnosis that
goes untreated for a long time.
And it can be recalcitrant and
and lingering.
And so I think that speaks a little
bit to where we can add some value,
but also that idea of confounding
variables that make diagnosis and
treatment challenging.
Yeah.
Yeah, I mean, that's a good point.
So, you know,
I don't know if I clarified that,
but we did exclude those who had symptoms
more than a year.
So not to say we can't provide benefit
to those patients,
but we also wanted to kind of mimic
other studies that were kind of using very
similar criteria as well.
So we could compare our results to some
of the other literature as well.
Yeah, that's awesome.
So diving into that article a little bit,
the case series with the eight treatments,
can you talk a little bit to the
audience like how you chose those eight
different cases and why,
and why that would be important for
somebody who's maybe dealing with this in
the clinic of using that as a reference
for different almost categories of heel
pain?
Yeah, I mean,
that is kind of the point.
So as I reflected on some of the
cases,
You know,
it did seem like there were definitely
different.
And again,
every patient I would say probably
received a little bit different treatment
because, again, it was pretty pragmatic.
But there were some staples across the
board in the treatment.
So in that study,
if you do look at the again,
this will be posted, I'm sure.
This is the case report published in
Physiotherapy Theory and Practice.
But we have some tables towards the end.
which can be useful to give you a
synopsis of what was done.
So since this is the AONT podcast,
we'll talk about the manual therapy first.
If you look across the board there,
almost everybody had myofascial treatments
to the calf.
So I would say this is something
clinically we find quite effective to help
manage our symptoms.
So we would treat their calf and the
foot as well.
But I think calf is definitely a nice
area because it's not right.
If their symptoms are really hot,
you're not...
directly intervening right where their
pain is the highest at.
You're dealing with an area that typically
tends to refer and can help calm that
down a little bit and open up the
door to more treatments.
We're very commonly doing dorsiflexion
mobilization,
so working on the talocrural joint,
working on the rear foot, which again,
from an anatomic standpoint,
makes a lot of sense.
And then from there,
you started to see some scattering of
things to where there were some patients
that tended to benefit a little bit more
from midfoot and forefoot mobilizations to
knee impairments,
treating knee impairments.
A lot of times if they lack a
knee extension, for example,
they're gonna load the heel a little bit
differently.
And there's some biomechanical rationale
behind why that might be an issue.
Similarly,
lumbar impairments were considerations,
again, not in everyone,
but in many of the cases.
And then neurodynamic impairments were
things that were addressed.
So those were some of the common things
from a manual therapy perspective that
were kind of done.
And again,
each of the eight different cases
illustrates kind of a different
combination of treatment,
including that manual therapy,
but then also the therapeutic exercise.
And then the exercise, the most common
I would say evidence-based treatment
includes stretching or some type of
mobilization of the calf and the foot in
the plantar fascia as well.
So we did use that most frequently in
almost every case,
following up if they endorse flexion
limitations with some type of mobility
exercise.
It could be kind of a mobilization with
movement type treatment.
So it would mimic a lot of the
manual intervention.
So almost every manual intervention that I
just described, in these cases,
there would be a corresponding exercise
intervention addressing that mobility
impairment.
Another thing I want to kind of highlight
that we did,
and I feel like there's a lot more
evidence in this area that's been great to
see,
and that's the strengthening component.
You know, our counterparts,
the podiatrists typically tend to put foot
inserts, which tend to support the arch.
And that does affect the activity of the
muscles, including the long-term strength.
And so I think it's also a nice
little pairing for us to work with those
individuals because we can actually show
them how to strengthen their foot,
how to strengthen their calf,
how to strengthen their hip,
or wherever the impairment is,
it might be related to muscle performance.
we can address those muscle performance
deficits and complement the more passive
modalities such as a foot orthosis that
could be in the long run detrimental to
foot strength.
And we did a prior study where we
actually looked at the correlation.
And again, it's a correlation,
not necessarily causation,
but a correlation between
how long someone has worn foot orthoses
and their foot strength with certain
measures that we did.
