Quality Tool Box Foot Pain - PowerPoint Presentation

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Quality Tool Box Foot Pain

Dr. David BerbrayerDivision Head, PhysiatrySunnybrook Health Sciences CentreUniversity of TorontoSlide2

Disclosures

Dr. David Berbrayer has no financial or other disclosures.Slide3

Sunnybrook Health Sciences CentreSlide4
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Learning Objectives

At the end of the presentation on foot evaluation, participants will be able to:Describe constructs for core sets for foot pain

Review assessment instruments for foot painReflect on quality metrics for foot painSlide6

Foot Anatomy Slide7

ReflexologySlide8

Causes of Hind-foot pain

Plantar fasciopathyCalcaneal apophysitisCalcaneal spurHeel pad fat atrophyNerve entrapment

Achilles tendinitisArterial insufficiencyJogger’s footTarsal tunnel syndromePeripheral ischemiaSlide9

Plantar Fasciopathy

Plantar fasciopathy is a painful condition of the foot caused by inflammation (which produces acute symptoms) or degeneration (a source of chronic pain) of the plantar fascia, which is the thick connective tissue extending from the calcaneus to the metatarsal heads.Function: static-supports arch Dynamic-medial arch flattens/ elevatesSlide10

Anatomy Plantar FasciaSlide11

Foot Pain: Core Constructs

PainMobility- Walking, Moving, TransferSelf-careParticipationLife satisfactionSlide12

PBAs vs. PROs

Provider based assessment instrument (PBA): Foot Function Index

Rowan Foot Pain Assessment Manchester Foot Pain Disability IndexPatient reported outcome measure (PRO): Foot Health Status Questionnaire Foot and Ankle Questionnaire –AAOS (Disability indices for lower limb core, global foot and ankle functionality, and shoe comfort are included.)Slide13

Physical Examination of Foot Pain

Reduced Quality life / Abnormal Gait Cycle-decrease stance on affected

footWindlass Test Restriction Ankle DorsiflexionLocalized Pain over Calcaneus Longitudinal Arch Impairment Slide14

Gait CycleSlide15
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Windlass MechanismSlide17

Windlass Test

NON-WEIGHT BEARINGWith the patient sitting, the examiner stabilizes the ankle joint in neutral with 1 hand placed just behind the first metatarsal head. The examiner then extends the first metatarsophalangeal joint, while allowing the interphalangeal joint to flex.

Passive extension (i.e., dorsiflexion) of the first metatarsophalangeal joint is continued to its end of range or until the patient’s pain is reproduced Weight BearingThe patient stands on a step stool and positions the metatarsal heads of the foot to be tested just over the edge of the step. The subject is instructed to place equal weight on both feet. The examiner then passively extends the first metatarsophalangeal joint while allowing the interphalangeal joint to flex. Passive extension (i.e., dorsiflexion) of the first metatarsophalangeal joint is continued to its end of range or until the patient’s pain is reproduced.Slide18

Active and Passive Dorsiflexion

DescriptionThe patient is positioned in prone with feet over the edge of the treatment table. The examiner asks the patient to

dorsiflex the ankle for an active measurement, or the examiner passively dorsiflexes the ankle, while ensuring that the foot does not evert or invert during the dorsiflexion maneuver. At the end of the active or passive dorsiflexion range of motion, the examiner aligns the stationary arm of the goniometer along the shaft of the fibula and aligns the moving arm of the goniometer along the shaft of the 5th metatarsal DiagramSlide19

Restriction Ankle

DorsiflectionSlide20

Localized Pain over CalcaneusSlide21

Nerve Distribution of FootSlide22

Medial/Lateral Longitudinal ArchSlide23

Longitudinal Arch Test

DescriptionWith the patient standing with equal weight on both feet, the midpoint of the medial malleolus, the navicular tuberosity, and the most medial prominence of the first metatarsal head are identified using palpation and marked with a pen. A goniometer is then used to measure the angle formed by the 3 points with the navicular tuberosity acting as the axis point.

MeasurementSlide24

Current Treatment Guidelines

Heel Pain-Plantar Fasciitis Guidelines  link International Classification of Functioning, Disability, and Health (ICF) body structures (ligaments, fascia of ankle and foot,  neural structures of lower leg) and ICF body functions (pain in lower limb, radiating pain in a segment or region) with World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD) health condition (plantar fascia fibromatosis/plantar fasciitis).Guidelines describe evidence-based physical therapy practice and provide recommendations for (1) examination and diagnostic classification based on body functions / structures, activity limitations, and participation restrictions, (2) prognosis, (3) interventions  and (4) assessment of outcome, musculoskeletal disorders.

McPoil TG, Martin RL, Cornwall MW, Wukich DK, Irrgang JJ, Godges JJ. Heel pain--plantar fasciitis: clinical practice guidelines linked to the International Classification of Function, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008 Apr;38(4):A1-18.Slide25

Assessment Measures for Activity/Participation

The Foot Function Index (FFI) is a 0-10 scale of pain and foot function over time in standing, walking, etc.  The Foot Health Status Questionnaire (FHSQ) is a 42-item questionnaire assessing quality of foot health. The Foot and Ankle Ability Measure (FAAM) is an activities-of-daily-living scale of foot health.Slide26

Foot Function Index

Foot Pain in past weekFoot Stiffness past weekDifficulty walking past weekDifficulty ADL past weekDifficulty Activity limitation past week

Difficulty social issues past weekThe Foot Function Index: a measure of foot pain and disability.Budiman-Mak E, Conrad KJ, Roach KE. J Clin Epidemiol. 1991;44(6):561-70Slide27

Foot Health Status Questionnaire (FHSQ)

Assess 4 domains:Foot Pain: type of pain, severity, durationFoot function: walking, working, stairsFootwear: lifestyle issues

General foot health: body imageDevelopment and Validation of a Questionnaire Designed to Measure Foot-Health Status Bennett et al. J Am Podiatr Med Assoc 88(9): 419-428, 1998Slide28

Foot and Ankle Ability Measure (FAAM)

Measures: standing, walking uneven ground, hills, stairs, curbsDifficulty: home, ADL, personal care, work(light, moderate, heavy),and recreationMartin, R; Irrgang

, J; Burdett, R; Conti, S; Van Swearingen, J: Evidence of Validity for the Foot and Ankle Ability Measure. Foot and Ankle International. Vol.26, No.11: 968-983, 2005.Slide29

Levels of Evidence-Treatment

AcuteSubacuteChronicStretching-highSteroid injection-highEatracorporeal-high

Orthotics-mediumAcupuncture-lowFoot orthotics-mediumIontophoresis-mediumManual therapy-lowBotox A-mediumLow dye taping-mediumNight splints-mediumNSAID-lowManual Therapy-lowThe formulation and grading of the recommendations were based on a review of the literature and on the 5 components of the FORM framework forevidence-based clinical guidelines: evidence based, consistency, clinical impact, generalizability, and applicability (Hillier S, Grimmer-Somers K, Merlin T, et al.FORM: An Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC Med Res Method 2011;11:23). Slide30

Major Evidence Based References

1. Update on Evidence –Based Treatments for Plantar FasciopathyDavid Berbrayer MD, Michael Fredericson MD

PM&R 2014;6:159-1692. Knowledge Now AAPM&R Plantar FasciitisDavid Berbrayer MD, FRCPCSlide31