In this episode of the Hands-On, Hands-Off Podcast, Dr. Trenton Rehman sits down with Dr. Shane McClinton to discuss plantar heel pain and the role of physical therapy in both clinical outcomes and healthcare costs.
Dr. McClinton walks through a series of studies stemming from his doctoral research, including a randomized clinical trial, a detailed case series, and a three-year cost-effectiveness analysis. Together, they explore how adding physical therapy to usual podiatry care impacts pain, function, quality of life, and long-term costs.
Key themes include manual therapy, impairment-based exercise, proximal contributions to heel pain, interdisciplinary collaboration, and why plantar heel pain may deserve the same clinical mindset as low back pain.
Key Takeaways (Listener-Facing)
Plantar heel pain is a multidimensional condition with local and proximal contributors.
Adding physical therapy to usual podiatry care improved outcomes and reduced costs over three years.
Manual therapy and exercise were delivered pragmatically and tailored to impairments.
Strengthening may be underutilized in plantar heel pain management.
Collaboration between physical therapists and podiatrists benefits patients and reduces downstream burden.
⏱️ TIMESTAMPED CHAPTERS (YouTube + Podcast)
00:00 – Introduction to the episode and guest
00:01 – Dr. Shane McClinton’s background and research focus
00:03 – Why plantar heel pain referrals to PT are low
00:07 – Rationale for studying cost-effectiveness
00:10 – Study design overview (RCT + pragmatic approach)
00:15 – Description of podiatry-only vs podiatry + PT care
00:17 – Inclusion and exclusion criteria
00:22 – Case series: why eight different heel pain presentations
00:26 – Manual therapy strategies used in the study
00:30 – Clinical practice guidelines and decision-making
00:32 – Pain mechanisms, education, and chronicity
00:35 – Proximal vs local treatment decisions
00:38 – Three-year cost-effectiveness results explained
00:44 – Implications for referrals and collaboration
00:48 – Final take-home message from Dr. McClinton
00:00:02 --> 00:00:03 Okay, recording starting.
00:00:03 --> 00:00:07 All right.
00:00:07 --> 00:00:08 Well, hello, everybody.
00:00:08 --> 00:00:10 My name is Dr. Trenton Raymond,
00:00:10 --> 00:00:13 and I'll be hosting today's episode of the
00:00:13 --> 00:00:15 Hands-On, Hands-Off podcast.
00:00:16 --> 00:00:18 Today's guest is a pioneer in the space
00:00:18 --> 00:00:21 of plantar heel pain, or PHP,
00:00:21 --> 00:00:22 which we'll reference it.
00:00:23 --> 00:00:25 And he has been published multiple times
00:00:25 --> 00:00:25 on this topic.
00:00:26 --> 00:00:28 Not only has he been a large advocate
00:00:28 --> 00:00:29 for the use of manual therapy in the
00:00:30 --> 00:00:31 treatment of PHP,
00:00:31 --> 00:00:33 but he has also tackled the large task
00:00:33 --> 00:00:35 of evaluating the cost-effectiveness of
00:00:35 --> 00:00:39 physical therapy compared to other more
00:00:39 --> 00:00:40 common management approaches.
00:00:41 --> 00:00:42 Today we have the pleasure of speaking
00:00:42 --> 00:00:43 with Dr. Shane McClinton.
00:00:44 --> 00:00:44 Dr.
00:00:44 --> 00:00:46 Shane McClinton is a fellowship-trained
00:00:46 --> 00:00:50 physical therapist and is a professor in
00:00:50 --> 00:00:52 the Department of Physical Therapy at Des
00:00:52 --> 00:00:53 Moines University.
00:00:54 --> 00:00:55 Thank you for joining us.
00:00:56 --> 00:00:57 Thanks for having me.
00:00:57 --> 00:00:58 Glad to be here.
00:00:58 --> 00:00:58 Awesome.
00:00:59 --> 00:00:59 Well,
00:01:00 --> 00:01:01 can you just start by giving us a
00:01:01 --> 00:01:04 little bit more about your background so
00:01:04 --> 00:01:05 that the audience kind of knows who we're
00:01:05 --> 00:01:09 talking with and maybe touch on just
00:01:09 --> 00:01:11 briefly your career path and an overview
00:01:12 --> 00:01:14 of what led you to this topic in
00:01:14 --> 00:01:14 this research?
00:01:16 --> 00:01:16 Great.
00:01:16 --> 00:01:16 Yeah, thank you.
00:01:17 --> 00:01:19 And I'm humbled to hear you say pioneer
00:01:20 --> 00:01:20 in this area.
00:01:20 --> 00:01:22 I'd probably refer to myself more as a
00:01:22 --> 00:01:24 private if this were in the military and
00:01:24 --> 00:01:27 just making some small contributions to an
00:01:27 --> 00:01:31 area that there's lots of outstanding
00:01:32 --> 00:01:34 individuals contributing to this area.
00:01:34 --> 00:01:35 But anyway, thank you for that.
00:01:37 --> 00:01:40 I obtained my initial physical therapy
00:01:40 --> 00:01:42 degree from Des Moines University, which,
00:01:42 --> 00:01:43 yes, I'm still there.
00:01:43 --> 00:01:45 I did work elsewhere for a few years,
00:01:45 --> 00:01:48 but I went on to get my DPT,
00:01:48 --> 00:01:50 it's transitional degree again through Des
00:01:50 --> 00:01:50 Moines University.
00:01:51 --> 00:01:51 After that,
00:01:52 --> 00:01:54 went through fellowship training at Regis
00:01:54 --> 00:01:55 University in Colorado.
00:01:56 --> 00:01:57 Then after that,
00:01:57 --> 00:01:58 I got my PhD through Rocky Mountain
00:01:58 --> 00:02:00 University in Provo, Utah.
00:02:01 --> 00:02:05 and actually this um this study is was
00:02:05 --> 00:02:07 part of my initial dissertation research
00:02:08 --> 00:02:10 and kind of an extension thereof so it's
00:02:10 --> 00:02:11 been something that i've been working on
00:02:11 --> 00:02:13 for some time it's an area that i've
00:02:13 --> 00:02:16 been interested in for quite some time and
00:02:16 --> 00:02:18 actually just happy to get out the last
00:02:18 --> 00:02:19 part of it which is the economic
00:02:19 --> 00:02:23 evaluation following a follow-up that we
00:02:23 --> 00:02:27 extended out to three years afterwards so
00:02:28 --> 00:02:30 So I think your question along with that
00:02:30 --> 00:02:32 was also what kind of prompted this study.
00:02:36 --> 00:02:37 Being in clinical practice,
00:02:38 --> 00:02:40 I work at a multi-specialty clinic.
00:02:40 --> 00:02:42 So we work with family care physicians
00:02:42 --> 00:02:42 that refer to us.
00:02:43 --> 00:02:44 We work with podiatrists as well.
00:02:44 --> 00:02:48 We also have osteopathic manual physicians
00:02:48 --> 00:02:49 who are in our clinical practice.
00:02:50 --> 00:02:53 And one of the observations I made when
00:02:53 --> 00:02:54 working with plantar heel pain patients is
00:02:54 --> 00:02:56 I would see the patients that would come
00:02:56 --> 00:02:57 and be referred to me directly,
00:02:58 --> 00:02:59 but I wouldn't see many patients that were
00:02:59 --> 00:03:01 being referred from other providers,
00:03:01 --> 00:03:01 even though
00:03:02 --> 00:03:04 It was a condition that in my experience
00:03:04 --> 00:03:05 and also the literature at the time,
00:03:06 --> 00:03:07 and even since then has really supported
00:03:07 --> 00:03:09 the fact that it's a very multidimensional
00:03:09 --> 00:03:10 problem.
00:03:10 --> 00:03:13 There's issues that extend proximally.
00:03:13 --> 00:03:15 So we see a lot of neurogenic factors
00:03:15 --> 00:03:17 that are contributing to their heel pain.
00:03:17 --> 00:03:19 They have proximal impairments in the
00:03:19 --> 00:03:21 lumbar spine and the hip and the knee.
00:03:22 --> 00:03:23 They benefit from manual intervention.
00:03:23 --> 00:03:25 It seemed like these patients were just
00:03:25 --> 00:03:26 right down in our wheelhouse,
00:03:27 --> 00:03:29 but the referral rate in our clinic and
00:03:29 --> 00:03:31 across the board was very, very low.
00:03:31 --> 00:03:32 So for example,
00:03:32 --> 00:03:35 seven percent upwards of twenty percent
00:03:35 --> 00:03:38 from other providers are referring those
00:03:38 --> 00:03:40 patients to physical therapists.
00:03:40 --> 00:03:42 So it just seemed to me like, well,
00:03:42 --> 00:03:44 this is a population that we really should
00:03:44 --> 00:03:45 have our hands on and we can really
00:03:46 --> 00:03:46 help.
00:03:47 --> 00:03:48 But we're not getting a lot of them
00:03:48 --> 00:03:49 in our door.
00:03:50 --> 00:03:51 And there's a lot of factors that we
00:03:51 --> 00:03:53 can explore and discuss about why that is,
00:03:53 --> 00:03:54 but regardless,
00:03:54 --> 00:03:56 that was the facts of the healthcare
00:03:56 --> 00:03:57 situation.
00:03:58 --> 00:04:01 And so we embarked upon this study to
00:04:01 --> 00:04:04 see if we could provide some evidence that
00:04:04 --> 00:04:07 we can add value to these other providers.
00:04:07 --> 00:04:08 We're not trying to take away from what
00:04:08 --> 00:04:08 they do,
00:04:09 --> 00:04:10 but we want to just show that we
00:04:10 --> 00:04:12 can add some value to the things they're
00:04:12 --> 00:04:12 currently doing.
00:04:13 --> 00:04:15 And in our clinic situation,
00:04:15 --> 00:04:16 eighty-some percent,
00:04:16 --> 00:04:18 almost ninety percent of the patients,
00:04:18 --> 00:04:20 when they were coming on their own,
00:04:20 --> 00:04:22 they were going to see the podiatrist.
00:04:22 --> 00:04:24 So by far, the majority of them,
00:04:24 --> 00:04:25 and it makes sense.
00:04:25 --> 00:04:27 If you have a foot problem,
00:04:27 --> 00:04:28 you would want to go see the foot
00:04:28 --> 00:04:28 doctor.
00:04:28 --> 00:04:30 That makes a lot of sense.
00:04:30 --> 00:04:32 And that's what most of them were doing.
00:04:33 --> 00:04:34 So we felt like it was a,
00:04:35 --> 00:04:36 you know,
00:04:36 --> 00:04:37 the best approach was to start working
00:04:37 --> 00:04:39 with them since that's where the majority
00:04:39 --> 00:04:40 of the patients were coming.
00:04:41 --> 00:04:43 So that's really was the premise behind
00:04:43 --> 00:04:43 the study.
00:04:44 --> 00:04:46 And we kind of knew that when you
00:04:46 --> 00:04:47 added physical therapy,
00:04:47 --> 00:04:49 it was probably going to add some costs.
00:04:49 --> 00:04:51 And that's also the barrier to it because
00:04:51 --> 00:04:51 patients,
00:04:52 --> 00:04:53 it's going to take them a little more
00:04:53 --> 00:04:53 time.
00:04:53 --> 00:04:55 They have to participate.
00:04:55 --> 00:04:56 They have to be more engaged.
00:04:57 --> 00:04:59 So there are some upfront costs.
00:04:59 --> 00:05:01 So that's why we wanted to study this
00:05:01 --> 00:05:02 at least a year and why we even
00:05:02 --> 00:05:04 extended out to two and three years,
00:05:04 --> 00:05:05 because we wanted to see if there were
00:05:05 --> 00:05:07 downstream savings that we could then
00:05:07 --> 00:05:08 provide evidence to say, yes,
00:05:08 --> 00:05:10 there might be a little more upfront,
00:05:11 --> 00:05:11 but in the long run,
00:05:11 --> 00:05:12 it's gonna be worth it.
00:05:12 --> 00:05:13 You're gonna have better outcomes,
00:05:14 --> 00:05:16 hopefully less likely to have these
00:05:16 --> 00:05:17 problems again.
00:05:17 --> 00:05:19 And by the way, in the long run,
00:05:19 --> 00:05:20 we're gonna have a lot of cost savings.
