Quality Tool Box Foot Pain
Dr. David Berbrayer
Division Head, Physiatry
Sunnybrook Health Sciences Centre
University of Toronto
Disclosures
• Dr. David Berbrayer has no financial or
other disclosures.
Sunnybrook Health Sciences Centre
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 pain
• Reflect on quality metrics for foot pain
Foot Anatomy
Reflexology
Causes of Hind-foot pain
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Plantar fasciopathy
Calcaneal apophysitis
Calcaneal spur
Heel pad fat atrophy
Nerve entrapment
Achilles tendinitis
Arterial insufficiency
Jogger’s foot
Tarsal tunnel syndrome
Peripheral ischemia
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/ elevates
Anatomy Plantar Fascia
Foot Pain: Core Constructs
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Pain
Mobility- Walking, Moving, Transfer
Self-care
Participation
Life satisfaction
PBAs vs. PROs
• Provider based assessment instrument (PBA):
Foot Function Index
Rowan Foot Pain Assessment
Manchester Foot Pain Disability Index
• Patient 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.)
Physical Examination of Foot Pain
• Reduced Quality life / Abnormal Gait
Cycle-decrease stance on affected foot
• Windlass Test
• Restriction Ankle Dorsiflexion
• Localized Pain over Calcaneus
• Longitudinal Arch Impairment
Gait Cycle
Windlass Mechanism
Windlass Test
Weight Bearing
NON-WEIGHT BEARING
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With 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
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The 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.
Active and Passive Dorsiflexion
Description
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The 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
Diagram
Restriction Ankle Dorsiflection
Localized Pain over Calcaneus
Nerve Distribution of Foot
Medial/Lateral Longitudinal Arch
Longitudinal Arch Test
Description
• With 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.
Measurement
Current Treatment Guidelines
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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.
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.
Foot Function Index
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Foot Pain in past week
Foot Stiffness past week
Difficulty walking past week
Difficulty ADL past week
Difficulty Activity limitation past week
Difficulty social issues past week
The Foot Function Index: a measure of foot pain and
disability.Budiman-Mak E, Conrad KJ, Roach KE. J
Clin Epidemiol. 1991;44(6):561-70
Foot Health Status Questionnaire
(FHSQ)
Assess 4 domains:
• Foot Pain: type of pain, severity, duration
• Foot function: walking, working, stairs
• Footwear: lifestyle issues
• General foot health: body image
Development and Validation of a Questionnaire
Designed to Measure Foot-Health Status Bennett
et al. J Am Podiatr Med Assoc 88(9): 419-428, 1998
Foot and Ankle Ability Measure
(FAAM)
• Measures: standing, walking uneven ground,
hills, stairs, curbs
• Difficulty: home, ADL, personal care,
work(light, moderate, heavy),and recreation
Martin, 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: 968983, 2005.
Levels of Evidence-Treatment
Acute
Subacute
Chronic
Stretching-high
Steroid injection-high
Eatracorporeal-high
Orthotics-medium
Acupuncture-low
Foot orthotics-medium
Iontophoresis-medium
Manual therapy-low
Botox A-medium
Low dye taping-medium
Night splints-medium
NSAID-low
Manual Therapy-low
The formulation and grading of the recommendations were based on a review of
the literature and on the 5 components of the FORM framework for
evidence-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).
Major Evidence Based References
1. Update on Evidence –Based Treatments for
Plantar Fasciopathy
David Berbrayer MD, Michael Fredericson MD
PM&R 2014;6:159-169
2. Knowledge Now AAPM&R Plantar Fasciitis
David Berbrayer MD, FRCPC