So toe intrinsic kind of flexor strength,
calf raises as well.
And we tend to find that those who
use foot orthoses for longer tend to have
more weakness.
So it seems to make sense that, hey,
maybe we can intervene in these
populations and help them with some
interventions and direct them how to
strengthen their foot and their lower leg
to not have these long standing
impairments that are likely only going to
get worse over time.
And then of course we would address their
movement proficiency.
So gait training and a lot of our
strengthening would work up the chain too.
So again,
if they had lumbopelvic or hip
impairments, we'd address those,
we'd try to integrate it into their
function.
So if they were a runner,
we'd try to,
if they had to back down from it,
we'd try to get them back into running
again.
So that in a nutshell is kind of
the intervention and some of which is
illustrated in that case series.
Yeah, and I think that's great.
I love the logical flow of, you know,
you find that impairment that was either a
direct area of nociceptive pain or a
contributing factor, you know,
that was driving the process of their
persistent pain.
And taking that approach of the passive
intervention paired with an active
intervention that fit the exact same,
whether it was arthrokinematics or just
functional goal.
So I thought that was awesome.
The,
the part that I would draw attention to
is I really loved appendix D where it
showed, um,
kind of like each case as a number
and then like, um,
which modality or which intervention was
used with each one.
And I loved obviously as an AM to
podcast that all of them got manual
therapy and, uh, in all,
but one of the cases,
they all got joint mobilization,
which I think is something that goes
underappreciated in the foot and ankle.
and not that that was the entire purpose
of this you know article but just from
my lens it was really cool to see
the use of things like uh manipulation of
the of the subtalar joint or the calcaneal
mobilizations which is um i mean maybe
anecdotally underutilized in the clinic i
think so very cool to see and i
would draw the reader's attention to that
appendix i thought it was really helpful
You mentioned evidence-based references to
driving decisions on what interventions to
use.
In the article,
it talks about the clinical practice
guideline.
And can you just maybe speak to how
much or how little that informed some of
these decisions and maybe how that guided
the more thorough explanations?
Yeah.
Well,
so at the time that this was designed,
I believe it was after the first
guideline.
The second guideline,
I don't think had been published quite
yet.
So they're actually,
when we designed this study,
we felt like there was a lot of
missing gaps and particularly in the
manual intervention area.
I think at that time there was only
like expert level evidence,
but I knew of a lot of articles
that were coming out
of which we've referenced that kind of
supported the fact that, hey,
this seems to be beneficial.
And again,
our clinical experience seemed to
corroborate that and to indicate that,
man,
these patients really do better when we
use manual therapy,
plus just the support of how the manual
therapy can inform our decision-making by
getting within sessions treatment,
or sorry,
within session changes that can then
direct.
So if they do respond to an accessory
mobilization of the talocrural joint,
it helps us to understand that, boy,
improving their dorsiflexion is going to
really help this patient.
And I'm going to really enforce that in
their home program.
So we certainly tried to revolve things
around the guidelines as much as possible.
But again, at the time, and remember,
this is now we're talking the design of
the study was kind of a while ago.
I still feel like what we did is
pretty relevant.
Of course,
there's always new little tricks and
techniques that kind of come out and
modifications.
One of the things that comes to mind
is in my practice,
I used a lot of trigger point dry
needling at the time I was trained,
but very recently trained.
And so we decided it was still fairly
new in the area.
I was one of the first three physical
therapists doing that in our state.
So we said, well,
maybe we shouldn't be doing this in the
study because not very many people will
know how to do it.
But nowadays, you know,
I think everybody does.
So I think you can kind of look
at the trigger point interventions we did.
And the study doesn't support that
necessarily.
But, you know,
I think you could infer that that would
be an intervention that could be included
and to use as an update to what
we didn't necessarily include in this
study.
Yeah, that's awesome.
I thought because the guidelines are great
and I use them frequently and I think
most people are encouraged to.
But they're a guideline.
They don't give the detail of like that
you illustrated in your articles,
which I find a really good reference for
different presentations.
