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Predictors of Response to Physical Therapy Intervention for Plantar Heel Pain

Shane M. McClinton, Joshua A. Cleland and Timothy W. Flynn
Foot Ankle Int published online 3 November 2014
DOI: 10.1177/1071100714558508

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research-article2014
FAIXXX10.1177/1071100714558508Foot & Ankle InternationalMcClinton et al

(Original) Clinical Research Article

Foot & Ankle International®

Predictors of Response to Physical Therapy

1­–9
© The Author(s) 2014
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DOI: 10.1177/1071100714558508
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Shane M. McClinton, DPT, FAAOMPT1,2, Joshua A. Cleland, PT, PhD3,

and Timothy W. Flynn, PT, PhD4

Abstract
Background: Age, weight, and duration of symptoms have been associated with a poor response to treatment for plantar
heel pain (PHP), but no studies were identified that examined predictors of response to physical therapy intervention.
The purpose of this investigation was to examine the influence of age, body mass index (BMI), and symptom duration on
treatment response to physical therapy intervention.
Methods: Sixty participants received 6 visits over 4 weeks of physical therapy intervention that included manual therapy
and exercise or electrophysiological agents and exercise. Outcomes were assessed using the Foot and Ankle Ability
Measure (FAAM), Numeric Pain Rating Scale (NPRS), and Global Rating of Change Scale (GRC). Logistic regression
(P < .05) was used to analyze age, BMI, and symptom duration as potential predictors of a successful response based on
the minimal clinically important difference of the outcome measures. Sensitivity analysis was used to assess the influence
of success based on minimal clinically important changes in the FAAM, NPRS, and GRC or only the FAAM and NPRS.
Receiver operating curves were used to determine the cut point for the significant predictor.
Results: At the 6-month follow-up to physical therapy intervention, NPRS was improved by 3 points (95% CI, 2.4-3.6)
and FAAM improved by 22.5 points (95% CI, 16.8-28.2). Individuals with symptoms less than 7.2 months were 4.2 (95%
CI, 1.3-13.8; P = .016) and 8.5 (95% CI, 2.5-28.9; P = .001) times more likely to respond to treatment based on the NPRS/
FAAM/GRC and NPRS/FAAM success criteria, respectively. Age and BMI were not significant predictors (P ≥ .455 and
P ≥ .450, respectively).
Conclusion: Age and BMI were not associated with outcomes and obese individuals did achieve a successful outcome
with the physical therapy intervention used in the clinical trial. Individuals with PHP symptoms longer than 7 months
require additional consideration and further investigation of effective strategies to improve treatment response.
Level of Evidence: Prognosis, level 2b comparative study.

Keywords: plantar fasciitis, prognosis, obese, manual therapy, exercise

Introduction advocated initially to manage PHP and most patients

respond positively to treatment.14,44,50,63 Despite improve-
Plantar heel pain (PHP), commonly referred to as plantar ment in most who are treated conservatively for PHP,
fasciitis, is a frequently occurring foot condition that results approximately 18% to 50% of individuals continue to have
in disability and limited function in work, recreation, and
daily activities. While plantar fasciitis has been reported as 1
Physical Therapy Department, Des Moines University, Des Moines, IA,
the most common cause of plantar heel pain, the term plan-
USA
tar heel pain is inclusive of other pathological and painful 2
Orthopaedic and Sports Science Program, Rocky Mountain University
conditions of the plantar fascia and heel that are often dif- of Health Professions, Provo, UT, USA
3
ficult to discriminate via history and physical examina- Physical Therapy Department, Franklin Pierce University, Manchester,
tion.6,70 Individuals with PHP incur approximately 800 000 NH, USA
4
Physical Therapy Department, Rocky Mountain University of Health
to 1 million visits to physicians annually at an estimated
Professions, Provo, UT, USA
cost of $192 to $376 million.57,64 In addition to physician
visits, PHP was the most prevalent condition treated by Corresponding Author:
Shane M. McClinton, DPT, FAAOMPT, Physical Therapist/Assistant
podiatrists and the most common foot condition seen by
Professor, Physical Therapy Department, Des Moines University, 3200
physical therapists.2,54 Conservative (ie, nonsurgical and Grand Avenue, Des Moines, IA 50312, USA.
non-extracorporeal shock wave therapy) interventions are Email: shane.mcclinton@dmu.edu