00:05:22 --> 00:05:24 from managing other conditions,
00:05:24 --> 00:05:25 from managing that condition,
00:05:25 --> 00:05:26 from missing work,
00:05:26 --> 00:05:28 a lot of the other factors that are
00:05:28 --> 00:05:30 the economic burden of suffering from
00:05:30 --> 00:05:31 plantar heel pain.
00:05:32 --> 00:05:33 I mean, that's awesome.
00:05:33 --> 00:05:35 Thank you for sharing that background.
00:05:35 --> 00:05:35 And I mean,
00:05:35 --> 00:05:37 the thing that jumps out to me is
00:05:37 --> 00:05:40 that seven to twenty percent just seems so
00:05:40 --> 00:05:43 low for an area that, you know,
00:05:43 --> 00:05:44 I think most of us feel very comfortable
00:05:45 --> 00:05:46 evaluating trading.
00:05:46 --> 00:05:47 And like you said,
00:05:47 --> 00:05:49 there's some research to support what we
00:05:49 --> 00:05:50 do works.
00:05:50 --> 00:05:51 But this is awesome to see this like
00:05:52 --> 00:05:53 this lens and this side of it.
00:05:56 --> 00:05:59 For the viewers and listeners who haven't
00:05:59 --> 00:06:00 read your work yet,
00:06:01 --> 00:06:02 could you just orient us a little bit
00:06:03 --> 00:06:07 to the idea of your primary study and
00:06:07 --> 00:06:08 the subsequent studies?
00:06:10 --> 00:06:12 Then when you get to the cost evaluation,
00:06:12 --> 00:06:15 maybe just discuss the design so that we
00:06:15 --> 00:06:17 know what that looked like.
00:06:17 --> 00:06:18 Yeah, absolutely.
00:06:20 --> 00:06:21 So we do have a couple of,
00:06:21 --> 00:06:21 as you mentioned,
00:06:21 --> 00:06:23 we have a couple of publications from the
00:06:23 --> 00:06:24 same study.
00:06:24 --> 00:06:27 So from the start of this study,
00:06:27 --> 00:06:31 we were planning to collect the pain
00:06:31 --> 00:06:33 function, quality of life,
00:06:34 --> 00:06:37 and all of the costs related outcomes.
00:06:37 --> 00:06:38 So I think that's an important factor is
00:06:38 --> 00:06:42 that the design did include not just the,
00:06:42 --> 00:06:42 you know,
00:06:42 --> 00:06:43 I guess what I'm getting at is the
00:06:43 --> 00:06:44 economic evaluation wasn't an
00:06:45 --> 00:06:45 afterthought.
00:06:46 --> 00:06:49 We were planning that from the inception
00:06:49 --> 00:06:51 and quite a bit of planning went into
00:06:51 --> 00:06:53 designing that aspect of it particularly.
00:06:55 --> 00:06:57 So the study was a two-arm study.
00:06:57 --> 00:06:59 We had a group and it was a
00:06:59 --> 00:07:02 randomized clinical trial and it was also
00:07:02 --> 00:07:03 a very pragmatic trial.
00:07:03 --> 00:07:04 So when we talked about intervention,
00:07:06 --> 00:07:06 it wasn't
00:07:08 --> 00:07:09 I mean, it was structured,
00:07:09 --> 00:07:10 but it wasn't scripted.
00:07:10 --> 00:07:12 So it's important to kind of understand
00:07:12 --> 00:07:14 that the individuals involved in the
00:07:14 --> 00:07:14 treatment,
00:07:14 --> 00:07:16 both the podiatrist and the physical
00:07:16 --> 00:07:16 therapist,
00:07:17 --> 00:07:18 were allowed to treat the patients,
00:07:18 --> 00:07:19 for the most part,
00:07:19 --> 00:07:20 how they normally would.
00:07:23 --> 00:07:25 So because the patients were coming to see
00:07:25 --> 00:07:25 the podiatrist first,
00:07:25 --> 00:07:27 that's where they entered the study.
00:07:27 --> 00:07:29 So when they were seen by the podiatrist
00:07:29 --> 00:07:30 at our clinic,
00:07:30 --> 00:07:31 at the Des Moines University Clinic,
00:07:32 --> 00:07:34 they were then asked to enroll in the
00:07:34 --> 00:07:34 study.
00:07:35 --> 00:07:37 And so every patient started with at least
00:07:38 --> 00:07:39 one visit from a podiatrist.
00:07:40 --> 00:07:40 Then from there,
00:07:40 --> 00:07:42 we randomized them into the two different
00:07:42 --> 00:07:43 groups.
00:07:43 --> 00:07:45 One group would just continue with the
00:07:45 --> 00:07:47 podiatrist based on their recommendations.
00:07:47 --> 00:07:49 For the most part, they did follow suit.
00:07:49 --> 00:07:52 Their referral rate didn't increase much.
00:07:52 --> 00:07:53 For the most part,
00:07:53 --> 00:07:55 they managed them the way that they
00:07:55 --> 00:07:56 normally did.
00:07:56 --> 00:07:57 In the other group,
00:07:57 --> 00:07:59 they started with a physical therapist
00:07:59 --> 00:08:00 right away.
00:08:02 --> 00:08:02 Again,
00:08:02 --> 00:08:03 the physical therapist still would
00:08:03 --> 00:08:04 collaborate with the podiatrist,
00:08:04 --> 00:08:05 but for the most part,
00:08:05 --> 00:08:07 the physical therapist provided the
00:08:07 --> 00:08:10 treatment that they felt was warranted for
00:08:10 --> 00:08:11 that patient.
00:08:12 --> 00:08:15 We collected our outcomes at six weeks to
00:08:15 --> 00:08:18 capture what was going on early on after
00:08:18 --> 00:08:20 that first visit, and then six months,
00:08:21 --> 00:08:23 and then every year thereafter up to three
00:08:23 --> 00:08:23 years.
00:08:24 --> 00:08:27 So that's the design.
00:08:27 --> 00:08:28 And so the outcomes were the numeric pain
00:08:28 --> 00:08:29 rating scale,
00:08:29 --> 00:08:31 but an ankle ability measure was our
00:08:31 --> 00:08:32 functional scale.
00:08:33 --> 00:08:34 And then the,
00:08:35 --> 00:08:37 we use the EQ five D to get
00:08:37 --> 00:08:39 their quality of life,
00:08:39 --> 00:08:40 which was used in the economic evaluation.
00:08:40 --> 00:08:43 And then we used our billing records to
00:08:43 --> 00:08:44 get costs.
00:08:44 --> 00:08:47 So we knew all the charges in all
00:08:47 --> 00:08:49 of the departments that they were seen in.
00:08:50 --> 00:08:52 And then anything, any,
00:08:52 --> 00:08:54 treatments that they had outside of our
00:08:54 --> 00:08:55 clinic,
00:08:55 --> 00:08:56 there was a questionnaire that we
00:08:56 --> 00:08:58 developed that was modeled off of other
00:08:58 --> 00:09:00 questionnaires that have been validated in
00:09:00 --> 00:09:02 order to capture all of the costs.
00:09:02 --> 00:09:04 So if they went to an acupuncturist,
00:09:04 --> 00:09:05 they were documenting that.
00:09:05 --> 00:09:06 If they had to travel to those
00:09:06 --> 00:09:08 appointments, they were documenting that.
00:09:08 --> 00:09:09 If they missed time from work,
00:09:09 --> 00:09:10 they were documenting that.
00:09:11 --> 00:09:13 So we captured as best we could all
00:09:13 --> 00:09:15 the costs that we related to treatment,
00:09:16 --> 00:09:18 either directly or indirectly.
00:09:21 --> 00:09:22 And yeah,
00:09:22 --> 00:09:24 I think that was the general design that,
00:09:24 --> 00:09:26 oh, uh, as far as the studies,
00:09:26 --> 00:09:29 then we had our initial publication was
00:09:29 --> 00:09:31 in, uh,
00:09:31 --> 00:09:33 and that was just the one year follow-up
00:09:33 --> 00:09:34 and just the outcomes.
00:09:34 --> 00:09:36 So our outcomes with regards to pain and
00:09:36 --> 00:09:38 function between the two groups.
00:09:38 --> 00:09:40 And of course we described the study
00:09:40 --> 00:09:41 methodology there.
00:09:42 --> 00:09:44 We followed up with that in the next
00:09:44 --> 00:09:46 year with a case series.
00:09:46 --> 00:09:47 And in that case series,
00:09:47 --> 00:09:47 what our intent was,
00:09:47 --> 00:09:49 was really to describe the details of the
00:09:49 --> 00:09:50 treatment provided,
00:09:50 --> 00:09:51 particularly in the
00:09:52 --> 00:09:55 podiatry plus physical therapy group.
00:09:55 --> 00:09:58 So we went through our decision-making,
00:09:58 --> 00:10:00 the process, the details,
00:10:00 --> 00:10:02 how we prioritized what treatments,
00:10:02 --> 00:10:03 how we decided what treatments.
00:10:04 --> 00:10:05 Again, even though it was pragmatic,
00:10:05 --> 00:10:09 there was an impairment-based logic behind
00:10:09 --> 00:10:11 it that we tried to outline as best
00:10:11 --> 00:10:12 we could in that article.
00:10:13 --> 00:10:15 We also have a nice appendix that
00:10:15 --> 00:10:17 describes the exercise interventions done,
00:10:17 --> 00:10:19 the manual interventions that are done.
00:10:19 --> 00:10:21 It gives you a little bit of a
00:10:21 --> 00:10:23 depiction of the frequency of some of
00:10:23 --> 00:10:24 those interventions as well.
00:10:25 --> 00:10:27 And that's also described in the initial
00:10:27 --> 00:10:28 paper too,
00:10:28 --> 00:10:30 the frequency of which interventions.
00:10:31 --> 00:10:32 So you kind of get a snapshot of
00:10:33 --> 00:10:33 what was done.
00:10:34 --> 00:10:35 And then lastly,
00:10:36 --> 00:10:37 and recently published was our economic
00:10:37 --> 00:10:40 evaluation because that included the three
00:10:40 --> 00:10:41 year outcomes.
00:10:42 --> 00:10:44 So in that study,
00:10:44 --> 00:10:47 the focus was obviously looking at the
00:10:47 --> 00:10:50 cost effectiveness between the two groups.
00:10:50 --> 00:10:55 So can we improve their health related
00:10:55 --> 00:10:59 quality of life at a lower cost across
00:10:59 --> 00:11:00 a three year time span?
00:11:00 --> 00:11:02 Uh, and,
00:11:02 --> 00:11:03 You know,
00:11:03 --> 00:11:04 I'll let the cat out of the bag.
00:11:04 --> 00:11:05 Hopefully everybody's read the article
00:11:05 --> 00:11:06 anyway.
00:11:07 --> 00:11:08 But the good news is,
00:11:08 --> 00:11:10 is we were able to demonstrate cost
00:11:10 --> 00:11:13 effectiveness in economic valuation
00:11:13 --> 00:11:14 language
00:11:15 --> 00:11:18 the usual podiatry plus physical therapy
00:11:18 --> 00:11:20 treatment dominated the usual podiatry
00:11:20 --> 00:11:24 treatment, meaning it was more effective.
00:11:24 --> 00:11:26 You got a better outcome and it was
00:11:27 --> 00:11:29 less costly, meaning it costs less.
00:11:29 --> 00:11:30 It's kind of a no brainer.
00:11:30 --> 00:11:31 When you go to the store and you
00:11:31 --> 00:11:33 find something that's a better value and
00:11:33 --> 00:11:34 it actually costs less,
00:11:35 --> 00:11:36 you're buying that every time.
00:11:37 --> 00:11:38 So that was the good news.
00:11:38 --> 00:11:39 And again,
00:11:40 --> 00:11:43 fairly robust across the different
00:11:43 --> 00:11:46 replicates that we we tried to utilize to
00:11:47 --> 00:11:49 to demonstrate some of the potential
00:11:49 --> 00:11:49 variability.
00:11:50 --> 00:11:51 And pretty consistently,
00:11:51 --> 00:11:53 things fell into that category of being
00:11:53 --> 00:11:54 cost effective.
00:11:56 --> 00:11:56 That's awesome.
00:11:56 --> 00:11:59 And thank you for lining that out because
00:11:59 --> 00:12:01 that'll be nice as we're going through our
00:12:01 --> 00:12:03 discussion to have that orientation to
00:12:03 --> 00:12:05 kind of like the three tiers of the
00:12:05 --> 00:12:07 publication and especially referencing
00:12:07 --> 00:12:09 that case series,
00:12:09 --> 00:12:11 which was illustrating the interventions
00:12:11 --> 00:12:13 for the different heel pain presentations.