So thank you for that.
I will say, though,
that the core of our treatment was very
much so the guidelines.
And I think that still is kind of
the case.
That still is the core.
And then in certain cases,
there's evidence that supports why maybe
that core is included plus a little bit
of a different direction.
Yeah.
Yeah, that's great.
Can you talk a little bit about,
because like just in my clinical
experience treating foot and ankle,
given the persistence of that pain,
there can be some chronicity to that
experience like sensitization to the
tissues locally,
more central sensitization processes.
Can you talk a little bit about how
that was considered in the patients that
were presenting to you?
And were any of these treatments maybe
delivered differently or tailored towards
that presentation versus a more acute
nociceptive presentation?
So we certainly,
our intervention was informed by
considering pain mechanisms.
And we did include, so for example,
we did include pain neuroscience
education.
So part of our treatment included
education.
That's always, I think in any trial,
it's kind of hard to control and kind
of hard to appreciate how much of an
effect that kind of has on things.
But certainly while we were doing our
manual intervention or exercise
intervention,
we were discussing their presentation and
factors that are contributing to their
pain.
One of the things that we described a
little bit,
not that we were giving a lot of
advice on weight management,
but there was a lot of discussion around
the time this study was designed.
uh, around, you know,
weight management and, and, and, and,
and some of those factors.
Um,
so we certainly provided some education,
uh, that revolved around,
things that could more positively affect
their pain experience and help them to
understand their pain experience,
as well as the prognosis, you know,
making sure their expectations aren't that
they're going to be better in two weeks
after treatment or fully cured in two
weeks when the literature supports that
this could take up to a year, honestly.
Now...
I like to think with the approach that
we took and which illustrates this and and
things that we can do,
we can improve that approach.
And some of those estimates that say it
can last a year are based on not
getting this treatment.
So I do think that we can reduce
that.
But I always like to kind of under
promise and over deliver versus the
opposite.
So getting them on on the same page.
So we definitely considered
you know, some of the pain mechanisms.
And that's also why we considered any
potential patho-neurodynamic contributions
to their symptoms.
So, you know,
if we were doing neurodynamic testing or
if we found palpatory tenderness along the
path of the nerve,
we were certainly providing intervention
at those areas to facilitate the nerve
being as healthy as possible and hopefully
reducing any potential for that to be
contributing to their pain experience.
Yeah, that's great.
I think that's really helpful.
And as I read through the article,
it kind of came to light that
decision-making I thought was great.
Um, especially just given, uh, well,
my fellowship training was very, um,
very heavily, um,
ingrained that process of like, uh,
persistent pain and, um,
just how that can affect different areas.
So the,
the heel is just a really good area
that I think it illustrates it well.
um with your you commented earlier so i
don't mean to be too redundant but i'd
love to hear your thought process on kind
of using the check recheck asterisk sign
and using that to differentiate between
picking the foot and ankle as your primary
source versus proximal sources as the area
to target uh with your primary
interventions like how did you choose
proximal versus local
So I would say just because our, again,
this comes back to the guidelines.
So I'm glad you kind of brought that
up.
So guidelines really support more of that
local intervention,
addressing impairments in the ankle and
foot.
And so I would say in almost all
cases,
we would definitely start there first and
we would kind of see, you know, let's,
let's find the impairments there first.
Not that we didn't look elsewhere.
We still screened our initial evaluation.
We're trying to take a big picture
overview first and then narrow down and
identifying.
you know, what impairments are A,
most significant.
So oftentimes as you kind of go through
the process, you can kind of say, wow,
the impairments in the ankle are kind of
minor.
but the impairments in the lumbar spine
are major.
So that might be something that would skew
me to go up a little bit more,
but I still,
I wouldn't ignore that foot and ankle.
I kind of want to do some intervention
there to see what effect that they had,
because again,
that's the most guideline and
evidence-based treatment is in that area.
and then assessing their response.
And then sometimes I would do that within
a session,
but it sometimes might be between
sessions.
