Fellow - Regis University Manual Physical Therapy Fellowship Program Faculty - Regis University Manual Physical Therapy Fellowship Program

MANUAL PHYSICAL THERAPY APPROACH IN THE TREATMENT OF HEEL PAIN: A CASE REPORT Chad Garvey, PT, DPT, OCS, CSCS1 Julie Whitman, PT, DSc, OCS, FAAOMPT

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Fellow - Regis University Manual Physical Therapy Fellowship Program

Manual Therapy Fellowship

Introduction: Little is known of the underlying disease process causing chronic heel pain and evidence for the effectiveness of current 1 treatments are unclear . Consequently, clinicians are left with little to guide clinical decision making in the treatment of this condition. Enthesopathy,/soft tissue insertion inflammation, the most common believed cause of heel pain, should not be the sole treatment focus. Purpose: To describe the examination, interventions, and clinical decision making for a patient with heel pain utilizing thrust manipulation and neurodynamic techniques. Currently there are no case studies describing combination utilization of neurodynamic techniques and thrust manipulation. Subject: A 59 y.o. male presented to physical therapy with an Orthopaedic referral for a 3 month history of right heel pain. His pain was worst in the morning and after driving for longer than 10 minutes. His management program consisted of physician prescribed NSAIDs and a self

Faculty - Regis University Manual Physical Therapy Fellowship Program Exam Findings/Impairments: •Tenderness over medial/inferior calcaneus near the plantar fascia insertion •3 degrees AROM R ankle DF •Reproduction of heel pain with ipsilateral slump test and great toe dorsiflexion •4/5 MMT ipsilateral hip abductors and extensors •Foot and Ankle Measure (FAAM) score Treatment: 42% •Primary interventions included thrust manipulation of the talo-crural and lateral midfoot joints, along with tibial nerve oscillation mobilizations performed in the slump position with great toe extension. Also included were self nerve mobilizations, hip strengthening and heel soft tissue mobilization HEP. •The patient was seen for 4 visits over the course of 7 days Talo-crural Slump tibial nerve distraction thrust mobilization manipulation

Outcomes: •FAAM score increase from 42% to 94% •Global Rating of Change +7 •Negative slump test •5/5 hip extensor and abductor strength •Resolution of presenting symptoms •7 degrees AROM DF R (=L) •No pain with driving or upon 1st morning step down

Discussion: There was a complete resolution of symptoms following 4 treatments of manual physical therapy and exercise. Symptom resolution remained at a 1 year follow up. Conclusion: The manual physical therapy to the foot and ankle coupled with neurodynamic techniques were effective at resolving the patient’s heel pain. Clinical Relevance: Although manual therapy is not specifically supported in high level peer reviewed 1 literature , clinically reasoned manual therapy may provide significant benefit in the treatment of chronic heel pain with a similar presentation. As well, despite demonstrated effectiveness within the study, higher quality evidence examining this References: intervention would be 1. Crawford F, Thomson C. needed to establish efficacy. Interventions for treating plantar heel pain. The Cochrane Collaboration. 2007, Issue 4.