00:12:14 --> 00:12:14 I find that one,
00:12:14 --> 00:12:15 I find all of it interesting.
00:12:16 --> 00:12:18 I just love diving into the actual
00:12:18 --> 00:12:19 interventions you chose and why.
00:12:19 --> 00:12:20 I thought that was awesome.
00:12:21 --> 00:12:22 So let's start.
00:12:24 --> 00:12:26 And you already prefaced some of this,
00:12:26 --> 00:12:28 but let's just start with talking a little
00:12:28 --> 00:12:30 bit about the cost effectiveness study.
00:12:32 --> 00:12:34 Can you just talk a little bit about
00:12:35 --> 00:12:39 the two branches that you chose and maybe
00:12:39 --> 00:12:41 just give another overview of kind of the
00:12:41 --> 00:12:44 results and the biggest kind of takeaway
00:12:44 --> 00:12:46 that you found from that one?
00:12:47 --> 00:12:48 Yeah,
00:12:48 --> 00:12:49 so the two branches of the study or
00:12:49 --> 00:12:51 the two arms of the study would have
00:12:51 --> 00:12:52 been usual podiatry care.
00:12:52 --> 00:12:52 So again,
00:12:53 --> 00:12:55 following the care that the podiatrist
00:12:55 --> 00:12:55 recommended,
00:12:57 --> 00:12:59 primarily it was a handout on certain
00:12:59 --> 00:13:03 exercises, you know, your calf stretching,
00:13:03 --> 00:13:05 some banded plantar flexion exercises.
00:13:06 --> 00:13:08 They would almost always prescribe a foot
00:13:09 --> 00:13:11 orthosis in most cases,
00:13:11 --> 00:13:12 typically over the counter.
00:13:13 --> 00:13:14 typically are getting some
00:13:14 --> 00:13:16 anti-inflammatory medications with that.
00:13:17 --> 00:13:18 On lesser occasions,
00:13:18 --> 00:13:20 they might have injections into the heel
00:13:20 --> 00:13:21 that are performed.
00:13:21 --> 00:13:23 And in even fewer circumstances,
00:13:23 --> 00:13:27 there were a few cases that did end
00:13:27 --> 00:13:29 up having a surgery on the plantar fascia.
00:13:31 --> 00:13:33 compared to the group that had that
00:13:33 --> 00:13:35 initial visit with the podiatrist and then
00:13:35 --> 00:13:36 they saw a physical therapist.
00:13:38 --> 00:13:40 We were typically assessing for
00:13:40 --> 00:13:42 impairments anywhere from the lumbar spine
00:13:43 --> 00:13:44 down to the ankle and foot,
00:13:44 --> 00:13:46 generally prioritizing a little bit of the
00:13:46 --> 00:13:47 ankle and foot.
00:13:47 --> 00:13:48 So limited dorsiflexion is a common
00:13:48 --> 00:13:49 impairment.
00:13:49 --> 00:13:50 We were using joint mobilization
00:13:50 --> 00:13:51 techniques,
00:13:51 --> 00:13:52 manual techniques to the calf and the
00:13:52 --> 00:13:53 plantar fascia.
00:13:53 --> 00:13:55 to address those impairments,
00:13:56 --> 00:13:59 both medial and lateral gliding of the
00:13:59 --> 00:14:00 calcaneus,
00:14:00 --> 00:14:02 addressing issues in the forefoot as well.
00:14:03 --> 00:14:03 So again,
00:14:03 --> 00:14:05 any impairment that we commonly find
00:14:06 --> 00:14:08 we were managing that using manual
00:14:08 --> 00:14:10 intervention and then typically
00:14:10 --> 00:14:13 complementing it with or augmenting it
00:14:13 --> 00:14:14 with an exercise that would kind of match
00:14:15 --> 00:14:15 that impairment.
00:14:15 --> 00:14:18 So I would suggest a very impairment-based
00:14:19 --> 00:14:19 approach that was taken,
00:14:20 --> 00:14:22 but also very pragmatic in the sense that
00:14:22 --> 00:14:24 some patients might have almost exclusive
00:14:24 --> 00:14:25 ankle and foot intervention.
00:14:25 --> 00:14:26 Other patients,
00:14:27 --> 00:14:28 the priority might have been more in the
00:14:28 --> 00:14:30 lumbopelvic area where they had
00:14:30 --> 00:14:32 more impairments up there that we felt
00:14:32 --> 00:14:33 were contributing to their symptoms,
00:14:34 --> 00:14:36 of which we typically tried to confirm
00:14:36 --> 00:14:37 with a pre-post-test kind of assessment.
00:14:37 --> 00:14:39 So we might do some manual intervention to
00:14:39 --> 00:14:40 the lumbar spine.
00:14:40 --> 00:14:43 And if we measured their asterisk or
00:14:43 --> 00:14:45 comparable sign and they got better,
00:14:45 --> 00:14:46 then we would say, hey,
00:14:46 --> 00:14:48 that's probably something we need to
00:14:48 --> 00:14:49 prioritize in their treatment,
00:14:49 --> 00:14:51 in addition to whatever else we might be
00:14:51 --> 00:14:51 doing.
00:14:53 --> 00:14:55 I'm probably missing some things that we
00:14:55 --> 00:14:56 did treatment-wise,
00:14:56 --> 00:14:58 but off the top of my head,
00:14:58 --> 00:15:01 those were the primary things that we were
00:15:01 --> 00:15:02 working on with those patients.
00:15:02 --> 00:15:03 So they definitely got a heavy dose of
00:15:03 --> 00:15:05 manual therapy, heavy dose of exercise.
00:15:05 --> 00:15:07 They were doing a home program.
00:15:07 --> 00:15:10 And we were following up typically a
00:15:10 --> 00:15:11 couple of times a week at first,
00:15:11 --> 00:15:12 but then we would decrease to once a
00:15:12 --> 00:15:13 week.
00:15:14 --> 00:15:15 And I think on average,
00:15:16 --> 00:15:18 somewhere around six visits or so per
00:15:18 --> 00:15:20 patient in that group.
00:15:23 --> 00:15:26 So, um, those, those were the two arms,
00:15:26 --> 00:15:27 um, of the study there.
00:15:27 --> 00:15:29 Um,
00:15:29 --> 00:15:30 and then what was the next follow-up you
00:15:30 --> 00:15:31 wanted?
00:15:31 --> 00:15:31 Well,
00:15:31 --> 00:15:33 I just had a quick question on the
00:15:33 --> 00:15:33 arms.
00:15:33 --> 00:15:37 Was there any discussion of a PT like
00:15:37 --> 00:15:39 only arm, you know,
00:15:39 --> 00:15:42 just to see how that would compare with
00:15:42 --> 00:15:43 the other two?
00:15:43 --> 00:15:43 Yeah.
00:15:43 --> 00:15:45 And it would have been nice to, yeah,
00:15:45 --> 00:15:46 it would have been really nice to have
00:15:46 --> 00:15:46 that.
00:15:46 --> 00:15:47 And, and, um,
00:15:49 --> 00:15:50 So a couple of issues with that,
00:15:50 --> 00:15:51 obviously it increased our sample size
00:15:51 --> 00:15:52 significantly if we're adding another
00:15:52 --> 00:15:54 group in there, you know,
00:15:55 --> 00:15:58 that makes it kind of difficult to get
00:15:58 --> 00:15:58 the enrollment.
00:15:59 --> 00:16:01 The second thing was, is again,
00:16:01 --> 00:16:02 the problem at the time that we were
00:16:02 --> 00:16:04 trying to address is the fact that we
00:16:04 --> 00:16:05 weren't really getting patients referred
00:16:05 --> 00:16:07 to us from these other providers.
00:16:08 --> 00:16:12 So I do feel like we can treat
00:16:12 --> 00:16:13 these patients off the street or in direct
00:16:13 --> 00:16:15 access quite well,
00:16:16 --> 00:16:16 but
00:16:18 --> 00:16:19 But at this point in time,
00:16:19 --> 00:16:21 we really wanted to provide some evidence
00:16:21 --> 00:16:22 to other providers that if they're seeing
00:16:22 --> 00:16:23 them,
00:16:23 --> 00:16:25 then we can provide an added benefit.
00:16:25 --> 00:16:26 So I would say that would be the
00:16:26 --> 00:16:28 main reason why we didn't go that route.
00:16:28 --> 00:16:29 But you're right,
00:16:29 --> 00:16:31 it makes a lot of sense.
00:16:32 --> 00:16:34 I think that's a great answer, though,
00:16:34 --> 00:16:37 because as we'll talk about later,
00:16:37 --> 00:16:39 some of the takeaways from this is working
00:16:39 --> 00:16:42 with clinicians and working in teams is
00:16:42 --> 00:16:44 usually a multidisciplinary approach.
00:16:45 --> 00:16:47 So I actually kind of like that idea
00:16:47 --> 00:16:48 of having the two arms,
00:16:48 --> 00:16:51 both including the referral source.
00:16:51 --> 00:16:56 So then when we go into looking at
00:16:56 --> 00:16:59 that case series of those eight
00:16:59 --> 00:17:01 treatments, can you talk a little bit,
00:17:01 --> 00:17:02 well, I guess this is for both studies,
00:17:03 --> 00:17:04 but can you talk a little bit about
00:17:04 --> 00:17:07 the inclusion criteria that was referenced
00:17:07 --> 00:17:08 in the article,
00:17:08 --> 00:17:10 just so we kind of understand the
00:17:10 --> 00:17:11 population that was being treated?
00:17:13 --> 00:17:13 Yeah,
00:17:14 --> 00:17:20 so the patients had to have symptoms for
00:17:20 --> 00:17:22 long enough, not for too long,
00:17:22 --> 00:17:25 but long enough that it wasn't just an
00:17:25 --> 00:17:27 acute kind of situation.
00:17:27 --> 00:17:35 So I'm actually gonna go.
00:17:35 --> 00:17:35 The...
00:17:37 --> 00:17:39 The diagnosis was made clinically as it
00:17:39 --> 00:17:40 normally is.
00:17:40 --> 00:17:42 So they need to have palpatory pain at
00:17:42 --> 00:17:45 the medial aspect of the calcaneus near
00:17:45 --> 00:17:47 the proximal attachment of the plantar
00:17:47 --> 00:17:48 fascia.
00:17:49 --> 00:17:53 And it needs to be worse with the
00:17:53 --> 00:17:53 initial steps,
00:17:53 --> 00:17:54 typically first thing in the morning,
00:17:54 --> 00:17:56 but it could be after they've been sitting
00:17:56 --> 00:17:57 for a long time.
00:17:58 --> 00:17:58 typical patterns,
00:17:58 --> 00:18:00 it dissipates and actually move a little
00:18:00 --> 00:18:00 bit,
00:18:00 --> 00:18:01 but then gets worse the more that they're
00:18:01 --> 00:18:02 on their feet.
00:18:03 --> 00:18:04 So if they're meeting kind of that
00:18:04 --> 00:18:05 criteria,
00:18:06 --> 00:18:09 they did need to have enough of a
00:18:09 --> 00:18:11 disability on the FAM in order for us
00:18:11 --> 00:18:12 to make a meaningful change.
00:18:13 --> 00:18:14 So, you know,
00:18:14 --> 00:18:16 that was another part of the criteria.
00:18:16 --> 00:18:18 It is the FAM had to be low
00:18:18 --> 00:18:20 enough that we could make enough
00:18:20 --> 00:18:22 improvement in their case.
00:18:22 --> 00:18:22 So they couldn't just have
00:18:23 --> 00:18:25 a little bit of plantar fasciitis symptoms
00:18:26 --> 00:18:28 affecting and barely affecting their
00:18:28 --> 00:18:28 disability.
00:18:29 --> 00:18:29 Similarly,
00:18:29 --> 00:18:32 we had to have enough sufficient pain to
00:18:32 --> 00:18:32 be included.
00:18:33 --> 00:18:36 We did try to exclude other factors that
00:18:36 --> 00:18:41 wouldn't be considered plantar fasciitis.
00:18:41 --> 00:18:47 So radiculopathy is one of the exclusion
00:18:47 --> 00:18:48 criteria,
00:18:49 --> 00:18:50 and that would be hard signs of
00:18:50 --> 00:18:51 radiculopathy.
