Table 2

Qualitative analysis of expert interview data pertaining to diagnosis and patient education

Findings Illustrative quotes
Theme 1: diagnosis
History
 Overview of key elements to exploreHigh repetitive use versus change of use; mechanical history essential to establish; rest-activity balance important; typically insidious onset but important to check injury; importance of ruling out other causes (inflammatory, tendinopathy and neuropathic masqueraders); reduction with movement.Q: If you have had an increase in weight, and that’s why you’ve got your heel pain, then that’s probably a point of discussion.11
Q: Was there an acute incident, to rule out fat pad contusion?10
Q: Those for whom it is part of a systemic arthritis are generally younger because seronegative arthropathy is often in a younger age group.9
 Relative importanceKey factor in establishing diagnosis; sets priorities for physical and imaging.Q: The primary diagnosis, when you first see someone, is generally clinical.14
Q: History essentially nails the diagnosis.8
Q: Only time I would really go for ultrasound would be if I am suspecting a tear or a rupture.8
 Presentation of painam pain pathognomic; first step pain most informative; pain after inactivity; well-localised to medial-inferior heel; worse at start and at end/after aggravating activity; description as sharp at worst versus ache at other times; mechanical versus psychosocial.Q: Very localised pain at the medial tubercle of the calcaneum.3
Q: First steps in the morning … after sitting for a long time … very good indication.4
Q: …Out of bed in the morning it’s like walking on shattered glass or walking on needles and pins.2
 SubgroupsLean versus high BMI; highly active versus relatively inactive; profession may indicate risk; overweight and standing job a particular risk.Q: One group is those with high BMI, and they stand up at work 7–8 hours a day, and other group is the lean runner maybe doing too much too soon.2
Q: You also have these people standing a lot standing 8 hours a day at their working place.6
Q: Take a good history … profession and their sport and fitness regime per week.8
Examination
 Physical testingPalpation at inferior medial heel (PF origin) or close to; check for ruptures; look for compensation movements; calf flexibility a key element.Q: I could leave out the US scan, but I would always do a through history on the patient, and palpate the area.4
Q: Also check their calf inflexibility.8
Q: Activate windlass mechanism to see if plantar fascia tightens.2
 Structures of interestConsider all aspects of fascia; consider old injuries (medial, lateral, distal); tendinopathy, neuropathy and bone key differentials.Q: Squeeze the calcaneus … if that causes some discomfort then I assume that there’s probably some bony oedema.11
Q: Dorsiflex the hallux, dorsiflex the ankle … start distally and palpate down the plantar fascia and work towards its origin.10
Q: Do some physical testing, I rule out other tendinopathy in the area.5
Imaging
 Decisions to use imagingUse is confirmatory not diagnostic; availability and specialty may dictate use; subordinate to history and examination.Q: US helps look at specific portion of fascia; check for tears and fibromas.8
Q: If I do an US, diagnostic US in someone, I cannot tell them that they have PF, that’s how crazy it is.5
Q: I think a lot of people go wrong, they look at imaging and try diagnosing, but really it comes down to the subjective features and the clinical features.4
 Perceptions of utilitySensitivity and specificity questionable; MRI unclear versus useful for bone oedema; US useful to exclude tears and lumps; US dimensions more useful than Doppler; changes likely bilateral even if unilateral pain.Q: The more imaging work I do the more I realise that there are other things that are going on.7
Q: The other advantage is that MRI you can start to see there is inflammation, say, in the facets of the subtalar joint. You can start to see if there is some bone oedema.12
Q: For the more resistant or long-term cases, then an MRI would be my investigation of choice.14
Theme 2: patient education
Importance of patient educationEducation key to prevent recurrence; importance as for all musculoskeletal conditions; aetiology must be understood; key to patient engagement, self-management and treatment success; treatment rationale important for patient to learn; requires mixed communication methods; under-researched area; focus on key pain driver; relate to specific patient presentation; include physical and non-physical factors; reassure about positive long-term prognosis.Q: If we leave these maladaptive beliefs unchecked, then it will lead to chronicity.3
Q: If they understand what the problem is and the course of it then it’s easier to have compliance.6
Q: If you don’t address those issues then it could be that if you remove your orthotics, stop taping or stopped your stretching or whatever, the pain is just going to come back so that’s where the education side of things is really important.7
Q: Overarching thing is that you’ve got to individualise it for the person.11
Teaching about load managementA primary goal of treatment; consider both static and dynamic weight-bearing load; change of overall load a risk factor for exacerbation; focus on function by unbundling erroneous patient perception of pain and pathology link; useful for patient to understand and self-manage a stepped approach to load increase with guidance; weight loss and associated metabolic factors poorly understood but impact on load management approach; need to address weight sensitively; therapists may not have weight management skills; key therapeutic effect mediator.Q: Load tolerance is probably a good way to describe the key treatment.3
Q: Obviously, there’s more load if you’ve got more weight, so if we can reduce that it’s going to help reduce the load on the plantar fascia.1
Q: Get down to business and talk to him about his training programme and talk about how many miles they do a week.2
Advice on footwearComfort is key modification guide; consider softness, shock absorption, rearfoot to forefoot drop and support; new shoes need to be socially acceptable; can use to offload tissue.Q: Getting patients into good footwear that has a small heel on it, because it takes the tension off the calf muscle and therefore the fascia, and having good cushioning or shock absorbency, are some key factors.14
Q: I don’t think minimalist (footwear) is made for everybody.13
  • BMI, body mass index; US, ultrasound.