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2 Foot & Ankle International 
symptoms after conservative treatment and 30% have recur-
rent symptoms.5,17,41,69
Incomplete recovery or failure to respond to conservative
treatment may be attributed to patient characteristics that
affect treatment response. Age, body mass, and duration of
symptoms have been identified as characteristics associated
with a reduced response to conservative treatment for plan-
tar heel pain.23,32,41,53,69 Recently, a randomized clinical trial
demonstrated clinically meaningful improvement following
multimodal physical therapy intervention for PHP,8 but did
not analyze the influence of age, body mass, or duration of
symptoms on treatment response. No other evidence was
found to indicate factors associated with treatment response
to multimodal physical therapy intervention. Knowledge of
factors that can potentially affect outcome can help identify
individuals less likely to respond to physical therapy inter-
vention. Once identified, additional research can focus on
strategies that may be more effective for subgroups of non-
responders and help to reduce the incidence of persistent or
recurrent symptoms in individuals with PHP. Therefore, the
purpose of this investigation was to identify if age, body
mass, or symptom duration were predictors of outcome to
physical therapy intervention in individuals with PHP.
Methods
Participants
The study population included 60 individuals who partici-
pated in a randomized clinical trial between October 2006
and January 2008.8 Participants included patients with PHP
between the ages of 27 and 63 years that presented at 1 of 2
outpatient orthopaedic physical therapy clinics. The diag-
nosis of PHP was based on pain localized to the medial cal-
caneal tubercle and pain worsened during the first steps
after awakening.11,16,44 Imaging was not used to further dis-
criminate the pathological conditions associated with the
clinical presentation of PHP. Patients with precautions to
manual therapy interventions (ie, tumor, fracture, rheuma-
toid arthritis, osteoporosis, prolonged history of steroid use,
severe vascular disease, etc); prior surgery to the distal
tibia, fibula, ankle joint, or rearfoot region (proximal to the
base of the metatarsals); insufficient English proficiency to
complete questionnaires; or inability to comply with treat-
ment and follow-up schedules were excluded. Prior to par-
ticipating in the clinical trial, patients reviewed and signed
a consent form approved by the Human Investigations
Committee , Concord Hospital, Concord, NH and the Lower
South Regional Ethics Committee, Dunedin, New Zealand.8
Measures
All participants in the clinical trial completed a standard-
ized baseline examination at the outset that recorded age,
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sex, duration of symptoms, body mass index (BMI), and
use of medications. In addition, the activities of daily living
subscale of the Foot and Ankle Ability Measure (FAAM),
the Lower Extremity Functional Scale (LEFS), the Beck
Anxiety Index (BAI), and the 3-item (current, best, worst
pain) Numeric Pain Rating Scale (NPRS) were completed
at baseline, 4 weeks, and 6 months after initiation of treat-
ment. Also, the Global Rating of Change Scale (GRC) was
completed at 4 weeks and 6 months after baseline. For the
purpose of this secondary analysis, the variables selected
included age, duration of symptoms, BMI, FAAM, NPRS,
and GRC. The FAAM consisted of 21 questions about the
difficulty (range: 0 = unable to do, through 4 = no diffi-
culty) of daily tasks due to foot and ankle problems. The
total score was divided by the highest possible score and
multiplied by 100, where 0 = no functional ability and 100
= highest state of functional ability. The FAAM has demon-
strated content and context validity, an intraclass correlation
coefficient (ICC) of 0.89, and a minimal clinically impor-
tant difference (MCID) of 8 points.40 An 11-point NPRS,
where 0 = no pain and 10 = worst imaginable pain was used
to capture pain intensity. The NPRS with 3 items has dem-
onstrated validity, a test-retest reliability of 0.61 to 0.88,
and an MCID of 2 points.7,20,33,34 The GRC was a single-
item questionnaire that ranked patient-perceived improve-
ment between –7 (a very great deal worse) to 0 (about the
same) to +7 (a very great deal better).31 Scores of +5 (quite
a bit better) have been used as an indicator of clinical
success.9,31,37
Procedures
Complete details of the clinical trial procedures are
described by Cleland et al.8 Participants received 6 visits
over 4 weeks of physical therapy intervention that included
manual therapy and exercise or electrophysiological agents
and exercise. Both groups received exercises that included
stretching and self-mobilization of the plantar fascia, calf
stretching with the knee flexed and extended, and ankle
eversion self-mobilization. All patients were instructed to
perform all activities of daily living that did not increase
symptoms and to avoid aggravating activities. In the group
that received manual therapy, intervention was based on
patient-specific impairments in the hip, knee, lower leg,
ankle, and foot regions. Manual therapy included joint
mobilization or manipulation to the aforementioned areas
and soft tissue mobilization to the plantar fascia and flexor
hallicus longus. In the group that received electrophysio-
logical agents, ultrasound (3 MHz, 1.5 W/cm2, 100-Hz,
20% duty cycle, 5 min duration) was performed to the
involved area followed by iontophoresis with dexametha-
sone (40 mA.min dose). Thirteen patients were taking anti-
inflammatory medication at the start of the study and were
instructed to continue usage as prescribed by their
McClinton et al 3

Table 1.  Participant Characteristics and Outcome Measures at Baseline and the 6-Month Follow-up (mean ± SD or frequency [%];
n = 60).

Variable Baseline 6 Month Difference (95% CI)

Age in years (range) 48 ± 9 (27-63) — —
Female participants (%) 33 (55) — —
BMI in kg/m2 31.9 ± 7.5 — —
Duration of symptoms in days 271.6 ± 212.7 — —
NPRS 4.7 ± 1.7 1.7 ± 1.82 –3 (–2.4, –3.6)
 Change ≥ 2 points (%) — 42 (70) —
FAAM 57.5 ± 14.9 80 ± 16.5 22.5 (16.8, 28.2)
 Change ≥ 8 points (%) — 46 (77) —
GRC ≥ +5 (%) — 40 (67) —
Successful response (%)  
  NPRS/FAAM/GRC criteria — 29 (48) —
  NPRS/FAAM criteria — 38 (63) —

Abbreviations: BMI, body mass index; FAAM, Foot and Ankle Ability Measure; GRC, Global Rating of Change; NPRS, Numeric Pain Rating Scale.