00:18:51 --> 00:18:53 So definitely seeing motor loss,
00:18:54 --> 00:18:54 sensory loss,
00:18:55 --> 00:18:57 that is something that we can measure with
00:18:57 --> 00:18:57 our clinical tests.
00:18:59 --> 00:19:00 And I say that because a lot of
00:19:00 --> 00:19:03 these patients seem to have something
00:19:03 --> 00:19:05 neurogenically going on when you test
00:19:05 --> 00:19:06 their neurodynamics, and again,
00:19:06 --> 00:19:07 when we treat the lumbar spine.
00:19:07 --> 00:19:09 So obviously there is something going on
00:19:09 --> 00:19:11 there that's the relationship between the
00:19:11 --> 00:19:13 lumbar spine, not just the nerves,
00:19:14 --> 00:19:15 but the structures of the lumbar spine are
00:19:16 --> 00:19:17 influencing their pain experience and
00:19:17 --> 00:19:18 their heal,
00:19:18 --> 00:19:20 which again is why I feel like physical
00:19:20 --> 00:19:21 therapists should be included in this
00:19:21 --> 00:19:22 population,
00:19:22 --> 00:19:23 at least just a screen for that.
00:19:24 --> 00:19:26 If we can't find any impairments in lumbar
00:19:26 --> 00:19:29 spine or with our neurodynamic testing,
00:19:30 --> 00:19:33 then very well some of the excellent
00:19:33 --> 00:19:34 treatment that our podiatrists and other
00:19:34 --> 00:19:35 providers provide might be all that they
00:19:35 --> 00:19:36 need.
00:19:38 --> 00:19:40 But in some cases that could be,
00:19:40 --> 00:19:42 I would suggest it could be the reason
00:19:42 --> 00:19:43 why many of these patients go on to
00:19:43 --> 00:19:45 have persisting symptoms and continued
00:19:45 --> 00:19:45 pain.
00:19:48 --> 00:19:50 So we also want to exclude anybody with,
00:19:51 --> 00:19:52 you know, tumor or fracture,
00:19:53 --> 00:19:54 rheumatic inflammatory disease,
00:19:54 --> 00:19:56 so rheumatoid or reactive or psoriatic
00:19:56 --> 00:19:58 arthritis, inflammatory bowel disease,
00:19:59 --> 00:20:01 some of these conditions that might mimic
00:20:02 --> 00:20:03 plantar heel pain.
00:20:03 --> 00:20:06 We wanted to also make sure they were
00:20:06 --> 00:20:07 clean from any treatment in the past six
00:20:07 --> 00:20:08 weeks.
00:20:08 --> 00:20:09 So if they'd seen other providers,
00:20:09 --> 00:20:10 we wanted to have kind of a washout
00:20:10 --> 00:20:13 period and would exclude those that have
00:20:13 --> 00:20:14 had more recent treatment.
00:20:17 --> 00:20:18 Yeah, that's great.
00:20:18 --> 00:20:20 Thank you for that background.
00:20:20 --> 00:20:23 And I thought it was a thorough and
00:20:23 --> 00:20:26 thoughtful inclusion criteria based on
00:20:26 --> 00:20:27 what you were just discussing.
00:20:27 --> 00:20:30 And I thought it was interesting to talk
00:20:30 --> 00:20:31 about timeline,
00:20:31 --> 00:20:34 patients with greater than a year of heel
00:20:34 --> 00:20:35 pain,
00:20:36 --> 00:20:39 given that this is often a diagnosis that
00:20:40 --> 00:20:41 goes untreated for a long time.
00:20:42 --> 00:20:44 And it can be recalcitrant and
00:20:45 --> 00:20:45 and lingering.
00:20:45 --> 00:20:49 And so I think that speaks a little
00:20:49 --> 00:20:52 bit to where we can add some value,
00:20:52 --> 00:20:53 but also that idea of confounding
00:20:53 --> 00:20:55 variables that make diagnosis and
00:20:55 --> 00:20:56 treatment challenging.
00:20:56 --> 00:20:57 Yeah.
00:20:57 --> 00:20:58 Yeah, I mean, that's a good point.
00:20:58 --> 00:20:59 So, you know,
00:20:59 --> 00:21:00 I don't know if I clarified that,
00:21:00 --> 00:21:02 but we did exclude those who had symptoms
00:21:02 --> 00:21:03 more than a year.
00:21:04 --> 00:21:06 So not to say we can't provide benefit
00:21:06 --> 00:21:07 to those patients,
00:21:07 --> 00:21:11 but we also wanted to kind of mimic
00:21:11 --> 00:21:13 other studies that were kind of using very
00:21:13 --> 00:21:14 similar criteria as well.
00:21:14 --> 00:21:17 So we could compare our results to some
00:21:17 --> 00:21:18 of the other literature as well.
00:21:19 --> 00:21:20 Yeah, that's awesome.
00:21:20 --> 00:21:24 So diving into that article a little bit,
00:21:25 --> 00:21:27 the case series with the eight treatments,
00:21:27 --> 00:21:29 can you talk a little bit to the
00:21:29 --> 00:21:32 audience like how you chose those eight
00:21:32 --> 00:21:33 different cases and why,
00:21:34 --> 00:21:35 and why that would be important for
00:21:35 --> 00:21:38 somebody who's maybe dealing with this in
00:21:38 --> 00:21:40 the clinic of using that as a reference
00:21:40 --> 00:21:42 for different almost categories of heel
00:21:42 --> 00:21:42 pain?
00:21:42 --> 00:21:44 Yeah, I mean,
00:21:44 --> 00:21:45 that is kind of the point.
00:21:45 --> 00:21:47 So as I reflected on some of the
00:21:47 --> 00:21:48 cases,
00:21:49 --> 00:21:49 You know,
00:21:49 --> 00:21:52 it did seem like there were definitely
00:21:52 --> 00:21:52 different.
00:21:53 --> 00:21:53 And again,
00:21:53 --> 00:21:55 every patient I would say probably
00:21:55 --> 00:21:56 received a little bit different treatment
00:21:56 --> 00:21:58 because, again, it was pretty pragmatic.
00:21:58 --> 00:22:01 But there were some staples across the
00:22:01 --> 00:22:01 board in the treatment.
00:22:01 --> 00:22:02 So in that study,
00:22:02 --> 00:22:05 if you do look at the again,
00:22:05 --> 00:22:06 this will be posted, I'm sure.
00:22:06 --> 00:22:07 This is the case report published in
00:22:08 --> 00:22:09 Physiotherapy Theory and Practice.
00:22:09 --> 00:22:11 But we have some tables towards the end.
00:22:12 --> 00:22:14 which can be useful to give you a
00:22:14 --> 00:22:15 synopsis of what was done.
00:22:15 --> 00:22:18 So since this is the AONT podcast,
00:22:18 --> 00:22:19 we'll talk about the manual therapy first.
00:22:19 --> 00:22:21 If you look across the board there,
00:22:21 --> 00:22:24 almost everybody had myofascial treatments
00:22:24 --> 00:22:25 to the calf.
00:22:26 --> 00:22:27 So I would say this is something
00:22:27 --> 00:22:31 clinically we find quite effective to help
00:22:31 --> 00:22:32 manage our symptoms.
00:22:32 --> 00:22:33 So we would treat their calf and the
00:22:33 --> 00:22:34 foot as well.
00:22:35 --> 00:22:37 But I think calf is definitely a nice
00:22:37 --> 00:22:38 area because it's not right.
00:22:38 --> 00:22:40 If their symptoms are really hot,
00:22:40 --> 00:22:40 you're not...
00:22:41 --> 00:22:43 directly intervening right where their
00:22:43 --> 00:22:44 pain is the highest at.
00:22:45 --> 00:22:46 You're dealing with an area that typically
00:22:46 --> 00:22:49 tends to refer and can help calm that
00:22:49 --> 00:22:50 down a little bit and open up the
00:22:50 --> 00:22:51 door to more treatments.
00:22:52 --> 00:22:54 We're very commonly doing dorsiflexion
00:22:54 --> 00:22:55 mobilization,
00:22:55 --> 00:22:56 so working on the talocrural joint,
00:22:56 --> 00:22:58 working on the rear foot, which again,
00:22:59 --> 00:23:00 from an anatomic standpoint,
00:23:00 --> 00:23:01 makes a lot of sense.
00:23:02 --> 00:23:03 And then from there,
00:23:03 --> 00:23:05 you started to see some scattering of
00:23:05 --> 00:23:07 things to where there were some patients
00:23:07 --> 00:23:10 that tended to benefit a little bit more
00:23:10 --> 00:23:13 from midfoot and forefoot mobilizations to
00:23:13 --> 00:23:15 knee impairments,
00:23:15 --> 00:23:16 treating knee impairments.
00:23:16 --> 00:23:18 A lot of times if they lack a
00:23:18 --> 00:23:19 knee extension, for example,
00:23:19 --> 00:23:21 they're gonna load the heel a little bit
00:23:21 --> 00:23:22 differently.
00:23:22 --> 00:23:24 And there's some biomechanical rationale
00:23:24 --> 00:23:26 behind why that might be an issue.
00:23:27 --> 00:23:27 Similarly,
00:23:27 --> 00:23:31 lumbar impairments were considerations,
00:23:31 --> 00:23:32 again, not in everyone,
00:23:32 --> 00:23:33 but in many of the cases.
00:23:33 --> 00:23:35 And then neurodynamic impairments were
00:23:36 --> 00:23:37 things that were addressed.
00:23:37 --> 00:23:39 So those were some of the common things
00:23:39 --> 00:23:41 from a manual therapy perspective that
00:23:41 --> 00:23:41 were kind of done.
00:23:42 --> 00:23:42 And again,
00:23:42 --> 00:23:44 each of the eight different cases
00:23:44 --> 00:23:45 illustrates kind of a different
00:23:45 --> 00:23:47 combination of treatment,
00:23:47 --> 00:23:48 including that manual therapy,
00:23:49 --> 00:23:50 but then also the therapeutic exercise.
00:23:51 --> 00:23:54 And then the exercise, the most common
00:23:55 --> 00:23:56 I would say evidence-based treatment
00:23:56 --> 00:23:59 includes stretching or some type of
00:23:59 --> 00:24:02 mobilization of the calf and the foot in
00:24:02 --> 00:24:03 the plantar fascia as well.
00:24:03 --> 00:24:05 So we did use that most frequently in
00:24:05 --> 00:24:06 almost every case,
00:24:08 --> 00:24:09 following up if they endorse flexion
00:24:09 --> 00:24:11 limitations with some type of mobility
00:24:11 --> 00:24:12 exercise.
00:24:12 --> 00:24:14 It could be kind of a mobilization with
00:24:14 --> 00:24:15 movement type treatment.
00:24:16 --> 00:24:17 So it would mimic a lot of the
00:24:17 --> 00:24:18 manual intervention.
00:24:18 --> 00:24:20 So almost every manual intervention that I
00:24:20 --> 00:24:23 just described, in these cases,
00:24:23 --> 00:24:25 there would be a corresponding exercise
00:24:25 --> 00:24:26 intervention addressing that mobility
00:24:27 --> 00:24:27 impairment.
00:24:28 --> 00:24:29 Another thing I want to kind of highlight
00:24:30 --> 00:24:31 that we did,
00:24:31 --> 00:24:33 and I feel like there's a lot more
00:24:33 --> 00:24:36 evidence in this area that's been great to
00:24:36 --> 00:24:37 see,
00:24:37 --> 00:24:39 and that's the strengthening component.
00:24:39 --> 00:24:41 You know, our counterparts,
00:24:41 --> 00:24:43 the podiatrists typically tend to put foot
00:24:43 --> 00:24:45 inserts, which tend to support the arch.
00:24:46 --> 00:24:48 And that does affect the activity of the
00:24:48 --> 00:24:51 muscles, including the long-term strength.
00:24:52 --> 00:24:54 And so I think it's also a nice
00:24:54 --> 00:24:55 little pairing for us to work with those
00:24:55 --> 00:24:57 individuals because we can actually show
00:24:57 --> 00:24:58 them how to strengthen their foot,
00:24:58 --> 00:24:59 how to strengthen their calf,
00:25:00 --> 00:25:01 how to strengthen their hip,
00:25:01 --> 00:25:03 or wherever the impairment is,
00:25:03 --> 00:25:05 it might be related to muscle performance.
00:25:06 --> 00:25:07 we can address those muscle performance
00:25:08 --> 00:25:10 deficits and complement the more passive
00:25:10 --> 00:25:12 modalities such as a foot orthosis that
00:25:12 --> 00:25:16 could be in the long run detrimental to
00:25:16 --> 00:25:17 foot strength.
