Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

Physical therapist decision-making in managing

plantar heel pain: cases from a pragmatic
randomized clinical trial

Shane McClinton PT, PhD, OCS, FAAOMPT, Bryan Heiderscheit PT, PhD,
Thomas G. McPoil PT, PhD & Timothy W. Flynn PT, PhD, OCS, FAAOMPT

To cite this article: Shane McClinton PT, PhD, OCS, FAAOMPT, Bryan Heiderscheit PT, PhD,
Thomas G. McPoil PT, PhD & Timothy W. Flynn PT, PhD, OCS, FAAOMPT (2018): Physical
therapist decision-making in managing plantar heel pain: cases from a pragmatic randomized
clinical trial, Physiotherapy Theory and Practice, DOI: 10.1080/09593985.2018.1490941

To link to this article: https://doi.org/10.1080/09593985.2018.1490941

Published online: 06 Jul 2018.

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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2018.1490941

CASE REPORT

Physical therapist decision-making in managing plantar heel pain: cases from a

pragmatic randomized clinical trial
Shane McClinton PT, PhD, OCS, FAAOMPT a, Bryan Heiderscheit PT, PhDb, Thomas G. McPoil PT, PhDc,
and Timothy W. Flynn PT, PhD, OCS, FAAOMPTd
a
Doctor of Physical Therapy Program, Des Moines University, Des Moines, IA, USA; bDepartments of Orthopedics & Rehabilitation and
Biomedical Engineering, and Doctor of Physical Therapy Program, University of Wisconsin-Madison, Madison, WI, USA; cSchool of Physical
Therapy, Regis University, Denver, CO, USA; dSchool of Physical Therapy, South College, Knoxville, TN, USA

ABSTRACT ARTICLE HISTORY

Introduction: Plantar heel pain (PHP) is a common condition managed by physical therapists that Received 13 November 2017
can, at times, be difficult to treat. Management of PHP is complicated by a variety of pathoana- Revised 23 May 2018
tomic features associated with PHP in addition to several treatment approaches with varying Accepted 30 May 2018
efficacy. Although clinical guidelines and clinical trial data support a general approach to manage- KEYWORDS
ment, the current literature is limited in case-specific descriptions of PHP management that Plantar fasciitis; clinical
addresses unique combinations of pathoanatomical, physical, and psychosocial factors that are reasoning; exercise; manual
associated with PHP. Purpose: The purpose of this case series is to describe physical therapist therapy; education; case
decision-making of individualized multimodal treatment for PHP cases presenting with varied series
clinical presentations. Treatment incorporated clinical guidelines and recent evidence including a
combination of manual therapy, patient education, stretching, resistance training, and neurody-
namic interventions. A common clinical decision-making framework was used to progress indivi-
dualized treatment from a focus on symptom modulation initially to increased load tolerance of
involved tissues and graded activity. In each case, patients met their individual goals and
demonstrated clinically meaningful improvements in pain, function, and global rating of change
that were maintained at the 1–2-year follow-up. Implications: This case series provides details of
physical therapist management of a variety of PHP clinical presentations that can be used to
complement clinical practice guidelines in the management of PHP.

Introduction McClinton, Weber, and Heiderscheit, 2018; Menz et al.,

2013; Riddle, Pulisic, Pidcoe, and Johnson, 2003; Schon,
Plantar heel pain (PHP) is the most common foot condition
Glennon, and Baxter, 1993; Wearing et al., 2006). Given the
seen by physical therapists (PTs) (McPoil et al., 2008;
multiple impairments and comorbidities identified in PHP,
Reischl, 2001). Although plantar fasciitis remains the most
a variety of treatment approaches are used by PTs indepen-
common term used by patients and many providers, the
dently or in collaboration with other healthcare providers.
term PHP encompasses a variety of pathoanatomical fea-
Clinical practice guidelines are available to help sum-
tures including plantar fascia inflammation, degeneration
marize existing evidence and guide clinical management of
or thickening, heel fat pad pathology, nerve irritation, and
PHP (Martin et al., 2014; McPoil et al., 2008). While the
heel spurs (Lemont, Ammirati, and Usen, 2003; Martin
clinical practice guidelines inform PT management of
et al., 2014; McPoil et al., 2008; Yi et al., 2011).
PHP, case reports can provide more details about indivi-
Additionally, individuals with PHP may present with
dual cases and clinical decision-making that cannot be
impairments in foot posture/mobility, ankle or hallux dor-
portrayed in clinical guidelines. Available case reports of
siflexion, weightbearing duration, lower leg/foot muscle
PHP management vary from a standard strategy of soft
performance, and neurodynamic function, as well as
tissue mobilization and stretching applied in all cases
comorbidities including stress, depression, obesity, and
(Looney, Srokose, Fernandez-de-las-Penas, and Cleland,
low back pain (Allen and Gross, 2003; Cotchett,
2011) to individual reports of various multimodal treat-
Whittaker, and Erbas, 2015; Irving, Cook, Young, and
ments and clinical decision-making (Klingman, 1999;
Menz, 2007; Kibler, Goldberg, and Chandler, 1991;
Meyer, Kulig, and Landel, 2002; Nguyen, 2010; Peplinski
McClinton, Collazo, Vincent, and Vardaxis, 2016;