physician. Patients were limited to intervention provided
within the clinical trial and did not receive any other inter-
vention; for example, injections, night splints, anti-inflam-
matory medication (other than that taken prior to outset of
the study), or immobilization were not utilized. The FAAM,
LEFS, BAI, NPRS, and GRC were administered at 4 weeks
and 6 months after the start of treatment.
Statistical Analysis
All data analyses and imputations were performed using
SPSS, Version 22.0 (SPSS Inc, Chicago, IL, USA). Despite
significant difference in outcomes between the 2 physical
therapy intervention groups, significant, and clinically
meaningful improvement was observed in both groups.8
Therefore, to provide the most comprehensive analysis that
included all responders to physical therapy intervention,
participants from both treatment groups were included in
the analysis consistent with multivariate prognostic model-
ing recommendations and procedures used by other
responder analyses of randomized clinical trials.22,26,27,35,48
This type of analysis allows a detailed analysis of whether
age, body mass, or symptom duration should alter the deci-
sion to manage PHP with physical therapy interventions.
Less than 12% of the original data was missing for the vari-
ables used in this investigation. Multiple imputation proce-
dures were used to handle missing values after analysis of
the missing data and observed absence of monotonicity.
Five imputed data sets were generated using the Markov
Chain Monte Carlo method and pooled estimates from the
multiple imputations were used when reporting data. Patient
characteristics and outcome variables were summarized
using the mean and standard deviation for continuous mea-
sures and the frequency and percentages for categorical
measures (Table 1).
Standard logistic regression (P < .05) was used to ana-
lyze age, BMI, and symptom duration as predictors of suc-
cessful treatment response based on the minimal clinically
important difference of the outcome measures. Predictor
variables were tested for multicollinearity and demonstrated
variance inflation factor values greater than 10 and toler-
ance values less than 0.10 in all imputed data sets. A sensi-
tivity analysis was conducted using 2 criteria to define
successful response to physical therapy intervention. In the
first scenario, participants were defined as having a suc-
cessful response if they exceeded MCID thresholds for 3
outcome measures (NPRS, 2 points; FAAM, 8 points; and
GRC, +5 or greater) at the 6 month follow-up similar to
procedures used by Cleland et al.10 In the second scenario,
successful response was defined only using the MCID of
the NPRS and FAAM. Recent evidence has demonstrated
concerns regarding the validity and stability of the GRC,
and therefore both analyses were conducted to assess the
influence of a successful response criterion that does not
include the GRC.24,59 Receiver operating curves were used
to determine the cut point for the significant predictor, and
the Nagelkerke R2 was used to describe the amount of varia-
tion explained by the significant predictor. The odds ratio
(95% CI) was reported to indicate the odds of a successful
response to treatment based on the determined cut point of
the significant predictor. Sensitivity, specificity, and posi-
tive and negative likelihood ratio values were calculated for
the predictor variable. In addition, MANCOVA and chi-
square tests were used to compare the FAAM, NPRS, and
GRC between individuals above and below the cut point for
the significant predictor using baseline scores as the
covariate.
Separate post hoc power analyses for logistic regression
analyses were performed using G*Power 3.1.6 using the
observed odds ratio, Pr (y = 1 | x = 1) H0 calculated from

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4 Foot & Ankle International 

Table 2.  Odds Ratio, Sensitivity, Specificity, and Positive and Negative Likelihood Ratio Values of Symptom Duration Less Than 7.2
Months as a Predictor of Successful Response to Physical Therapy Intervention.

Successful Response Odds Ratio Sensitivity Specificity + LR – LR

Criteria (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
NPRS/FAAM/GRC 4.2 0.58 0.75 2.3 0.56
  (1.3, 13.8) (0.41, 0.74) (0.57, 0.87) (1.2, 4.7) (0.35, 0.89)
NPRS/FAAM 8.5 0.76 0.73 2.8 0.33
  (2.5, 28.9) (0.6, 0.87) (0.52, 0.87) (1.4, 5.6) (0.18, 0.62)

Abbreviations: FAAM, Foot and Ankle Ability Measure; GRC, Global Rating of Change; LR, likelihood ratio; NPRS, Numeric Pain Rating Scale.

Table 3.  Outcome Comparison of Individuals With Symptom Duration Above and Below the 7.2 Month Cut Point (mean ± SD or
frequency [%]; n = 60)a.

Symptoms < 7.2 Symptoms > 7.2 Difference

Outcome Variable Months (n = 35) Months (n = 25) (95% CI) P Value
FAAM
 Baseline 53.3 ± 15.4 63.2 ± 15 –9.9 (–1.9, –18) <.001
  6 month 82 ± 17.2b 77.2 ± 17.5b 4.8 (–4.3, 13.9)b >.19b
  Change score 24.5 ± 17.2b 19.6 ± 17.5b 4.4 (–4.7, 13.5)b >.19b
NPRS
 Baseline 5.5 ± 1.6 3.7 ± 1.5 1.8 (1, 2.6) <.001
  6 month 1.4 ± 2.2b 2.1 ± 2.1b –0.7 (–1.8, 0.4)b >.08b
  Change score –4 ± 2.2b –1.7 ± 2.1b –2.3 (–1.2, –3.4)b >.08b
GRC (%)
  6 month 25 (68.6) 16 (64) — >.36c
a
The P values indicate the lowest value from MANCOVA for all imputed data sets unless otherwise indicated. FAAM, Foot and Ankle Ability Measure;
GRC, Global Rating of Change; NPRS, Numeric Pain Rating Scale.
b
Adjusted for baseline score.
c
Calculated via chi-square test.