So might just only treat the foot and
ankle one session or treat kind of more
locally.
Next session they come back,
I might start,
if I had found some things in lumbar
spine, I'm like, boy,
your response to the foot and ankle was
kind of mediocre,
or maybe it didn't have any much of
an effect when they come back or even
within a session.
So then I go up and I treat,
you know,
whatever the other most significant
impairment was.
And if we get a more substantial change,
then to me that gives a little more
credence that that's kind of one of the
driving factors in their symptoms.
And especially if we get that response on
multiple occasions now.
And I still feel like you can do
that fairly well, even with, like I said,
on average, I believe our visits were,
say, around six visits per patient.
Again,
some patients had a little bit more.
Actually,
some patients had fewer than that.
I still think you can do that reasonably
well within that timeframe.
And to me, that just adds
more evidence to where the impairment is
coming from and what they can dedicate
their time working on.
Because the other thing is we only have
so much time in the clinic,
but also our patients only have so much
time out of there.
So if I can just give them a
handful of things to work on,
I find that tends to work a lot
better than, you know,
we're throwing everything at them and
they're doing a pretty bad job at all
of them,
doing a really good job at just a
few of them.
Yeah, I think that's awesome.
Thank you.
for kind of talking us through that
because I think it's super helpful using
that thought process.
But then definitely when you have a
complex case with so many impairments and
factors,
I think it's nice to take that approach
of like take one primary,
treat it and see if it changes so
we don't cloud the whole scenario too
much.
So then kind of walking this back to
that original article.
So we just had a great discussion on
how there was this original basically
report about treating the foot and heel
pain.
And then there was a breakdown of the
eight cases that presented differently and
our manual interventions for those.
And then that final kind of like piece
to the original idea was the cost
effectiveness study.
Can we...
Talk a little bit more.
You gave a synopsis of like the how
it turned out.
But can you just talk to us again
about the results and if it surprised you
or not?
And kind of how that goes together with
how as a profession,
we're trying to push ourselves as like a
primary provider in that area.
Yeah.
So I would say as far as surprising,
obviously I had some expectations and that
we would add value and that we could
produce better outcomes.
at a lower cost.
I guess I was maybe hoping it would
be more of a slam dunk per se,
but I think part of it is we
did get ninety five participants in the
study,
which is which was really hard to do,
to be honest,
over a long period of time and probably
was a little bit more than I should
have tried to bite in a PhD program.
But it's
It's added years of enjoyment in getting
to follow this up and to see some
of the stuff come to fruition.
But yeah, if we had a larger sample,
I think we would have a little more
confidence.
But regardless,
we did some sensitivity analyses.
So again, the primary results,
when we look at the base case,
so everyone that was allocated into both
of the groups kept them in those groups.
We didn't exclude,
we didn't take anyone and remove them from
the data set,
analyzed all the data and analyzed all of
the cost,
all of the cost data that we had
available to us.
which again,
that would include the direct costs of the
treatments,
so the podiatry and the physical therapy
treatments,
but also if they saw their primary care
physician for back pain,
if they had a surgery,
a bariatric surgery,
a couple of the patients had bariatric
surgeries,
which we know that patients with plantar
heel pain struggle with weight because
they can't exercise.
there's some other little interesting cost
kind of things there too for things that
could be somewhat indirectly related to
their heel pain but anyway all the costs
were included in that base case and we
saw that the plus physical therapist
approach uh was we had better outcomes so
their quality of life so again the eq-d
measures a person's quality of life uh and
it
basically we will index it to a zero
to one scale where one is a year
of optimal health and so we follow this
up over three years so we have three
years to where you know they could get
a score from zero to one uh and
we saw that those in the plus pt
group uh rated their their health
is their quality of their health to be
greater in the end.
And that was even as early as one
year, we saw that kind of coming out.
The cost as well at about one year,
we saw the costs,
all those costs being less in the plus
physical therapist group.
And then of course,
when you look at that cumulatively over
three years,
uh, it was, it was cost savings.