CONTACT Shane McClinton, PT, PhD, OCS, FAAOMPT shane.mcclinton@dmu.edu Doctor of Physical Therapy Program, Des Moines University, Des
Moines, IA, USA.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp.
© 2018 Taylor & Francis
2 S. MCCLINTON ET AL.

and Irwin, 2010; Santos et al., 2016; Young, Walker,
Strunce, and Boyles, 2004). PHP case reports are limited
to the isolated management of one case or a few cases with
similar impairments although the impairments vary from
reduced foot posture (e.g., pronated) (Klingman, 1999;
Meyer, Kulig, and Landel, 2002; Peplinski and Irwin,
2010; Young, Walker, Strunce, and Boyles, 2004); foot,
ankle, and calf mobility (Klingman, 1999; Looney,
Srokose, Fernandez-de-las-Penas, and Cleland, 2011;
Meyer, Kulig, and Landel, 2002; Nguyen, 2010; Peplinski
and Irwin, 2010; Santos et al., 2016; Young, Walker,
Strunce, and Boyles, 2004); gait dysfunction (Klingman,
1999; Meyer, Kulig, and Landel, 2002; Peplinski and
Irwin, 2010; Young, Walker, Strunce, and Boyles, 2004);
abnormal neurodynamics (Klingman, 1999; Meyer, Kulig,
and Landel, 2002); and hip or posterior tibialis weakness
(Meyer, Kulig, and Landel, 2002; Santos et al., 2016). There
is limited literature that describes a management strategy
for individual cases with various local and proximal
impairments that incorporates clinical guidelines and
recent evidence including manual therapy (Ajimsha,
Binsu, and Chithra, 2014; Saban, Deutscher, and Ziv,
2014), patient education (Louw, Diener, Butler, and
Puentedura, 2011; Louw, Puentedura, and Mintken, 2012;
Louw, Zimney, Puentedura, and Diener, 2016), resistance
training (Kamonseki, Gonçalves, Yi, and Júnior, 2016;
Rathleff et al., 2015), and neurodynamic interventions
(Saban, Deutscher, and Ziv, 2014). Therefore, the purpose
of this case series is to describe the PT clinical decision-
making of individualized multimodal treatment for PHP
using a series of cases that presented with varied clinical
presentations.
Case description
Patients
Cases were nonconsecutive participants from a rando-
mized clinical trial that received treatment from a PT
between June 2014 and June 2016 (Table 1) (McClinton
et al., 2013). Cases that completed treatment provided
by a PT from this trial were selected to illustrate a
variety of clinical presentations and individualized
treatments that were common in the clinical trial.
Cases were selected to demonstrate common presenta-
tions such as calf soft tissue impairments (case 1);
dorsiflexion limitations (cases 1 and 2); hip weakness
affecting gait and foot function (case 3); limited lumbar,
hamstring, and/or sciatic/tibial neurodynamic mobility
(cases 4, 6, and 7); foot pronation and dynamic valgus
(case 5); foot and/or lower leg weakness (cases 1, 5, 6,
and 7); and knee impairments that affected foot func-
tion and pain (case 8). All cases initially presented to a
doctor of podiatric medicine (DPM) who diagnosed
PHP based on pain localized to the plantar heel that
was worse with the first step in the morning or after
prolonged sitting and pain that progressed with weight-
bearing activities. Patients demonstrated limitations in
body functions and structure, activity, and participation
consistent with the International Classification of
Functioning Disability and Health categories b28015
Pain in lower limb, b2804 Radiating pain in a segment
or region, s75023 Ligaments and fascia of ankle and
foot, s75028 Structure of ankle and foot, neural, d4500
Walking short distances, d4501 Walking long distances,
and d4154 Maintaining a standing position. Individuals
were excluded from the study if they had prior surgery
of the foot, ankle or lower leg, clinical signs of radicu-
lopathy, contraindications to manual therapy, plantar
fascia rupture, symptoms for longer than 1 year, or
were not between the ages of 18–70. Although the
prognosis for improvement in PHP with conservative
treatment is generally good (Martin et al., 2014), higher
body mass index (BMI) and longer symptom duration
have been associated with a limited prognosis (Ortega-
Avila et al., 2016; Wolgin, Cook, Graham, and Mauldin,
1994). Specifically, symptom duration longer than