00:25:18 --> 00:25:19 And we did a prior study where we
00:25:19 --> 00:25:20 actually looked at the correlation.
00:25:21 --> 00:25:22 And again, it's a correlation,
00:25:22 --> 00:25:23 not necessarily causation,
00:25:23 --> 00:25:24 but a correlation between
00:25:25 --> 00:25:27 how long someone has worn foot orthoses
00:25:27 --> 00:25:29 and their foot strength with certain
00:25:29 --> 00:25:30 measures that we did.
00:25:30 --> 00:25:33 So toe intrinsic kind of flexor strength,
00:25:33 --> 00:25:34 calf raises as well.
00:25:35 --> 00:25:36 And we tend to find that those who
00:25:36 --> 00:25:38 use foot orthoses for longer tend to have
00:25:38 --> 00:25:39 more weakness.
00:25:39 --> 00:25:40 So it seems to make sense that, hey,
00:25:41 --> 00:25:42 maybe we can intervene in these
00:25:42 --> 00:25:44 populations and help them with some
00:25:44 --> 00:25:46 interventions and direct them how to
00:25:46 --> 00:25:48 strengthen their foot and their lower leg
00:25:49 --> 00:25:50 to not have these long standing
00:25:50 --> 00:25:52 impairments that are likely only going to
00:25:52 --> 00:25:53 get worse over time.
00:25:54 --> 00:25:55 And then of course we would address their
00:25:55 --> 00:25:56 movement proficiency.
00:25:56 --> 00:25:59 So gait training and a lot of our
00:25:59 --> 00:26:00 strengthening would work up the chain too.
00:26:00 --> 00:26:01 So again,
00:26:01 --> 00:26:03 if they had lumbopelvic or hip
00:26:03 --> 00:26:04 impairments, we'd address those,
00:26:04 --> 00:26:06 we'd try to integrate it into their
00:26:06 --> 00:26:06 function.
00:26:07 --> 00:26:07 So if they were a runner,
00:26:08 --> 00:26:08 we'd try to,
00:26:08 --> 00:26:10 if they had to back down from it,
00:26:10 --> 00:26:11 we'd try to get them back into running
00:26:11 --> 00:26:12 again.
00:26:13 --> 00:26:15 So that in a nutshell is kind of
00:26:15 --> 00:26:19 the intervention and some of which is
00:26:19 --> 00:26:20 illustrated in that case series.
00:26:21 --> 00:26:23 Yeah, and I think that's great.
00:26:23 --> 00:26:26 I love the logical flow of, you know,
00:26:26 --> 00:26:29 you find that impairment that was either a
00:26:29 --> 00:26:33 direct area of nociceptive pain or a
00:26:33 --> 00:26:36 contributing factor, you know,
00:26:36 --> 00:26:37 that was driving the process of their
00:26:37 --> 00:26:38 persistent pain.
00:26:39 --> 00:26:40 And taking that approach of the passive
00:26:41 --> 00:26:43 intervention paired with an active
00:26:43 --> 00:26:44 intervention that fit the exact same,
00:26:45 --> 00:26:47 whether it was arthrokinematics or just
00:26:47 --> 00:26:49 functional goal.
00:26:49 --> 00:26:50 So I thought that was awesome.
00:26:50 --> 00:26:51 The,
00:26:51 --> 00:26:54 the part that I would draw attention to
00:26:54 --> 00:26:57 is I really loved appendix D where it
00:26:57 --> 00:26:58 showed, um,
00:26:58 --> 00:27:00 kind of like each case as a number
00:27:00 --> 00:27:02 and then like, um,
00:27:02 --> 00:27:04 which modality or which intervention was
00:27:04 --> 00:27:05 used with each one.
00:27:06 --> 00:27:08 And I loved obviously as an AM to
00:27:08 --> 00:27:10 podcast that all of them got manual
00:27:10 --> 00:27:13 therapy and, uh, in all,
00:27:13 --> 00:27:14 but one of the cases,
00:27:14 --> 00:27:16 they all got joint mobilization,
00:27:16 --> 00:27:18 which I think is something that goes
00:27:18 --> 00:27:20 underappreciated in the foot and ankle.
00:27:21 --> 00:27:23 and not that that was the entire purpose
00:27:23 --> 00:27:26 of this you know article but just from
00:27:26 --> 00:27:28 my lens it was really cool to see
00:27:28 --> 00:27:31 the use of things like uh manipulation of
00:27:31 --> 00:27:34 the of the subtalar joint or the calcaneal
00:27:34 --> 00:27:37 mobilizations which is um i mean maybe
00:27:37 --> 00:27:39 anecdotally underutilized in the clinic i
00:27:39 --> 00:27:41 think so very cool to see and i
00:27:41 --> 00:27:43 would draw the reader's attention to that
00:27:43 --> 00:27:45 appendix i thought it was really helpful
00:27:47 --> 00:27:51 You mentioned evidence-based references to
00:27:52 --> 00:27:54 driving decisions on what interventions to
00:27:54 --> 00:27:54 use.
00:27:55 --> 00:27:56 In the article,
00:27:56 --> 00:27:57 it talks about the clinical practice
00:27:58 --> 00:27:58 guideline.
00:27:59 --> 00:28:01 And can you just maybe speak to how
00:28:01 --> 00:28:04 much or how little that informed some of
00:28:04 --> 00:28:07 these decisions and maybe how that guided
00:28:08 --> 00:28:09 the more thorough explanations?
00:28:09 --> 00:28:11 Yeah.
00:28:11 --> 00:28:12 Well,
00:28:12 --> 00:28:14 so at the time that this was designed,
00:28:15 --> 00:28:19 I believe it was after the first
00:28:19 --> 00:28:20 guideline.
00:28:20 --> 00:28:21 The second guideline,
00:28:21 --> 00:28:23 I don't think had been published quite
00:28:23 --> 00:28:23 yet.
00:28:24 --> 00:28:25 So they're actually,
00:28:25 --> 00:28:26 when we designed this study,
00:28:26 --> 00:28:28 we felt like there was a lot of
00:28:28 --> 00:28:30 missing gaps and particularly in the
00:28:30 --> 00:28:31 manual intervention area.
00:28:31 --> 00:28:33 I think at that time there was only
00:28:33 --> 00:28:34 like expert level evidence,
00:28:34 --> 00:28:36 but I knew of a lot of articles
00:28:36 --> 00:28:37 that were coming out
00:28:38 --> 00:28:39 of which we've referenced that kind of
00:28:39 --> 00:28:41 supported the fact that, hey,
00:28:41 --> 00:28:42 this seems to be beneficial.
00:28:43 --> 00:28:43 And again,
00:28:43 --> 00:28:45 our clinical experience seemed to
00:28:45 --> 00:28:48 corroborate that and to indicate that,
00:28:48 --> 00:28:48 man,
00:28:48 --> 00:28:50 these patients really do better when we
00:28:50 --> 00:28:51 use manual therapy,
00:28:51 --> 00:28:53 plus just the support of how the manual
00:28:53 --> 00:28:56 therapy can inform our decision-making by
00:28:56 --> 00:28:57 getting within sessions treatment,
00:28:58 --> 00:28:58 or sorry,
00:28:58 --> 00:29:02 within session changes that can then
00:29:02 --> 00:29:02 direct.
00:29:02 --> 00:29:04 So if they do respond to an accessory
00:29:04 --> 00:29:06 mobilization of the talocrural joint,
00:29:07 --> 00:29:09 it helps us to understand that, boy,
00:29:09 --> 00:29:12 improving their dorsiflexion is going to
00:29:12 --> 00:29:13 really help this patient.
00:29:13 --> 00:29:15 And I'm going to really enforce that in
00:29:15 --> 00:29:16 their home program.
00:29:18 --> 00:29:20 So we certainly tried to revolve things
00:29:20 --> 00:29:22 around the guidelines as much as possible.
00:29:22 --> 00:29:24 But again, at the time, and remember,
00:29:24 --> 00:29:25 this is now we're talking the design of
00:29:25 --> 00:29:29 the study was kind of a while ago.
00:29:29 --> 00:29:30 I still feel like what we did is
00:29:30 --> 00:29:32 pretty relevant.
00:29:34 --> 00:29:34 Of course,
00:29:34 --> 00:29:36 there's always new little tricks and
00:29:36 --> 00:29:38 techniques that kind of come out and
00:29:38 --> 00:29:38 modifications.
00:29:40 --> 00:29:41 One of the things that comes to mind
00:29:41 --> 00:29:42 is in my practice,
00:29:42 --> 00:29:43 I used a lot of trigger point dry
00:29:43 --> 00:29:45 needling at the time I was trained,
00:29:46 --> 00:29:47 but very recently trained.
00:29:47 --> 00:29:50 And so we decided it was still fairly
00:29:50 --> 00:29:51 new in the area.
00:29:51 --> 00:29:53 I was one of the first three physical
00:29:53 --> 00:29:55 therapists doing that in our state.
00:29:56 --> 00:29:57 So we said, well,
00:29:57 --> 00:29:58 maybe we shouldn't be doing this in the
00:29:58 --> 00:30:00 study because not very many people will
00:30:00 --> 00:30:01 know how to do it.
00:30:01 --> 00:30:02 But nowadays, you know,
00:30:02 --> 00:30:03 I think everybody does.
00:30:04 --> 00:30:05 So I think you can kind of look
00:30:05 --> 00:30:06 at the trigger point interventions we did.
00:30:07 --> 00:30:09 And the study doesn't support that
00:30:09 --> 00:30:10 necessarily.
00:30:10 --> 00:30:11 But, you know,
00:30:11 --> 00:30:12 I think you could infer that that would
00:30:12 --> 00:30:14 be an intervention that could be included
00:30:14 --> 00:30:18 and to use as an update to what
00:30:18 --> 00:30:19 we didn't necessarily include in this
00:30:19 --> 00:30:20 study.
00:30:20 --> 00:30:21 Yeah, that's awesome.
00:30:22 --> 00:30:24 I thought because the guidelines are great
00:30:24 --> 00:30:26 and I use them frequently and I think
00:30:26 --> 00:30:27 most people are encouraged to.
00:30:29 --> 00:30:31 But they're a guideline.
00:30:31 --> 00:30:34 They don't give the detail of like that
00:30:34 --> 00:30:36 you illustrated in your articles,
00:30:36 --> 00:30:38 which I find a really good reference for
00:30:38 --> 00:30:39 different presentations.
00:30:40 --> 00:30:42 So thank you for that.
00:30:43 --> 00:30:43 I will say, though,
00:30:43 --> 00:30:46 that the core of our treatment was very
00:30:46 --> 00:30:47 much so the guidelines.
00:30:47 --> 00:30:49 And I think that still is kind of
00:30:50 --> 00:30:50 the case.
00:30:50 --> 00:30:51 That still is the core.
00:30:51 --> 00:30:53 And then in certain cases,
00:30:53 --> 00:30:57 there's evidence that supports why maybe
00:30:57 --> 00:31:00 that core is included plus a little bit
00:31:01 --> 00:31:02 of a different direction.
00:31:02 --> 00:31:02 Yeah.
00:31:03 --> 00:31:04 Yeah, that's great.
00:31:04 --> 00:31:06 Can you talk a little bit about,
00:31:06 --> 00:31:09 because like just in my clinical
00:31:09 --> 00:31:11 experience treating foot and ankle,
00:31:11 --> 00:31:13 given the persistence of that pain,
00:31:13 --> 00:31:16 there can be some chronicity to that
00:31:16 --> 00:31:19 experience like sensitization to the
00:31:19 --> 00:31:20 tissues locally,
00:31:21 --> 00:31:23 more central sensitization processes.
00:31:24 --> 00:31:27 Can you talk a little bit about how
00:31:27 --> 00:31:29 that was considered in the patients that
00:31:29 --> 00:31:30 were presenting to you?
00:31:30 --> 00:31:34 And were any of these treatments maybe
00:31:34 --> 00:31:36 delivered differently or tailored towards
00:31:36 --> 00:31:38 that presentation versus a more acute
00:31:38 --> 00:31:39 nociceptive presentation?
00:31:42 --> 00:31:44 So we certainly,
00:31:44 --> 00:31:48 our intervention was informed by
00:31:48 --> 00:31:50 considering pain mechanisms.
00:31:51 --> 00:31:54 And we did include, so for example,
00:31:54 --> 00:31:55 we did include pain neuroscience
00:31:55 --> 00:31:56 education.