So when you put those two together,
an equation of cost effectiveness,
the costs of the plus physical therapist
minus the podiatry, uh, and then the,
sorry, the outcomes over the costs, uh,
we saw that plus physical therapist was
lower costs,
plus that we saw a better outcome.
Uh, and, uh,
So the takeaways are is that, you know,
we can collaborate with our podiatry
partners to provide better care for our
patients and they can achieve better
outcomes.
And many patients are,
and I'd say podiatrists as well,
the podiatrists are hesitant to send them
to physical therapy.
Because they know it's going to be an
extra burden to their patients and they
don't want to impose that greater burden
on their patients, that greater cost,
having them to go through all these
additional visits and these additional
costs and transportation costs and missing
work and all the things that go into
it.
But hopefully they can use this data then
to say, hey, yes,
it might cost a little more up front.
It's going to be a little more work
up front.
But in the long run,
what could happen is this could go on
and on and on,
and you're gonna end up missing more work
days.
You might have other problems.
You might end up not being able to
manage your weight as well.
There's a lot of downstream consequences
that perhaps if we nip it earlier,
then we won't have those downstream
issues.
And this study provides support to that,
that yes, it was cost-effective.
In the long run,
it costs less and you got a greater
value.
So the base case showed that we did
some sensitivity analysis because some of
the patients, I mean, spoiler alert here,
they didn't participate in the program in
the plus physical therapist program.
You know, I don't know about you,
but I have a few patients that tend
not to be adherent to the things we
might recommend.
no matter how hard I try.
And this was the case in the study
too.
So we found a way to kind of
say, okay, well,
what if we remove them from there?
And again,
we saw a little bit better results,
but still for the most part,
we had the same, we had cost,
we demonstrated cost effectiveness in the
base case.
We also demonstrated it when we removed
those who did not complete with treatment.
And then we also just looked at plantar
heel pain costs.
So we tried to say, okay,
let's cut out all the other stuff
what was just related to managing their
plantar heel pain.
And again,
we saw very similar cost-effectiveness of
which the plus physical therapist approach
was more cost-effective in all of those
sensitivity analyses.
That's great.
I mean, in my mind, right,
obviously I'm biased because I'm a
physical therapist,
but it makes sense that if you see
more preventative care, conservative care,
less aggressive care maybe that follows
evidence-based guidelines,
you'd think it would give you better
outcomes,
but it's nice to have a study that
supports that.
So do you see,
now that this has been out,
have you seen it making changes in...
the behavior of patients or podiatry or
even other physical therapists and their
approach or like, you know, marketing or.
Yeah, it's a great question.
And, you know,
I've reflected on this a little bit.
My practice is a little unique.
I would say, oh,
maybe it's not all that unique,
but the majority of my patients are direct
access.
So not that I don't have anyone that's
referred,
but most of my patients are direct access.
So it really would be nice,
and I haven't had time to really look
into this,
but it would be nice to do some
follow-up just to see if anything is
changing there.
Now, granted, this study just came out.
You know, the outcome studies were out.
The case series was out,
has been out for a little bit now.
So I don't really think there's enough
time there to be much impact other than
I would just like to think that even
before this study came out,
hopefully others were realizing this.
Like you said,
it kind of it seems like it makes
a little bit of sense.
And so I'd like to think that this
will make some changes,
but I'm not sure that we're seeing
anything yet.
Although I would love to hear from others
who might be seeing something different,
but also I'm hoping that we can be
change agents with this information now
and help
you know help our patients who may not
be getting uh the plus physical therapist
approach who might need and benefit this
and and maybe spreading the word uh will
then help to make that shift and we'll
start to see that in the coming years
yeah i mean that's great and i i
guess it's you know it's new so that's
not the fairest question but so my
follow-up to that i work in private
practice
So cultivating referral sources is a big
part of my role at our clinic.
So maybe just ask you to speculate on
this a little bit or give some advice.
Do you view this as a marketing tool?
And do you have advice of how to
use it?
I see it as a good selling point
of how we can work together and how
we should be involved in more cases than
seven percent.