Table 1. Characteristics of patients.

FPI* Symptom DF‡ (KE, KF)
†
Case Age Sex BMI (right, left) Involved side duration (days) Hours spent on feet/day (W, total) FABQ (PA, W) Right Left
1 46 ♀ 33.3 3, 5 Bilateral 360 0.25, 5 0,1 14, 27 13, 21
2 41 ♂ 33.9 5, 7 Left 243 0.5, 4 2,1 7, 18 4.5, 10
3 62 ♀ 35.1 0, 3 Right 60 5, 7 3,2 12, 15 9, 15
−
4 48 ♂ 35 3, 3 Left 40 0.5, 7 3,1 14, 21 15, 22
5 64 ♀ 26.2 4, 9 Right 180 NA, 8 4,1 7, 22 10, 25
6 68 ♂ 25.1 9, 6 Bilateral 30 NA, 4 2,0 4, 7 0, 4
7 62 ♀ 29.7 8, 6 Right 249 9, 15 2,1 8, 15 11, 15
8 57 ♀ 39.3 1, 3 Left 90 0.5, 1 3,0 18, 22 12, 21
*Foot posture category as defined by Redmond (2005), normal = 0–5, pronated = 6–9, highly pronated = 10+, supinated = −1–−4, highly supinated −5–−12.
†
Rated on a Likert scale where 0 = completely disagree and 4 = completely agree with screening questions for PA, “I should not do physical activities which
(might) make my pain worse,” and W, “I cannot do my normal work with my present pain.”
‡
Measured in prone as described by Riddle, Pulisic, Pidcoe, and Johnson (2003) but added a second measure with the knee flexed.
DF, dorsiflexion; FABQ, Fear Avoidance Beliefs Questionnaire; FPI, foot posture index; KE, knee extended; KF, knee flexed; NA, not applicable; PA, physical
activity; PT, physical Therapy; W, work
 PHYSIOTHERAPY THEORY AND PRACTICE 3