00:31:56 --> 00:31:57 So part of our treatment included
00:31:57 --> 00:31:58 education.
00:31:58 --> 00:32:02 That's always, I think in any trial,
00:32:03 --> 00:32:05 it's kind of hard to control and kind
00:32:05 --> 00:32:06 of hard to appreciate how much of an
00:32:06 --> 00:32:08 effect that kind of has on things.
00:32:09 --> 00:32:11 But certainly while we were doing our
00:32:11 --> 00:32:12 manual intervention or exercise
00:32:12 --> 00:32:13 intervention,
00:32:13 --> 00:32:16 we were discussing their presentation and
00:32:17 --> 00:32:18 factors that are contributing to their
00:32:18 --> 00:32:18 pain.
00:32:19 --> 00:32:20 One of the things that we described a
00:32:20 --> 00:32:21 little bit,
00:32:21 --> 00:32:23 not that we were giving a lot of
00:32:23 --> 00:32:24 advice on weight management,
00:32:24 --> 00:32:26 but there was a lot of discussion around
00:32:26 --> 00:32:27 the time this study was designed.
00:32:28 --> 00:32:29 uh, around, you know,
00:32:29 --> 00:32:32 weight management and, and, and, and,
00:32:32 --> 00:32:33 and some of those factors.
00:32:34 --> 00:32:35 Um,
00:32:35 --> 00:32:37 so we certainly provided some education,
00:32:37 --> 00:32:39 uh, that revolved around,
00:32:40 --> 00:32:44 things that could more positively affect
00:32:44 --> 00:32:45 their pain experience and help them to
00:32:46 --> 00:32:47 understand their pain experience,
00:32:47 --> 00:32:50 as well as the prognosis, you know,
00:32:51 --> 00:32:52 making sure their expectations aren't that
00:32:52 --> 00:32:53 they're going to be better in two weeks
00:32:53 --> 00:32:56 after treatment or fully cured in two
00:32:56 --> 00:32:58 weeks when the literature supports that
00:32:58 --> 00:33:00 this could take up to a year, honestly.
00:33:00 --> 00:33:00 Now...
00:33:01 --> 00:33:03 I like to think with the approach that
00:33:03 --> 00:33:06 we took and which illustrates this and and
00:33:06 --> 00:33:07 things that we can do,
00:33:07 --> 00:33:08 we can improve that approach.
00:33:08 --> 00:33:10 And some of those estimates that say it
00:33:10 --> 00:33:12 can last a year are based on not
00:33:12 --> 00:33:13 getting this treatment.
00:33:13 --> 00:33:15 So I do think that we can reduce
00:33:15 --> 00:33:15 that.
00:33:15 --> 00:33:20 But I always like to kind of under
00:33:20 --> 00:33:22 promise and over deliver versus the
00:33:22 --> 00:33:22 opposite.
00:33:23 --> 00:33:26 So getting them on on the same page.
00:33:27 --> 00:33:28 So we definitely considered
00:33:30 --> 00:33:32 you know, some of the pain mechanisms.
00:33:32 --> 00:33:35 And that's also why we considered any
00:33:35 --> 00:33:38 potential patho-neurodynamic contributions
00:33:38 --> 00:33:39 to their symptoms.
00:33:39 --> 00:33:40 So, you know,
00:33:40 --> 00:33:42 if we were doing neurodynamic testing or
00:33:42 --> 00:33:45 if we found palpatory tenderness along the
00:33:45 --> 00:33:46 path of the nerve,
00:33:46 --> 00:33:47 we were certainly providing intervention
00:33:47 --> 00:33:50 at those areas to facilitate the nerve
00:33:50 --> 00:33:53 being as healthy as possible and hopefully
00:33:53 --> 00:33:55 reducing any potential for that to be
00:33:55 --> 00:33:56 contributing to their pain experience.
00:33:57 --> 00:33:58 Yeah, that's great.
00:33:59 --> 00:34:00 I think that's really helpful.
00:34:00 --> 00:34:02 And as I read through the article,
00:34:02 --> 00:34:04 it kind of came to light that
00:34:04 --> 00:34:05 decision-making I thought was great.
00:34:06 --> 00:34:09 Um, especially just given, uh, well,
00:34:09 --> 00:34:12 my fellowship training was very, um,
00:34:12 --> 00:34:13 very heavily, um,
00:34:14 --> 00:34:17 ingrained that process of like, uh,
00:34:17 --> 00:34:19 persistent pain and, um,
00:34:19 --> 00:34:21 just how that can affect different areas.
00:34:21 --> 00:34:21 So the,
00:34:21 --> 00:34:24 the heel is just a really good area
00:34:24 --> 00:34:25 that I think it illustrates it well.
00:34:26 --> 00:34:29 um with your you commented earlier so i
00:34:29 --> 00:34:31 don't mean to be too redundant but i'd
00:34:31 --> 00:34:34 love to hear your thought process on kind
00:34:34 --> 00:34:36 of using the check recheck asterisk sign
00:34:37 --> 00:34:39 and using that to differentiate between
00:34:41 --> 00:34:43 picking the foot and ankle as your primary
00:34:43 --> 00:34:46 source versus proximal sources as the area
00:34:46 --> 00:34:48 to target uh with your primary
00:34:48 --> 00:34:50 interventions like how did you choose
00:34:50 --> 00:34:51 proximal versus local
00:34:52 --> 00:34:54 So I would say just because our, again,
00:34:54 --> 00:34:55 this comes back to the guidelines.
00:34:55 --> 00:34:56 So I'm glad you kind of brought that
00:34:56 --> 00:34:57 up.
00:34:57 --> 00:34:58 So guidelines really support more of that
00:34:59 --> 00:34:59 local intervention,
00:35:00 --> 00:35:01 addressing impairments in the ankle and
00:35:01 --> 00:35:02 foot.
00:35:02 --> 00:35:04 And so I would say in almost all
00:35:04 --> 00:35:04 cases,
00:35:04 --> 00:35:06 we would definitely start there first and
00:35:06 --> 00:35:08 we would kind of see, you know, let's,
00:35:08 --> 00:35:10 let's find the impairments there first.
00:35:10 --> 00:35:11 Not that we didn't look elsewhere.
00:35:11 --> 00:35:13 We still screened our initial evaluation.
00:35:13 --> 00:35:14 We're trying to take a big picture
00:35:14 --> 00:35:17 overview first and then narrow down and
00:35:17 --> 00:35:18 identifying.
00:35:18 --> 00:35:21 you know, what impairments are A,
00:35:21 --> 00:35:23 most significant.
00:35:24 --> 00:35:25 So oftentimes as you kind of go through
00:35:26 --> 00:35:28 the process, you can kind of say, wow,
00:35:28 --> 00:35:30 the impairments in the ankle are kind of
00:35:30 --> 00:35:30 minor.
00:35:31 --> 00:35:32 but the impairments in the lumbar spine
00:35:33 --> 00:35:34 are major.
00:35:35 --> 00:35:38 So that might be something that would skew
00:35:38 --> 00:35:39 me to go up a little bit more,
00:35:39 --> 00:35:40 but I still,
00:35:40 --> 00:35:41 I wouldn't ignore that foot and ankle.
00:35:41 --> 00:35:43 I kind of want to do some intervention
00:35:43 --> 00:35:44 there to see what effect that they had,
00:35:45 --> 00:35:45 because again,
00:35:45 --> 00:35:47 that's the most guideline and
00:35:47 --> 00:35:48 evidence-based treatment is in that area.
00:35:50 --> 00:35:51 and then assessing their response.
00:35:51 --> 00:35:53 And then sometimes I would do that within
00:35:54 --> 00:35:54 a session,
00:35:54 --> 00:35:56 but it sometimes might be between
00:35:56 --> 00:35:56 sessions.
00:35:56 --> 00:35:58 So might just only treat the foot and
00:35:58 --> 00:36:01 ankle one session or treat kind of more
00:36:01 --> 00:36:01 locally.
00:36:02 --> 00:36:03 Next session they come back,
00:36:03 --> 00:36:03 I might start,
00:36:03 --> 00:36:05 if I had found some things in lumbar
00:36:05 --> 00:36:06 spine, I'm like, boy,
00:36:06 --> 00:36:07 your response to the foot and ankle was
00:36:07 --> 00:36:09 kind of mediocre,
00:36:10 --> 00:36:12 or maybe it didn't have any much of
00:36:12 --> 00:36:14 an effect when they come back or even
00:36:14 --> 00:36:14 within a session.
00:36:15 --> 00:36:16 So then I go up and I treat,
00:36:16 --> 00:36:17 you know,
00:36:17 --> 00:36:18 whatever the other most significant
00:36:18 --> 00:36:19 impairment was.
00:36:19 --> 00:36:21 And if we get a more substantial change,
00:36:21 --> 00:36:23 then to me that gives a little more
00:36:23 --> 00:36:26 credence that that's kind of one of the
00:36:26 --> 00:36:28 driving factors in their symptoms.
00:36:29 --> 00:36:30 And especially if we get that response on
00:36:30 --> 00:36:32 multiple occasions now.
00:36:33 --> 00:36:34 And I still feel like you can do
00:36:34 --> 00:36:37 that fairly well, even with, like I said,
00:36:37 --> 00:36:39 on average, I believe our visits were,
00:36:40 --> 00:36:42 say, around six visits per patient.
00:36:43 --> 00:36:43 Again,
00:36:44 --> 00:36:45 some patients had a little bit more.
00:36:45 --> 00:36:46 Actually,
00:36:46 --> 00:36:47 some patients had fewer than that.
00:36:48 --> 00:36:49 I still think you can do that reasonably
00:36:49 --> 00:36:51 well within that timeframe.
00:36:51 --> 00:36:52 And to me, that just adds
00:36:54 --> 00:36:56 more evidence to where the impairment is
00:36:56 --> 00:36:58 coming from and what they can dedicate
00:36:58 --> 00:36:59 their time working on.
00:36:59 --> 00:37:01 Because the other thing is we only have
00:37:01 --> 00:37:02 so much time in the clinic,
00:37:02 --> 00:37:03 but also our patients only have so much
00:37:03 --> 00:37:04 time out of there.
00:37:04 --> 00:37:05 So if I can just give them a
00:37:05 --> 00:37:07 handful of things to work on,
00:37:08 --> 00:37:09 I find that tends to work a lot
00:37:09 --> 00:37:10 better than, you know,
00:37:11 --> 00:37:13 we're throwing everything at them and
00:37:13 --> 00:37:15 they're doing a pretty bad job at all
00:37:15 --> 00:37:15 of them,
00:37:16 --> 00:37:18 doing a really good job at just a
00:37:18 --> 00:37:18 few of them.
00:37:18 --> 00:37:20 Yeah, I think that's awesome.
00:37:21 --> 00:37:21 Thank you.
00:37:22 --> 00:37:23 for kind of talking us through that
00:37:23 --> 00:37:26 because I think it's super helpful using
00:37:26 --> 00:37:28 that thought process.
00:37:28 --> 00:37:30 But then definitely when you have a
00:37:30 --> 00:37:32 complex case with so many impairments and
00:37:32 --> 00:37:32 factors,
00:37:32 --> 00:37:35 I think it's nice to take that approach
00:37:35 --> 00:37:36 of like take one primary,
00:37:36 --> 00:37:38 treat it and see if it changes so
00:37:38 --> 00:37:40 we don't cloud the whole scenario too
00:37:40 --> 00:37:41 much.
00:37:42 --> 00:37:45 So then kind of walking this back to
00:37:45 --> 00:37:46 that original article.
00:37:46 --> 00:37:48 So we just had a great discussion on
00:37:49 --> 00:37:52 how there was this original basically
00:37:52 --> 00:37:55 report about treating the foot and heel
00:37:55 --> 00:37:55 pain.
00:37:56 --> 00:37:58 And then there was a breakdown of the
00:37:58 --> 00:38:00 eight cases that presented differently and
00:38:00 --> 00:38:01 our manual interventions for those.
00:38:02 --> 00:38:05 And then that final kind of like piece
00:38:05 --> 00:38:06 to the original idea was the cost
00:38:07 --> 00:38:08 effectiveness study.
00:38:09 --> 00:38:09 Can we...
00:38:10 --> 00:38:11 Talk a little bit more.
00:38:11 --> 00:38:13 You gave a synopsis of like the how
00:38:13 --> 00:38:13 it turned out.