classification tables and R2 obtained from both response cri-
teria analyses, and α = .05.21
Results
The characteristics of the sample included middle-aged par-
ticipants who were, on average, obese (Table 1).47 Mean
changes in NPRS and FAAM scores in response to physical
therapy intervention at the 6-month follow-up exceeded the
MCID of 2 and 8 points, respectively (Table 1). Also, the
lower confidence interval of the FAAM and NPRS change
score exceeded the MCID. In addition, 67% of participants
reported a GRC of +5 (quite a bit better) or greater.
The sensitivity analysis demonstrated different frequen-
cies of successful response between the 2 criteria used. The
NPRS/FAAM/GRC criteria resulted in 29 cases deemed a
successful response and the NPRS/FAAM criteria defined a
successful response in 38 cases (Table 1). Duration of
symptoms was the only significant predictor in logistic
regression analyses using the NPRS/FAAM/GRC and the
NPRS/FAAM criteria. Age and BMI were not significant
predictors (P ≥ .455 and P ≥ .450, respectively) of
successful treatment response. Analysis of the receiver
operating curves for symptom duration identified a cut
point of 218 days (ie, 7.2 months) for both successful
response criteria. Individuals with symptoms less than 7.2
months were 4.2 (P = .016) and 8.5 (P = .001) times more
likely to respond to treatment based on the NPRS/FAAM/
GRC, and NPRS/FAAM success criteria, respectively
(Table 2). Sensitivity, specificity, and positive and negative
likelihood ratio values for the accuracy of symptoms less
than 7.2 months to predict a positive response to physical
therapy intervention are listed in Table 2. Using the response
rate of the sample and calculated likelihood ratios (Tables 1
and 2), the probability of successful response to physical
therapy intervention if symptoms were present less than 7.2
months increased from 48% to 68% (95% CI, 52-81) using
the NPRS/FAAM/GRC criteria and from 63% to 83% (95%
CI, 70-91) using the NPRS/FAAM criteria. Differences in
the FAAM, NPRS, and GRC between individuals with
symptoms less than, and greater than, 7.2 months are pro-
vided in Table 3.
For the logistic regression analysis using the NPRS/
FAAM/GRC criteria, the Nagelkerke R2 ranged from 0.117