7 months is associated with decreased likelihood of
success to manual therapy and exercise provided by a
PT (McClinton, Cleland, and Flynn, 2015). Five out of
eight cases in this series had a BMI greater than 33 kg/
m2 and three out of eight had symptoms for more than
7 months (Table 1). This study was approved by the
Des Moines University and Rocky Mountain University
of Health Professions Review Boards. Verbal and writ-
ten consent to participate in the clinical trial and this
case series was obtained from each participant and the
rights of participants were protected. The cases from
this case series were part of a clinical trial that was
registered at ClinicalTrials.gov (NCT01865734).
Physical therapist
The primary PT who examined and treated all cases
had 13 years of clinical experience in orthopedic phy-
sical therapy, was a board-certified specialist in ortho-
pedic physical therapy, and was a Fellow of the
American Academy of Orthopaedic Manual Physical
Therapists.
Evaluation
Initial evaluation by the PT occurred between 5 and
24 days following the initial evaluation by the DPM
(Table 2). The PT collected information on factors
likely related to the patient’s PHP and treatment
including mechanism of onset, goals related to activity
and participation, BMI, and screening for fear-avoid-
ance beliefs (Hart et al., 2009). The PT examination
focused on identifying impairments in body structure
or function contributing to the patient’s PHP with an
emphasis of factors likely related to the onset mechan-
ism (e.g., increase in weightbearing activity, altered gait
due to knee pain or immobilization), more severe
impairments, and/or findings that were different from
the uninvolved side in unilateral cases. The examina-
tion was informed by clinical practice guidelines
(Martin et al., 2014; McPoil et al., 2008) and evidence
of risk factors and impairments commonly associated
with PHP as indicated below. The following was exam-
ined in every case: point of maximum tenderness;
assessment of trigger points in the calf and foot muscles
(Cotchett, Munteanu, and Landorf, 2014; Renan-
Ordine et al., 2011); observational gait quality; active
motion of the lower half using the Selective Functional
Movement Assessment (SFMA) (Glaws et al., 2014);
ankle and hallux metatarsophalangeal dorsiflexion
active range of motion (Allen, and Gross, 2003;
DiGiovanni et al., 2003); foot posture using the foot
posture index (FPI) (Redmond, 2005); and windlass
(Jack’s) and dorsiflexion/eversion tests (McPoil et al.,
2008). The SFMA was used to screen for impairments
in body structure and function proximal to the ankle
and foot. The lower half of the SFMA is performed in
standing and uses a four-item qualitative criterion to
determine quality of the following fundamental move-
ments: multi-segmental flexion when bending to touch
toes, multi-segmental extension when doing a back-
ward bend, multi-segmental rotation by twisting the
upper body with feet fixed, single leg stance, and squat-
ting deeply with feet straight and arms overhead.
Further screening of common impairments in PHP
was selected based on the case presentation and
included ankle plantar flexion performance: heel raise
test (Ross and Fontenot, 2000); rocker board plantar
flexion test (McClinton, Collazo, Vincent, and
Vardaxis, 2016); foot intrinsic testing (i.e. manual mus-
cle testing of intrinsic and extrinsic toe flexors or paper
grip test (McClinton, Collazo, Vincent, and Vardaxis,
2016); manual muscle and active motion testing of
ankle dorsiflexion, eversion and inversion; tibial nerve
palpation; and neurodynamic testing (Klingman, 1999;
Meyer, Kulig, and Landel, 2002). For example, if a

Table 2. Treatment visit and adherence details for each patient.

Adherence (6 week, 6 month, 1 year)†
# of visits # of visits Time until 1st visit with Duration of visits with Foot Exercises Exercises
Case with DPM with PT PT (days)* PT (weeks) Medication Footwear orthosis from DPM‡ from PT
1 2 6 7 6 9, 5, 10 0, 6, 10 5, 5, 10 5 10, 10, 10
2 1 3 21 6 8.5, 8.5, 9 9, 3, 3 8, 3, 2 8 9, 10, 10
3 1 5 9 6 NA 0, 8, 0 10, 8, 8.5 5 5.3, 8, 6.5
4 2 4 5 7 10, 9.7, 10 10, 10, 10 NA 3 9, 9, 10
5 2 9 24 15 NA 10, 9, 9 10, 10, 9 10 9.5, 9, 8.5
6 2 11 14 10 5, 10, 8 10, 8, 10 10, 10, 7 7 9, 8, 8.5
7 2 7 21 23 NA 9.8, 9.8, 9.8 10, 10, 10 NA 8, 9, 10
8 1 3 13 4 0, 0, 0 9.8, 10, 9 0, 0, 0 0 9.5, 10, 9.5
*Length of time between the initial evaluation by DPM and the first PT visit.
†
Rated on a numeric rating scale where 0 = no treatment completed and 10 = completed all treatment as instructed.
‡
Exercises from DPM only performed during the time between the initial evaluation by DPM and the first PT visit and therefore 6 month and 1 year adherence
is not applicable.
4 S. MCCLINTON ET AL.