00:38:13 --> 00:38:15 But can you just talk to us again
00:38:15 --> 00:38:17 about the results and if it surprised you
00:38:17 --> 00:38:18 or not?
00:38:18 --> 00:38:21 And kind of how that goes together with
00:38:21 --> 00:38:23 how as a profession,
00:38:23 --> 00:38:25 we're trying to push ourselves as like a
00:38:25 --> 00:38:27 primary provider in that area.
00:38:27 --> 00:38:27 Yeah.
00:38:29 --> 00:38:31 So I would say as far as surprising,
00:38:32 --> 00:38:36 obviously I had some expectations and that
00:38:36 --> 00:38:38 we would add value and that we could
00:38:38 --> 00:38:39 produce better outcomes.
00:38:40 --> 00:38:41 at a lower cost.
00:38:42 --> 00:38:43 I guess I was maybe hoping it would
00:38:43 --> 00:38:45 be more of a slam dunk per se,
00:38:46 --> 00:38:48 but I think part of it is we
00:38:48 --> 00:38:50 did get ninety five participants in the
00:38:50 --> 00:38:50 study,
00:38:50 --> 00:38:52 which is which was really hard to do,
00:38:52 --> 00:38:53 to be honest,
00:38:53 --> 00:38:55 over a long period of time and probably
00:38:55 --> 00:38:57 was a little bit more than I should
00:38:57 --> 00:39:01 have tried to bite in a PhD program.
00:39:01 --> 00:39:03 But it's
00:39:03 --> 00:39:06 It's added years of enjoyment in getting
00:39:06 --> 00:39:08 to follow this up and to see some
00:39:08 --> 00:39:10 of the stuff come to fruition.
00:39:10 --> 00:39:13 But yeah, if we had a larger sample,
00:39:13 --> 00:39:14 I think we would have a little more
00:39:14 --> 00:39:15 confidence.
00:39:16 --> 00:39:17 But regardless,
00:39:17 --> 00:39:19 we did some sensitivity analyses.
00:39:20 --> 00:39:22 So again, the primary results,
00:39:22 --> 00:39:24 when we look at the base case,
00:39:24 --> 00:39:26 so everyone that was allocated into both
00:39:26 --> 00:39:28 of the groups kept them in those groups.
00:39:28 --> 00:39:29 We didn't exclude,
00:39:29 --> 00:39:31 we didn't take anyone and remove them from
00:39:31 --> 00:39:31 the data set,
00:39:31 --> 00:39:34 analyzed all the data and analyzed all of
00:39:34 --> 00:39:34 the cost,
00:39:34 --> 00:39:36 all of the cost data that we had
00:39:36 --> 00:39:36 available to us.
00:39:37 --> 00:39:38 which again,
00:39:38 --> 00:39:40 that would include the direct costs of the
00:39:40 --> 00:39:41 treatments,
00:39:41 --> 00:39:43 so the podiatry and the physical therapy
00:39:43 --> 00:39:43 treatments,
00:39:44 --> 00:39:45 but also if they saw their primary care
00:39:45 --> 00:39:47 physician for back pain,
00:39:47 --> 00:39:50 if they had a surgery,
00:39:50 --> 00:39:51 a bariatric surgery,
00:39:51 --> 00:39:52 a couple of the patients had bariatric
00:39:52 --> 00:39:53 surgeries,
00:39:53 --> 00:39:54 which we know that patients with plantar
00:39:54 --> 00:39:56 heel pain struggle with weight because
00:39:56 --> 00:39:57 they can't exercise.
00:39:58 --> 00:40:00 there's some other little interesting cost
00:40:00 --> 00:40:03 kind of things there too for things that
00:40:03 --> 00:40:05 could be somewhat indirectly related to
00:40:05 --> 00:40:07 their heel pain but anyway all the costs
00:40:07 --> 00:40:10 were included in that base case and we
00:40:10 --> 00:40:12 saw that the plus physical therapist
00:40:12 --> 00:40:16 approach uh was we had better outcomes so
00:40:16 --> 00:40:18 their quality of life so again the eq-d
00:40:19 --> 00:40:22 measures a person's quality of life uh and
00:40:22 --> 00:40:22 it
00:40:23 --> 00:40:25 basically we will index it to a zero
00:40:25 --> 00:40:27 to one scale where one is a year
00:40:27 --> 00:40:30 of optimal health and so we follow this
00:40:30 --> 00:40:32 up over three years so we have three
00:40:32 --> 00:40:34 years to where you know they could get
00:40:34 --> 00:40:36 a score from zero to one uh and
00:40:36 --> 00:40:38 we saw that those in the plus pt
00:40:38 --> 00:40:40 group uh rated their their health
00:40:42 --> 00:40:44 is their quality of their health to be
00:40:44 --> 00:40:46 greater in the end.
00:40:46 --> 00:40:47 And that was even as early as one
00:40:47 --> 00:40:49 year, we saw that kind of coming out.
00:40:51 --> 00:40:52 The cost as well at about one year,
00:40:52 --> 00:40:53 we saw the costs,
00:40:54 --> 00:40:57 all those costs being less in the plus
00:40:57 --> 00:40:58 physical therapist group.
00:40:58 --> 00:40:59 And then of course,
00:40:59 --> 00:41:00 when you look at that cumulatively over
00:41:00 --> 00:41:00 three years,
00:41:01 --> 00:41:03 uh, it was, it was cost savings.
00:41:03 --> 00:41:05 So when you put those two together,
00:41:05 --> 00:41:07 an equation of cost effectiveness,
00:41:07 --> 00:41:10 the costs of the plus physical therapist
00:41:10 --> 00:41:13 minus the podiatry, uh, and then the,
00:41:13 --> 00:41:16 sorry, the outcomes over the costs, uh,
00:41:16 --> 00:41:19 we saw that plus physical therapist was
00:41:19 --> 00:41:20 lower costs,
00:41:20 --> 00:41:22 plus that we saw a better outcome.
00:41:22 --> 00:41:25 Uh, and, uh,
00:41:26 --> 00:41:28 So the takeaways are is that, you know,
00:41:28 --> 00:41:30 we can collaborate with our podiatry
00:41:32 --> 00:41:34 partners to provide better care for our
00:41:34 --> 00:41:36 patients and they can achieve better
00:41:36 --> 00:41:37 outcomes.
00:41:37 --> 00:41:40 And many patients are,
00:41:40 --> 00:41:41 and I'd say podiatrists as well,
00:41:42 --> 00:41:44 the podiatrists are hesitant to send them
00:41:44 --> 00:41:44 to physical therapy.
00:41:45 --> 00:41:46 Because they know it's going to be an
00:41:46 --> 00:41:48 extra burden to their patients and they
00:41:48 --> 00:41:51 don't want to impose that greater burden
00:41:51 --> 00:41:52 on their patients, that greater cost,
00:41:52 --> 00:41:54 having them to go through all these
00:41:54 --> 00:41:56 additional visits and these additional
00:41:56 --> 00:41:58 costs and transportation costs and missing
00:41:58 --> 00:42:00 work and all the things that go into
00:42:00 --> 00:42:00 it.
00:42:01 --> 00:42:03 But hopefully they can use this data then
00:42:03 --> 00:42:04 to say, hey, yes,
00:42:04 --> 00:42:06 it might cost a little more up front.
00:42:06 --> 00:42:07 It's going to be a little more work
00:42:07 --> 00:42:07 up front.
00:42:08 --> 00:42:09 But in the long run,
00:42:10 --> 00:42:12 what could happen is this could go on
00:42:12 --> 00:42:13 and on and on,
00:42:13 --> 00:42:14 and you're gonna end up missing more work
00:42:14 --> 00:42:14 days.
00:42:15 --> 00:42:16 You might have other problems.
00:42:16 --> 00:42:17 You might end up not being able to
00:42:17 --> 00:42:18 manage your weight as well.
00:42:19 --> 00:42:21 There's a lot of downstream consequences
00:42:21 --> 00:42:22 that perhaps if we nip it earlier,
00:42:23 --> 00:42:26 then we won't have those downstream
00:42:26 --> 00:42:26 issues.
00:42:26 --> 00:42:28 And this study provides support to that,
00:42:29 --> 00:42:31 that yes, it was cost-effective.
00:42:31 --> 00:42:32 In the long run,
00:42:32 --> 00:42:34 it costs less and you got a greater
00:42:34 --> 00:42:34 value.
00:42:35 --> 00:42:37 So the base case showed that we did
00:42:37 --> 00:42:39 some sensitivity analysis because some of
00:42:39 --> 00:42:42 the patients, I mean, spoiler alert here,
00:42:42 --> 00:42:45 they didn't participate in the program in
00:42:45 --> 00:42:47 the plus physical therapist program.
00:42:47 --> 00:42:49 You know, I don't know about you,
00:42:49 --> 00:42:52 but I have a few patients that tend
00:42:52 --> 00:42:54 not to be adherent to the things we
00:42:54 --> 00:42:55 might recommend.
00:42:56 --> 00:42:57 no matter how hard I try.
00:42:58 --> 00:42:59 And this was the case in the study
00:42:59 --> 00:42:59 too.
00:42:59 --> 00:43:01 So we found a way to kind of
00:43:01 --> 00:43:01 say, okay, well,
00:43:01 --> 00:43:04 what if we remove them from there?
00:43:04 --> 00:43:04 And again,
00:43:04 --> 00:43:05 we saw a little bit better results,
00:43:05 --> 00:43:07 but still for the most part,
00:43:07 --> 00:43:09 we had the same, we had cost,
00:43:10 --> 00:43:11 we demonstrated cost effectiveness in the
00:43:11 --> 00:43:12 base case.
00:43:12 --> 00:43:14 We also demonstrated it when we removed
00:43:14 --> 00:43:16 those who did not complete with treatment.
00:43:16 --> 00:43:19 And then we also just looked at plantar
00:43:19 --> 00:43:20 heel pain costs.
00:43:20 --> 00:43:21 So we tried to say, okay,
00:43:21 --> 00:43:22 let's cut out all the other stuff
00:43:23 --> 00:43:24 what was just related to managing their
00:43:24 --> 00:43:25 plantar heel pain.
00:43:25 --> 00:43:26 And again,
00:43:26 --> 00:43:31 we saw very similar cost-effectiveness of
00:43:31 --> 00:43:33 which the plus physical therapist approach
00:43:33 --> 00:43:36 was more cost-effective in all of those
00:43:37 --> 00:43:38 sensitivity analyses.
00:43:39 --> 00:43:40 That's great.
00:43:40 --> 00:43:42 I mean, in my mind, right,
00:43:42 --> 00:43:43 obviously I'm biased because I'm a
00:43:43 --> 00:43:44 physical therapist,
00:43:44 --> 00:43:49 but it makes sense that if you see
00:43:49 --> 00:43:52 more preventative care, conservative care,
00:43:52 --> 00:43:57 less aggressive care maybe that follows
00:43:58 --> 00:43:59 evidence-based guidelines,
00:43:59 --> 00:44:00 you'd think it would give you better
00:44:00 --> 00:44:01 outcomes,
00:44:01 --> 00:44:02 but it's nice to have a study that
00:44:02 --> 00:44:03 supports that.
00:44:03 --> 00:44:04 So do you see,
00:44:05 --> 00:44:06 now that this has been out,
00:44:06 --> 00:44:08 have you seen it making changes in...
00:44:09 --> 00:44:13 the behavior of patients or podiatry or
00:44:13 --> 00:44:15 even other physical therapists and their
00:44:15 --> 00:44:18 approach or like, you know, marketing or.
00:44:19 --> 00:44:20 Yeah, it's a great question.
00:44:21 --> 00:44:21 And, you know,
00:44:22 --> 00:44:23 I've reflected on this a little bit.
00:44:23 --> 00:44:24 My practice is a little unique.
00:44:24 --> 00:44:26 I would say, oh,
00:44:26 --> 00:44:27 maybe it's not all that unique,
00:44:27 --> 00:44:32 but the majority of my patients are direct
00:44:32 --> 00:44:32 access.
00:44:32 --> 00:44:34 So not that I don't have anyone that's
00:44:34 --> 00:44:35 referred,
00:44:35 --> 00:44:36 but most of my patients are direct access.
00:44:36 --> 00:44:38 So it really would be nice,
00:44:38 --> 00:44:39 and I haven't had time to really look
00:44:39 --> 00:44:40 into this,
00:44:40 --> 00:44:41 but it would be nice to do some
00:44:41 --> 00:44:42 follow-up just to see if anything is
00:44:43 --> 00:44:43 changing there.