I could also see it as potentially
competitive, you know, because in that,
in the article,
it talks about how people who went to
PT went to the podiatry less often,
but ultimately it was better for the
patients.
So do you have thoughts on that and
how it could be implemented in more of
the, like the private practice setting?
Yeah, so I will say this, though.
I don't think they necessarily saw the
podiatrist a lot less.
I feel like their average was even like
two visits,
even if you were just in that group.
It might have been a little bit more.
Don't quote me off the top of my
head.
I think it was maybe on average two
compared to six in the plus physical
therapist approach.
So I don't think we'd be stealing a
lot of business from them.
And I would also suggest that as you
kind of alluded to,
that's not really the point.
The point is,
We both,
podiatrists and physical therapists,
want our patients to get better.
And so if this is a way,
if it was something else besides plus
physical therapist,
I think the podiatrist would be on board.
I don't see any reason why they wouldn't
be on board with this if it's put
in that context.
There are patients that we should be
referring to our podiatrist because
there's things that they can do that we
can't.
So I think it's a two-way street,
and I think if we approach it that
way, and like I said,
this study really is an example of shared
decision-making between the podiatrist,
the patient, and the physical therapist,
although some of them were kind of
strongly encouraged to add a plus physical
therapist approach to their treatment.
But yeah, in my opinion,
maybe I'm overly optimistic.
I see nothing but a win-win in this
case because they're still going to go
see, they are still the foot experts,
right?
A podiatrist is still known for their
expertise in the foot.
Patients are still going to go see them.
And if they see us as well,
more patients, unfortunately,
this is a very common condition and I
don't see it going away anytime soon.
But we'd like to try to decrease the
repeat offenders and the longer disability
that's associated with it.
It's a great point.
And thank you for the clarification on
that.
That really does help understand like
keeping it all in context.
So thank you.
Okay.
So Shane, I think this has been great.
One of the things we do here at
the very end is just like a take-home
message or like if there is one thing
or one comment you had that you wanted
all the listeners to take away,
could you please just share us with that
message?
Yeah, thanks.
And again, thanks for having me on.
This has been a great conversation.
I think we just discussed probably
something that I think is good for
everyone to kind of reflect on,
and that's the collaboration with our
healthcare partners.
And it's really for the betterment of our
patients.
So if they need to see a dietician,
if we don't have the expertise in that
area,
and that's gonna help them manage their
weight, then we need to work with them.
If we need to work with a podiatrist
because they do shockwave therapy,
or they perhaps might need an injection to
give us a window of opportunity based on
what's going on,
or maybe they do need some specialized
foot orthoses for a while that we can
then use to complement our treatment with
too.
I think it's important that we make sure
to continue to work together
collaboratively.
I'd like to think that this is to
some extent an example of that and how
we can be better together
than necessarily in isolation and i know
we don't know what the isolated plus uh
sorry isolated physical therapy arm might
have been and we can suppose what that
is but but again i still feel like
there's there's there's things we can do
uh together and then the other part which
is an interest of mine that i continue
to explore and that is the strengthening
part of it i feel like in in
plantar heel pain uh strengthening has
been underutilized and underdosed
And I would suggest that we shouldn't be
afraid to utilize those interventions in
this population as well if you do find
yourself not utilizing them commonly.
Not to undervalue manual intervention.
I know this is a podcast through the
AOMT.
It's definitely of high value here.
I see plantar heel pain being very similar
to low back.
So I would say...
Uh,
plantar heel pain is the low back pain
of the lower extremity.
So a lot of the approaches that we
take in the lumbar spine, uh,
I think can be very similarly applied, uh,
in, uh, persons with plantar heel pain.
That's awesome.
Um,
thank you so much for taking your time
and sharing your expertise and for doing
all this work to support the profession.
I mean, this stuff is,
we can't do what we want to do
without it.
So thank you so much.
Yeah.
Thank you.
All right.
Thank you, listeners.
That's today's episode of Hands On,
Hands Off podcast.