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McClinton et al 5
to 0.181 in the 5 imputed data sets and indicated that dura-
tion of symptoms predicted 18.1% of the variation, at best.
The Nagelkerke R2 using the NPRS/FAAM criteria range
between 0.258 to 0.326 and therefore duration of symptoms
explained 32.6% of the variation, at best.
Results of post hoc power analysis indicated a power of
0.97 for the analysis including the NPRS/FAAM/GRC cri-
teria and a power of 0.99 using the NPRS/FAAM criteria.
Discussion
In the clinical trial, 48% to 63% of individuals with PHP
demonstrated a successful response to 6 sessions of multi-
modal physical therapy intervention conducted over 4
weeks. If PHP symptoms were present for less than 7.2
months, the probability of a successful response increased
to 68% and 83% for the NPRS/FAAM/GRC and NPRS/
FAAM criteria, respectively. There were no other investiga-
tions found that examined success to intervention for PHP
based on the 2 criteria used in this investigation. The criteria
and rate of success to conservative intervention for PHP
varies widely between studies making direct comparison
difficult. Some investigations have reported success rates
ranging from 44% to 89% based on patient reports of
improvement of symptoms, no pain, total/100% relief, reso-
lution of symptoms, good to excellent results, or 80% relief
of symptoms.4,15,23,41,46,49,58,61,69 Other investigations have
used outcome instruments to define success that included
an 11-point visual analog scale (VAS) less than 5, GRC
greater than +4, GRC greater than +5, or FAAM change
greater than 8 points and have reported success rates rang-
ing from 45% to 80%.18,37,39 When looking at the success
rates of individual measures from the clinical trial (Table 1),
rates of success were similar to other investigations that
demonstrated 80% success based on FAAM change greater
than or equal to 8 and 70% success based on GRC greater
than or equal to +5.18,37
While no responder criteria was found to determine the
cut point for successful response in individuals with PHP,
responder criteria based on multiple measurement domains
including pain, function, and patient’s global rating of
change has been developed and used in other popula-
tions.10,51,52 The successful response criteria used in this
investigation was chosen to minimize the possibility of
deeming a response successful based on only 1 domain of
response to treatment where unsuccessful responses may
still be observed in other domains. As a result, the success
rates observed in this investigation may be lower than
investigations using only 1 measure to determine success.
In addition to using criteria involving 3 measures of
response to treatment, a parallel analysis was conducted
only using the NPRS and FAAM criteria. While the NPRS/
FAAM/GRC and NPRS/FAAM criteria produced similar
results in logistic regression analysis, the NPRS/FAAM
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analysis resulted in an increased success rate and a higher
odds ratio associated with the predictor variable. The
increased success rate and odds ratio is likely attributed to
the lower standards to achieve success in the NPRS/FAAM
criteria; namely, 2 versus 3 measures used as the cut point
for successful response. Despite evidence that the GRC
lacked correlation with functional change measures, GRC
may represent an important treatment response construct
worthy of consideration when determining treatment suc-
cess.24,59 In this study, a more conservative estimate of suc-
cessful response to treatment was obtained when the GRC
was added to the pain and function measures compared to
the pain and function measures alone. Further consensus is
needed to improve consistency in reporting of response to
PHP conservative treatment so that better comparisons can
be made between investigations.
A successful response to physical therapy intervention
was found in this analysis despite a sample that included
individuals who, on average, were obese (Table 1).47
Furthermore, high BMI was not a predictor of poor response
to treatment in the logistic regression analysis. Previously,
increased weight or obesity had been associated with an
increased risk of PHP.25,29,30,56 In addition, individuals who
are overweight or obese were reportedly less responsive to
conservative treatment for PHP.23,32,69 Because PHP often
limits weightbearing exercise, individuals with PHP are less
able to use exercise to manage their weight.50 The results of
this analysis are promising in that individuals who are over-
weight or obese can have a successful response to physical
therapy intervention for PHP allowing them to reap the ben-
efits of weightbearing exercise.
Increased age is another factor that has been associated
with PHP and decreased response to conservative treat-
ment.29,53 In this analysis, age was not a significant factor
that predicted successful response to treatment, but this
sample was limited to individuals between the ages of 27 to
63. Because of the limited age range of this sample, it is
unclear if individuals greater than 63 years of age have a
different rate of success than individuals less than 63 years
old. Approximately 15% of individuals with PHP are greater
65 years or older, and therefore it is important to identify
successful interventions for PHP in older adults.57
The results of this analysis indicated that individuals with
PHP symptom duration less than 7 months were more likely
to respond to the physical therapy intervention included in
the clinical trial. Two other studies were found that reported
a reduced response to conservative intervention for PHP if
symptoms were present for a longer duration, namely, 12 or
more months.41,69 In a telephone survey of 100 patients
treated conservatively by 3 orthopaedic surgeons, a good
result (defined as no symptoms) was achieved in 14 of 22
(64%) with symptoms for 12 or more months compared to
68 of 78 (87%) with symptoms less than 12 months (P <
.003).69 Conservative treatment was case-specific and
6 Foot & Ankle International 
included stretching, cushion or hard shoe inserts, anti-
inflammatory medication or injections, ice or heat, heel cup,
night splint, or foot strapping. Similarly, in a mailed follow-
up survey to 157 PHP patients who received conservative
treatment from 1 orthopaedic surgeon, patients with symp-
toms greater than 12 months were less likely to have a good
outcome defined as no pain (P < .04).41 Conservative treat-
ment included anti-inflammatory medication or injection,
night splint, at least 1 session of exercise instruction pro-
vided by a physical therapist, and a custom orthosis or heel
cup. In the clinical trial that provided the sample for this
analysis, patients received physical therapy intervention that