00:44:44 --> 00:44:46 Now, granted, this study just came out.
00:44:46 --> 00:44:48 You know, the outcome studies were out.
00:44:48 --> 00:44:49 The case series was out,
00:44:50 --> 00:44:51 has been out for a little bit now.
00:44:52 --> 00:44:54 So I don't really think there's enough
00:44:54 --> 00:44:56 time there to be much impact other than
00:44:56 --> 00:44:58 I would just like to think that even
00:44:58 --> 00:44:59 before this study came out,
00:44:59 --> 00:45:02 hopefully others were realizing this.
00:45:02 --> 00:45:02 Like you said,
00:45:02 --> 00:45:04 it kind of it seems like it makes
00:45:04 --> 00:45:05 a little bit of sense.
00:45:07 --> 00:45:09 And so I'd like to think that this
00:45:09 --> 00:45:10 will make some changes,
00:45:10 --> 00:45:11 but I'm not sure that we're seeing
00:45:11 --> 00:45:12 anything yet.
00:45:14 --> 00:45:16 Although I would love to hear from others
00:45:16 --> 00:45:17 who might be seeing something different,
00:45:17 --> 00:45:20 but also I'm hoping that we can be
00:45:20 --> 00:45:23 change agents with this information now
00:45:24 --> 00:45:24 and help
00:45:27 --> 00:45:30 you know help our patients who may not
00:45:30 --> 00:45:32 be getting uh the plus physical therapist
00:45:32 --> 00:45:34 approach who might need and benefit this
00:45:35 --> 00:45:38 and and maybe spreading the word uh will
00:45:38 --> 00:45:40 then help to make that shift and we'll
00:45:40 --> 00:45:41 start to see that in the coming years
00:45:42 --> 00:45:44 yeah i mean that's great and i i
00:45:44 --> 00:45:46 guess it's you know it's new so that's
00:45:46 --> 00:45:48 not the fairest question but so my
00:45:48 --> 00:45:50 follow-up to that i work in private
00:45:50 --> 00:45:50 practice
00:45:52 --> 00:45:54 So cultivating referral sources is a big
00:45:54 --> 00:45:57 part of my role at our clinic.
00:45:58 --> 00:46:00 So maybe just ask you to speculate on
00:46:01 --> 00:46:02 this a little bit or give some advice.
00:46:02 --> 00:46:05 Do you view this as a marketing tool?
00:46:05 --> 00:46:06 And do you have advice of how to
00:46:07 --> 00:46:07 use it?
00:46:09 --> 00:46:11 I see it as a good selling point
00:46:11 --> 00:46:13 of how we can work together and how
00:46:14 --> 00:46:16 we should be involved in more cases than
00:46:16 --> 00:46:16 seven percent.
00:46:17 --> 00:46:19 I could also see it as potentially
00:46:20 --> 00:46:22 competitive, you know, because in that,
00:46:22 --> 00:46:23 in the article,
00:46:23 --> 00:46:24 it talks about how people who went to
00:46:24 --> 00:46:26 PT went to the podiatry less often,
00:46:27 --> 00:46:29 but ultimately it was better for the
00:46:29 --> 00:46:29 patients.
00:46:30 --> 00:46:31 So do you have thoughts on that and
00:46:31 --> 00:46:33 how it could be implemented in more of
00:46:33 --> 00:46:35 the, like the private practice setting?
00:46:37 --> 00:46:39 Yeah, so I will say this, though.
00:46:39 --> 00:46:41 I don't think they necessarily saw the
00:46:41 --> 00:46:43 podiatrist a lot less.
00:46:43 --> 00:46:45 I feel like their average was even like
00:46:45 --> 00:46:46 two visits,
00:46:46 --> 00:46:48 even if you were just in that group.
00:46:48 --> 00:46:50 It might have been a little bit more.
00:46:50 --> 00:46:52 Don't quote me off the top of my
00:46:52 --> 00:46:52 head.
00:46:54 --> 00:46:56 I think it was maybe on average two
00:46:56 --> 00:46:57 compared to six in the plus physical
00:46:57 --> 00:46:58 therapist approach.
00:46:58 --> 00:47:01 So I don't think we'd be stealing a
00:47:01 --> 00:47:02 lot of business from them.
00:47:04 --> 00:47:06 And I would also suggest that as you
00:47:06 --> 00:47:07 kind of alluded to,
00:47:07 --> 00:47:08 that's not really the point.
00:47:08 --> 00:47:09 The point is,
00:47:10 --> 00:47:10 We both,
00:47:10 --> 00:47:12 podiatrists and physical therapists,
00:47:12 --> 00:47:13 want our patients to get better.
00:47:13 --> 00:47:15 And so if this is a way,
00:47:16 --> 00:47:18 if it was something else besides plus
00:47:18 --> 00:47:19 physical therapist,
00:47:19 --> 00:47:21 I think the podiatrist would be on board.
00:47:22 --> 00:47:23 I don't see any reason why they wouldn't
00:47:23 --> 00:47:24 be on board with this if it's put
00:47:25 --> 00:47:26 in that context.
00:47:26 --> 00:47:28 There are patients that we should be
00:47:28 --> 00:47:29 referring to our podiatrist because
00:47:29 --> 00:47:30 there's things that they can do that we
00:47:30 --> 00:47:31 can't.
00:47:32 --> 00:47:34 So I think it's a two-way street,
00:47:35 --> 00:47:36 and I think if we approach it that
00:47:36 --> 00:47:37 way, and like I said,
00:47:38 --> 00:47:40 this study really is an example of shared
00:47:40 --> 00:47:42 decision-making between the podiatrist,
00:47:42 --> 00:47:45 the patient, and the physical therapist,
00:47:45 --> 00:47:46 although some of them were kind of
00:47:46 --> 00:47:50 strongly encouraged to add a plus physical
00:47:50 --> 00:47:52 therapist approach to their treatment.
00:47:53 --> 00:47:56 But yeah, in my opinion,
00:47:56 --> 00:47:58 maybe I'm overly optimistic.
00:47:58 --> 00:48:00 I see nothing but a win-win in this
00:48:00 --> 00:48:02 case because they're still going to go
00:48:02 --> 00:48:05 see, they are still the foot experts,
00:48:05 --> 00:48:05 right?
00:48:05 --> 00:48:08 A podiatrist is still known for their
00:48:08 --> 00:48:09 expertise in the foot.
00:48:09 --> 00:48:11 Patients are still going to go see them.
00:48:12 --> 00:48:14 And if they see us as well,
00:48:16 --> 00:48:17 more patients, unfortunately,
00:48:17 --> 00:48:19 this is a very common condition and I
00:48:19 --> 00:48:21 don't see it going away anytime soon.
00:48:22 --> 00:48:23 But we'd like to try to decrease the
00:48:23 --> 00:48:28 repeat offenders and the longer disability
00:48:28 --> 00:48:29 that's associated with it.
00:48:30 --> 00:48:31 It's a great point.
00:48:31 --> 00:48:33 And thank you for the clarification on
00:48:33 --> 00:48:33 that.
00:48:33 --> 00:48:36 That really does help understand like
00:48:36 --> 00:48:37 keeping it all in context.
00:48:37 --> 00:48:38 So thank you.
00:48:40 --> 00:48:40 Okay.
00:48:40 --> 00:48:44 So Shane, I think this has been great.
00:48:44 --> 00:48:45 One of the things we do here at
00:48:45 --> 00:48:47 the very end is just like a take-home
00:48:47 --> 00:48:50 message or like if there is one thing
00:48:50 --> 00:48:52 or one comment you had that you wanted
00:48:52 --> 00:48:54 all the listeners to take away,
00:48:54 --> 00:48:56 could you please just share us with that
00:48:56 --> 00:48:57 message?
00:48:58 --> 00:48:59 Yeah, thanks.
00:48:59 --> 00:49:00 And again, thanks for having me on.
00:49:00 --> 00:49:02 This has been a great conversation.
00:49:04 --> 00:49:07 I think we just discussed probably
00:49:07 --> 00:49:08 something that I think is good for
00:49:08 --> 00:49:10 everyone to kind of reflect on,
00:49:10 --> 00:49:12 and that's the collaboration with our
00:49:12 --> 00:49:13 healthcare partners.
00:49:13 --> 00:49:16 And it's really for the betterment of our
00:49:16 --> 00:49:16 patients.
00:49:16 --> 00:49:18 So if they need to see a dietician,
00:49:19 --> 00:49:20 if we don't have the expertise in that
00:49:20 --> 00:49:20 area,
00:49:20 --> 00:49:22 and that's gonna help them manage their
00:49:22 --> 00:49:23 weight, then we need to work with them.
00:49:23 --> 00:49:25 If we need to work with a podiatrist
00:49:25 --> 00:49:27 because they do shockwave therapy,
00:49:27 --> 00:49:29 or they perhaps might need an injection to
00:49:29 --> 00:49:31 give us a window of opportunity based on
00:49:31 --> 00:49:32 what's going on,
00:49:33 --> 00:49:34 or maybe they do need some specialized
00:49:34 --> 00:49:37 foot orthoses for a while that we can
00:49:37 --> 00:49:39 then use to complement our treatment with
00:49:39 --> 00:49:39 too.
00:49:39 --> 00:49:42 I think it's important that we make sure
00:49:42 --> 00:49:43 to continue to work together
00:49:43 --> 00:49:44 collaboratively.
00:49:44 --> 00:49:46 I'd like to think that this is to
00:49:46 --> 00:49:48 some extent an example of that and how
00:49:48 --> 00:49:50 we can be better together
00:49:50 --> 00:49:53 than necessarily in isolation and i know
00:49:53 --> 00:49:55 we don't know what the isolated plus uh
00:49:55 --> 00:49:58 sorry isolated physical therapy arm might
00:49:58 --> 00:50:00 have been and we can suppose what that
00:50:00 --> 00:50:02 is but but again i still feel like
00:50:02 --> 00:50:03 there's there's there's things we can do
00:50:04 --> 00:50:07 uh together and then the other part which
00:50:07 --> 00:50:09 is an interest of mine that i continue
00:50:09 --> 00:50:12 to explore and that is the strengthening
00:50:12 --> 00:50:14 part of it i feel like in in
00:50:14 --> 00:50:16 plantar heel pain uh strengthening has
00:50:16 --> 00:50:18 been underutilized and underdosed
00:50:19 --> 00:50:21 And I would suggest that we shouldn't be
00:50:21 --> 00:50:26 afraid to utilize those interventions in
00:50:26 --> 00:50:28 this population as well if you do find
00:50:28 --> 00:50:30 yourself not utilizing them commonly.
00:50:31 --> 00:50:32 Not to undervalue manual intervention.
00:50:32 --> 00:50:35 I know this is a podcast through the
00:50:35 --> 00:50:35 AOMT.
00:50:36 --> 00:50:38 It's definitely of high value here.
00:50:39 --> 00:50:41 I see plantar heel pain being very similar
00:50:41 --> 00:50:43 to low back.
00:50:43 --> 00:50:43 So I would say...
00:50:44 --> 00:50:45 Uh,
00:50:45 --> 00:50:46 plantar heel pain is the low back pain
00:50:47 --> 00:50:47 of the lower extremity.
00:50:48 --> 00:50:49 So a lot of the approaches that we
00:50:49 --> 00:50:51 take in the lumbar spine, uh,
00:50:51 --> 00:50:54 I think can be very similarly applied, uh,
00:50:54 --> 00:50:56 in, uh, persons with plantar heel pain.
00:50:57 --> 00:50:58 That's awesome.
00:50:58 --> 00:50:59 Um,
00:50:59 --> 00:51:01 thank you so much for taking your time
00:51:01 --> 00:51:03 and sharing your expertise and for doing
00:51:03 --> 00:51:05 all this work to support the profession.
00:51:05 --> 00:51:06 I mean, this stuff is,
00:51:07 --> 00:51:08 we can't do what we want to do
00:51:08 --> 00:51:08 without it.
00:51:08 --> 00:51:09 So thank you so much.
00:51:10 --> 00:51:10 Yeah.
00:51:10 --> 00:51:11 Thank you.
00:51:12 --> 00:51:13 All right.
00:51:13 --> 00:51:13 All right.
00:51:13 --> 00:51:14 Thank you, listeners.
00:51:14 --> 00:51:16 That's today's episode of Hands On,
00:51:16 --> 00:51:18 Hands Off podcast.