patient reported ankle or foot weakness during daily
activities or demonstrated foot posture or function
associated with foot and lower leg muscle function
impairments (e.g. excessive pronation (Fiolkowski et
al, 2003; Headlee et al, 2008; Snook, 2001); and/or
decreased or delayed heel rise at pre-swing phase of
gait indicating plantar flexor insufficiency (Apti et al,
2016; Neptune, Kautz, and Zajac, 2001)), then foot and
lower leg muscle performance testing was performed.
Similarly, patients that reported symptoms proximal to
the heel or tenderness of Baxter’s nerve at the medial
aspect of the heel were screened for tibial nerve tender-
ness or abnormal tibial neurodynamics in addition to
calf trigger points. Examination of the knee, thigh, hip,
or lumbopelvic areas was performed if indicated.
Examination of regions proximal to the heel was
prompted by patient report of pain or problems in
the knee, thigh, hip, or low back. Another prompt for
proximal examination was proximal impairments iden-
tified during gait and SFMA screening that could con-
tribute to PHP (e.g., increased knee flexion during gait
that has been associated with altered plantar pressures
typical of PHP patients) (Harty, Soffe, O’Toole, and
Stephens, 2005). Although patients were part of a clin-
ical trial, examination and interventions were per-
formed under usual clinical circumstances. Therefore,
selection of appropriate tests and measures was at the
discretion of the PT and no special accommodations
were made to allow for additional time with the
patients for evaluation or treatment.
Outcome measures
Outcomes were assessed 6 weeks, 6 months, 1 year,
and, in some cases, 2 years following the initial
appointment with the DPM. The current, best, and
worst levels of pain over the prior week were measured
using an 11-point numeric pain rating scale (NPRS),
where 0 indicated no pain and 10 was the worst pain
imaginable. This three-item NPRS has test–retest
reliability equal to ICC = 0.61 (95% confidence interval
[CI]: 0.3, 0.77) and minimal clinically important differ-
ence (MCID) of 2 points (Childs, Piva, and Fritz, 2005;
Farrar et al., 2001). Functional level was captured using
the activities of daily living subscale of the foot and
ankle ability measure (FAAM), which is a 21-item
questionnaire scored from 0 to 100, where 0 represents
an inability to perform daily activities because of the
feet and ankles and 100 indicates no difficulty. The
FAAM has test–retest reliability equal to ICC = 0.89
and an MCID of 8 points (Martin et al., 2005). Patient-
perceived global improvement was assessed using the
global rating of change scale (GRC), where improve-
ment was ranked from −7 (a very great deal worse) to 0
(about the same) to +7 (a very great deal better)
(Jaeschke, Singer, and Guyatt, 1989). Scores equal to
or greater than + 5 (quite a bit better) have been used
as an indicator of clinical success in PHP (Looney,
Srokose, Fernandez-de-las-Penas, and Cleland, 2011;
McClinton, Cleland, and Flynn, 2015).
Intervention
The DPM initially provided education about the diag-
nosis, recommended wearing supportive shoes as much
as possible, prescribed medication and/or orthotics
(Table 3), and provided a handout that emphasized
calf and plantar foot stretches. As part of their routine
practice, the DPMs involved in this case series prescribe
a foot orthosis if the patient had not tried one already
and if they had a pronated foot type or excessive pro-
nation observed during walking. In addition, the DPMs
reserved prescription of custom foot orthosis for cases
that did not respond to over-the-counter orthosis. Each
DPM has a preferred over-the-counter foot orthosis
resulting in the variability in orthosis types prescribed
to the cases in this series (Table 3). During the first visit
with the PT, all patients received a review and indivi-
dualized modifications to the plantar fascia and calf
stretching initiated by the DPM. Additional

Table 3. Prescribed foot orthosis and/or medication by doctor of podiatric medicine (DPM).
Case Foot orthosis* prescribed by DPM Medication prescribed by DPM
1 Spenco RX®†: hard, non-posted molded, ¾ length with soft topcover Diclofenac and Medrol Dosepak
2 ProLab P3‡: hard, posted molded, full length with soft topcover OTC NSAID
3 None§ None
4 None§ Diclofenac
5 ProLab P3‡: hard, posted molded, full length with soft topcover None
6 None§ OTC NSAID
7 None§ None
8 ProLab P3‡: hard, posted molded, full length with soft topcover OTC NSAID
*Hard material was classified as a Shore A durometer rating of 93–99; soft was 23–51. Posting and molding categories as defined by Mills et al. (2010).
†
Spenco, Waco, TX.
‡
ProLab Orthotics, Napa, CA.
§
Patient was already using an OTC foot orthosis for at least 6 weeks prior to seeing the DPM.
OTC, over-the-counter; NSAID, non-steroidal anti-inflammatory drug.
 PHYSIOTHERAPY THEORY AND PRACTICE 5