included stretching and self-mobilization exercises to the
lower leg, ankle, and foot in addition to manual therapy or
electrophysiological modalities. Despite the different con-
servative treatments provided to the participants that formed
the sample for this analysis and in other studies that demon-
strated reduced response with longer symptom duration,
symptom duration appears to be a significant prognostic fac-
tor to consider in the conservative management of individu-
als with PHP.
Individuals with longer symptom duration may develop
different pain mechanisms that contribute to their PHP
experience and response to treatment. Individuals with a
longer duration of pain demonstrated maladaptive psycho-
social factors consistent with a central sensitization versus
nociceptive pain mechanism.62 The reduced treatment
response associated with longer duration of PHP symptoms
and evidence of lower foot function in PHP patients with
higher stress and depression indicates the potential for cen-
tral sensitization mechanisms in patients with a longer dura-
tion of PHP.13 Therefore, clinical reasoning models that
integrate intervention with consideration of pain mecha-
nism and clinical presentation may benefit individuals with
longer PHP symptoms. Therapeutic pain neuroscience edu-
cation is one intervention that is recommended in the pres-
ence of central sensitization and has demonstrated positive
effects on pain, disability, anxiety, and stress in chronic
musculoskeletal pain conditions.38 No evidence was found
on the effects of therapeutic pain neuroscience education in
individuals with PHP although a clinical trial is underway
that includes this as one part of the conservative manage-
ment plan.42 In addition to therapeutic pain neuroscience
education, other interventions directed at proximal inputs to
PHP through central or peripheral neurodynamic mecha-
nisms, for example, myofasicial trigger points, may be of
additional benefit. Myofascial trigger point manual and dry
needling intervention has demonstrated significant improve-
ment of PHP, pain pressure thresholds, and foot-related
function.1,12,55 In investigations of myofascial trigger point
therapy on PHP, only Cotchett et al12 included a sample of
participants with an average duration greater than 7 months.
Further research is needed to identify factors related to lon-
ger duration of PHP and to test the effects of pain
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neuroscience education and myofascial trigger point inter-
vention on chronic PHP.
The results of this analysis indicated that symptom dura-
tion was a significant predictor of response to physical ther-
apy intervention for PHP. While the results of this analysis
provide evidence of an improved response with a shorter
duration of symptoms and a lesser response with a longer
duration of symptoms, caution is warranted in generalizing
the results. As indicated in Table 3, individuals with symp-
toms longer than 7 months had higher functional scores on
the FAAM and lower pain on the NPRS at baseline that may
have limited potential for improvement. Conversely, indi-
viduals with a lower duration of symptoms had lower func-
tional scores and higher pain scores at baseline, which may
have contributed to greater potential for improvement.
Therefore, because the responder criteria were based on the
magnitude of response, namely, the MCID of outcome mea-
sures, the effect of duration determined from logistic regres-
sion may have been affected by the baseline differences
between individuals above and below the 7-month duration
cut point. Despite the statistical significance that demon-
strated greater odds of successful outcome in individuals
with symptoms less than 7 months, clinically meaningful
changes were also observed in individuals with symptoms
greater than 7 months based on the MCID of the NPRS and
FAAM (Table 3). In addition, an equal proportion of indi-
viduals with symptoms greater and less than 7 months dem-
onstrated GRC of +5 or greater (Table 3). While further
research is warranted to examine effective solutions in indi-
viduals with a longer duration of symptoms, the physical
therapy intervention provided in this clinical trial resulted
in clinically meaningful changes regardless of symptom
duration and was still effective in individuals with symp-
toms greater than 7 months.
In addition to duration of symptoms, there may be other
factors that were not recorded during the clinical trial or
considered in this analysis that may predict successful treat-
ment response. Symptom duration explained 11.7% to
32.6% of the variation in the data, and therefore other fac-
tors are likely to contribute to the remaining variability in
treatment response. Few studies were found that investi-
gated factors related to response to conservative treatment
other than age, BMI, and symptom duration. Several other
factors derived from the history and physical examination
including foot posture/mobility, ankle or hallux dorsiflex-
ion, daily weightbearing duration, lower leg/foot strength,
neurodynamic dysfunction, stress, depression, and low
back pain have demonstrated an association with PHP or
foot function and may contribute to the response to physical
therapy intervention.3,13,28,30,36,45,56,60,66 Additional informa-
tion derived from imaging including heel pad energy dissi-
pation ratio, hyperemia, thickened plantar fascia, and heel
spurs may also contribute to prediction of response to treat-
ment.29,43,65,67,68 While the historical, physical examination,
McClinton et al 7
and imaging factors listed previously may occur more com-
monly in some populations of PHP, they are also present in
asymptomatic individuals and the impact of these factors on
clinical management including prediction of successful
response requires further investigation.19
Conclusion
Individuals with PHP for less than 7 months were more
likely to respond to the physical therapy interventions pro-
vided in the clinical trial, but age and BMI were not predic-
tive of treatment response. Despite the improved response
of individuals with symptoms less than 7 months, some
individuals with symptoms greater than 7 months were still
able to demonstrate clinically meaningful changes in
response to physical therapy intervention. Participants in
this trial were obese based on the average BMI yet were
responsive to physical therapy intervention despite previous
reports of the associations of obesity with PHP and a poor
treatment response. The upper age range in this sample was
limited, and further analysis is needed to assess the influ-
ence of age on treatment response in individuals greater
than 63 years old. Further research is needed to elucidate
additional strategies effective for PHP lasting longer than 7
months and matched to individual patient characteristics
and preferences.
Acknowledgments
Thanks to Tom Cappaert, PhD, ATC, Rocky Mountain University
of Health Professions, Provo, UT; Joanne Totten, PT, and Sue
Kennedy, School of Physiotherapy, University of Otago, Dunedin,
New Zealand, for their essential contributions.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was supported by the American Academy of Orthopaedic
Manual Physical Therapists, Cardon Rehabilitation Products
Grant. In addition, Empi Inc. (St. Paul, MN) kindly provided ion-
tophoresis units and supplies to one clinical site. These organiza-
tions played no role in the study design, conduct and reporting, or
manuscript publication decisions.
References
1. Ajimsha MS, Binsu D, Chithra S. Effectiveness of myofascial
release in the management of plantar heel pain: a randomized
controlled trial. Foot (Edinb). 2014;24:66-71.
2. Al Fischer Associates Inc. 2002 Podiatric Practice Survey.
Statistical results. J Am Podiatr Med Assoc. 2003;93:67-86.
Downloaded from fai.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 18, 2014
3. Allen RH, Gross MT. Toe flexors strength and passive exten-
sion range of motion of the first metatarsophalangeal joint in
individuals with plantar fasciitis. J Orthop Sports Phys Ther.
2003;33:468-478.
4. Amis J, Jennings L, Graham D, Graham CE. Painful heel syn-
drome: radiographic and treatment assessment. Foot Ankle.
1988;9:91-95.
5. Beyzadeoglu T, Gokce A, Bekler H. The effectiveness of
dorsiflexion night splint added to conservative treatment for
plantar fasciitis. Acta Orthop Traumatol Turc. 2007;41:220-
224.
6. Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J
Med. 2004;350:2159-2166.
7. Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric
pain rating scale in patients with low back pain. Spine (Phila
Pa 1976). 2005;30:1331-1334.
8. Cleland JA, Abbott JH, Kidd MO, et al. Manual physical ther-
apy and exercise versus electrophysical agents and exercise
in the management of plantar heel pain: a multicenter ran-
domized clinical trial. J Orthop Sports Phys Ther. 2009;39:
573-585.
9. Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL.
Development of a clinical prediction rule for guiding treat-
ment of a subgroup of patients with neck pain: use of thoracic
spine manipulation, exercise, and patient education. Phys
Ther. 2007;87:9-23.
10. Cleland JA, Fritz JM, Whitman JM, Heath R. Predictors of
short-term outcome in people with a clinical diagnosis of cer-
vical radiculopathy. Phys Ther. 2007;87:1619-1632.
11. Cornwall MW, McPoil TG. Plantar fasciitis: etiology and
treatment. J Orthop Sports Phys Ther. 1999;29:756-760.
12. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of
trigger point dry needling for plantar heel pain: a randomized
controlled trial. Phys Ther. 2014;94(8):1083-1094.
13. Cotchett MP, Whittaker G, Erbas B. Psychological variables
associated with foot function and foot pain in patients with
plantar heel pain [published online March 20, 2014]. Clin
Rheumatol. 2014. doi:10.1007/s10067-014-2565.
14. Covey CJ, Mulder MD. Plantar fasciitis: how best to treat? J
Fam Pract. 2013;62:466-471.
15. Davis PF, Severud E, Baxter DE. Painful heel syn-
drome: results of nonoperative treatment. Foot Ankle Int.
1994;15:531-535.
16. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-
specific plantar fascia-stretching exercise enhances outcomes
in patients with chronic heel pain. A prospective, randomized
study. J Bone Joint Surg Am. 2003;85-A:1270-1277.
17. DiGiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar
fascia-specific stretching exercise improves outcomes in
patients with chronic plantar fasciitis. A prospective clini-
cal trial with two-year follow-up. J Bone Joint Surg Am.
2006;88:1775-1781.
18. Drake M, Bittenbender C, Boyles RE. The short-term effects
of treating plantar fasciitis with a temporary custom foot
orthosis and stretching. J Orthop Sports Phys Ther. 2011;41:
221-231.
19. Ehrmann C, Maier M, Mengiardi B, Pfirrmann CW, Sutter
R. Calcaneal attachment of the plantar fascia: MR findings in
asymptomatic volunteers. Radiology. 2014;272:807-814.
8 Foot & Ankle International 
20. Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM.
Clinical importance of changes in chronic pain intensity
measured on an 11-point numerical pain rating scale. Pain.
2001;94:149-158.
21. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a
flexible statistical power analysis program for the social,
behavioral, and biomedical sciences. Behav Res Methods.
2007;39:175-191.
22. French HP, Galvin R, Cusack T, McCarthy GM. Predictors of
short-term outcome to exercise and manual therapy for people
with hip osteoarthritis. Phys Ther. 2014;94:31-39.
23. Furey JG. Plantar fasciitis. The painful heel syndrome. J Bone
Joint Surg Am. 1975;57:672-673.
24. Garrison C, Cook C. Clinimetrics corner: the Global Rating
of Change Score (GRoC) poorly correlates with functional
measures and is not temporally stable. J Man Manip Ther.
2012;20:178-181.
25. Gill LH, Kiebzak GM. Outcome of nonsurgical treatment for
plantar fasciitis. Foot Ankle Int. 1996;17:527-532.
26. Hagen EM, Svensen E, Eriksen HR. Predictors and modifi-
ers of treatment effect influencing sick leave in subacute low
back pain patients. Spine (Phila Pa 1976). 2005;30:2717-
2723.
27. Harrell FE, Lee KL, Mark DB. Multivariable prognostic
models: issues in developing models, evaluating assumptions
and adequacy, and measuring and reducing errors. Stat Med.
1996;15:361-387.
28. Hendrix CL, Jolly GP, Garbalosa JC, Blume P,
DosRemedios E. Entrapment neuropathy: the etiology of
intractable chronic heel pain syndrome. J Foot Ankle Surg.
1998;37:273-279.
29. Irving DB, Cook JL, Menz HB. Factors associated with
chronic plantar heel pain: a systematic review. J Sci Med
Sport. 2006;9:11-22.
30. Irving DB, Cook JL, Young MA, Menz HB. Obesity and
pronated foot type may increase the risk of chronic plantar
heel pain: a matched case-control study. BMC Musculoskelet
Disord. 2007;8:41.
31. Jaeschke R, Singer J, Guyatt GH. Measurement of health sta-
tus. Ascertaining the minimal clinically important difference.
Control Clin Trials. 1989;10:407-415.
32. Japour CJ, Vohra R, Vohra PK, Garfunkel L, Chin N.
Management of heel pain syndrome with acetic acid ionto-
phoresis. J Am Podiatr Med Assoc. 1999;89:251-257.
33. Jensen MP, McFarland CA. Increasing the reliability and
validity of pain intensity measurement in chronic pain
patients. Pain. 1993;55:195-203.
34. Jensen MP, Turner JA, Romano JM, Fisher LD. Comparative
reliability and validity of chronic pain intensity measures.
Pain. 1999;83:157-162.
35. Jones ML, Evans N, Tefertiller C, et al. Activity-based ther-
apy for recovery of walking in chronic spinal cord injury:
results from a secondary analysis to determine responsiveness
to therapy [published online August 4, 2014]. Arch Phys Med
Rehabil. doi:10.1016/j.apmr.2014.07.401.
36. Kibler WB, Goldberg C, Chandler TJ. Functional biomechan-
ical deficits in running athletes with plantar fasciitis. Am J
Sports Med. 1991;19:66-71.
Downloaded from fai.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 18, 2014
37. Looney B, Srokose T, Fernandez-de-las-Penas C, Cleland JA.
Graston instrument soft tissue mobilization and home stretch-
ing for the management of plantar heel pain: a case series. J
Manipulative Physiol Ther. 2011;34:138-142.
38. Louw A, Diener I, Butler DS, Puentedura EJ. The effect of
neuroscience education on pain, disability, anxiety, and stress
in chronic musculoskeletal pain. Arch Phys Med Rehabil.
2011;92:2041-2056.
39. Lynch DM, Goforth WP, Martin JE, Odom RD, Preece CK,
Kotter MW. Conservative treatment of plantar fasciitis. A
prospective study. J Am Podiatr Med Assoc. 1998;88:375-
380.
40. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen
JM. Evidence of validity for the Foot and Ankle Ability
Measure (FAAM). Foot Ankle Int. 2005;26:968-983.
41. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects
with insertional plantar fasciitis. Foot Ankle Int. 1998;19:803-
811.
42. McClinton SM, Flynn TW, Heiderscheit BC, et al. Comparison
of usual podiatric care and early physical therapy intervention
for plantar heel pain: study protocol for a parallel-group ran-
domized clinical trial. Trials. 2013;14:414.
43. McMillan AM, Landorf KB, Gregg JM, De Luca J, Cotchett
MP, Menz HB. Hyperemia in plantar fasciitis determined
by power Doppler ultrasound. J Orthop Sports Phys Ther.
2013;43:875-880.
44. McPoil TG, Martin RL, Cornwall MW, Wukich DK, Irrgang
JJ, Godges JJ. Heel pain—plantar fasciitis: clinical practice
guildelines linked to the international classification of func-
tion, disability, and health from the orthopaedic section of
the American Physical Therapy Association. J Orthop Sports
Phys Ther. 2008;38:A1-A18.
45. Menz HB, Dufour AB, Riskowski JL, Hillstrom HJ,
Hannan MT. Foot posture, foot function and low back
pain: the Framingham Foot Study. Rheumatology (Oxford).
2013;52:2275-2282.
46. Mizel MS, Marymont JV, Trepman E. Treatment of plantar
fasciitis with a night splint and shoe modification consisting
of a steel shank and anterior rocker bottom. Foot Ankle Int.
1996;17:732-735.
47. National Institutes of Health, United States Department
of Health and Human Services. The Practical Guide:
Identification, Evaluation, and Treatment of Overweight
and Obesity in Adults. Bethesda, MD: National Institutes
of Health publication 00-4084. http://www.nhlbi.nih.gov/
files/docs/guidelines/prctgd_c.pdf. Published October 2000.
Accessed September 28, 2014.
48. Nee RJ, Vicenzino B, Jull GA, Cleland JA, Coppieters MW.
Baseline characteristics of patients with nerve-related neck
and arm pain predict the likely response to neural tissue man-
agement. J Orthop Sports Phys Ther. 2013;43:379-391.
49. O’Brien D, Martin WJ. A retrospective analysis of heel pain.
J Am Podiatr Med Assoc. 1985;75:416-418.
50. Orchard J. Plantar fasciitis. BMJ. 2012;345:e6603.
51. Pham T, van der Heijde D, Altman RD, et al. OMERACT-
OARSI initiative: osteoarthritis Research Society International
set of responder criteria for osteoarthritis clinical trials revis-
ited. Osteoarthritis Cartilage. 2004;12:389-399.
McClinton et al 9
52. Pham T, Van Der Heijde D, Lassere M, et al. Outcome vari-
ables for osteoarthritis clinical trials: the OMERACT-OARSI
set of responder criteria. J Rheumatol. 2003;30:1648-1654.
53. Probe RA, Baca M, Adams R, Preece C. Night splint treat-
ment for plantar fasciitis. A prospective randomized study.
Clin Orthop Relat Res. 1999;368:190-195.
54. Reischl S. Physical therapist foot care survey. Orthop Pract.
2001;13:27.
55. Renan-Ordine R, Alburquerque-Sendin F, de Souza DP,
Cleland JA, Fernandez-de-Las-Penas C. Effectiveness of
myofascial trigger point manual therapy combined with a
self-stretching protocol for the management of plantar heel
pain: a randomized controlled trial. J Orthop Sports Phys
Ther. 2011;41:43-50.
56. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for
plantar fasciitis: a matched case-control study. J Bone Joint
Surg Am. 2003;85-A:872-877.
57. Riddle DL, Schappert SM. Volume of ambulatory care vis-
its and patterns of care for patients diagnosed with plantar
fasciitis: a national study of medical doctors. Foot Ankle Int.
2004;25:303-310.
58. Scherer PR. Heel spur syndrome. Pathomechanics and non-
surgical treatment. Biomechanics Graduate Research Group
for 1988. J Am Podiatr Med Assoc. 1991;81:68-72.
59. Schmitt JS, Abbott JH. Patient global ratings of change did
not adequately reflect change over time: a clinical cohort
study. Phys Ther. 2014;94(4):534-542.
60. Schon LC, Glennon TP, Baxter DE. Heel pain syndrome:
electrodiagnostic support for nerve entrapment. Foot Ankle.
1993;14:129-135.
61. Shikoff MD, Figura MA, Postar SE. A retrospective study
of 195 patients with heel pain. J Am Podiatr Med Assoc.
1986;76:71-75.
Downloaded from fai.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 18, 2014
62. Smart KM, Blake C, Staines A, Thacker M, Doody C.
Mechanisms-based classifications of musculoskeletal pain:
part 1 of 3: symptoms and signs of central sensitisation in
patients with low back (± leg) pain. Man Ther. 2012;17:336-
344.
63. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis
and treatment of heel pain: a clinical practice guideline-revi-
sion 2010. J Foot Ankle Surg. 2010;49:S1-19.
64. Tong KB, Furia J. Economic burden of plantar fasciitis treat-
ment in the United States. Am J Orthop (Belle Mead NJ).
2010;39:227-231.
65. Wearing SC, Smeathers JE, Sullivan PM, Yates B, Urry SR,
Dubois P. Plantar fasciitis: are pain and fascial thickness asso-
ciated with arch shape and loading? Phys Ther. 2007;87:1002-
1008.
66. Wearing SC, Smeathers JE, Urry SR, Hennig EM, Hills
AP. The pathomechanics of plantar fasciitis. Sports Med.
2006;36:585-611.
67. Wearing SC, Smeathers JE, Urry SR, Sullivan PM, Yates
B, Dubois P. Plantar enthesopathy: thickening of the
enthesis is correlated with energy dissipation of the plantar
fat pad during walking. Am J Sports Med. 2010;38:2522-
2527.
68. Wearing SC, Smeathers JE, Yates B, Urry SR, Dubois P. Bulk
compressive properties of the heel fat pad during walking: a
pilot investigation in plantar heel pain. Clin Biomech (Bristol,
Avon). 2009;24:397-402.
69. Wolgin M, Cook C, Graham C, Mauldin D. Conservative
treatment of plantar heel pain: long-term follow-up. Foot
Ankle Int. 1994;15:97-102.
70. Yi TI, Lee GE, Seo IS, Huh WS, Yoon TH, Kim BR. Clinical
characteristics of the causes of plantar heel pain. Ann Rehabil
Med. 2011;35:507-513.