intervention provided by the PT was based on impair-
ments and centered on each individual patient’s pre-
sentation, goals, and short-term treatment response.
Although intervention selection was individualized to
patient presentation, an evidence-based clinical deci-
sion-making framework was used in all cases
(Figure 1). Within this framework, interventions were
prioritized based on the most relevant local and prox-
imal impairments and modified based on short-term
response, treatment was progressed in phases (Table 4),
and patient education was emphasized in all phases to
facilitate patient understanding of their condition and
strategies to improve their PHP. Each aspect is
described in greater detail below.
Interventions were directed at the most significant
impairments (i.e., primary) based on the evaluation and
were subsequently modified based on symptom
response within or between treatment sessions (Cook,
Showalter, Kabbaz, and O’Halloran, 2012; Jones and
Rivett, 2004). Attention was first directed to the foot,
ankle, and lower leg in accordance with the quantity of
evidence of impairments and effective treatments
demonstrated in those areas in individuals with PHP
(Martin et al., 2014). In the absence of additional prox-
imal dysfunction identified in the examination or his-
tory, the entire treatment remained focused on the foot
and ankle region. For example, case 2 had limited
dorsiflexion identified using the ankle lunge test
(Bennell et al., 1998) and observed during gait analysis
without a history of proximal impairments, injury, or
evidence of dysfunction during SFMA and gait screen-
ing (Appendix A). Manual interventions were directed
to the ankle based on evidence of interventions used
effectively in PHP populations including ankle
dorsiflexion mobilization with and without movement
(non-weightbearing and weightbearing); ankle distrac-
tion thrust manipulation; and rearfoot medial glide
(Appendix C) (Cleland et al., 2009; DiGiovanni et al.,
2002; Young, Walker, Strunce, and Boyles, 2004). In
addition, mobilization of the calf (Appendix C) was
performed based on evidence of PHP symptom mod-
ulation (Ajimsha, Binsu, and Chithra, 2014; Looney,
Srokose, Fernandez-de-las-Penas, and Cleland, 2011;
Renan-Ordine et al., 2011) and the potential to improve
dorsiflexion mobility. During each session of manual
intervention, the patient reported immediate reduction
in PHP when walking. His home program was used to
reinforce the response to treatment by emphasizing
calf/dorsiflexion stretching, dorsiflexion lunge mobili-
zation with movement (Appendix B), and regularly
monitoring his progress at home using the ankle
lunge test (Bennell et al., 1998). In contrast to case 2,
case 8 had multiple local and regional impairments
including dorsiflexion limitation, dynamic valgus, and
limited knee extension on the involved side. While she
demonstrated a positive within-session change in pain
during walking following mobilization of the calf and
dorsiflexion mobilization, additional relief was
observed following knee extension mobilization and
neurodynamic mobilization emphasizing ankle dorsi-/
plantar flexion in full knee extension (Appendix C).
Knee interventions were informed by evidence of
increased and prolonged forefoot pressure when greater
knee flexion is used during walking (Harty, Soffe,
O’Toole, and Stephens, 2005) and the potential for
irritation of the tibial nerve in the popliteal fossa
(Alshami, Souvlis, and Coppieters, 2008; Klingman,
1999). Because of the response to within-session

Figure 1. Clinical decision-making framework used to guide individualized PHP examination and intervention. The three phases of
rehabilitation are directed and modified throughout the episode of care based on the patient’s response to intervention(s) and
alliance of the PT and patient’s ongoing assessment of the problem. The PT’s assessment is informed by PHP guidelines, current
evidence, and the patient’s examination findings (e.g., onset mechanism, BMI, and impairments [Appendix A]). Biopsychosocial
factors contributing to the patient’s assessment of the problem are included in the assessment and educational strategies (including
pain neuroscience) are used to bridge gaps between the PT and patient assessments of the problem. Interventions are directed at
the most significant local and or proximal impairments based on the evaluation and within- and between-session response to
intervention(s) .
6 S. MCCLINTON ET AL.

Table 4. Phases and progression of physical therapy treatment.

Phase Goals Criteria to advance to next phase Interventions
1 1. Decrease irritability 1. Mild (< 3/10) to moderate (4–6/10) pain (Boonstra et al., 2016) 1. Patient education
2. Education about condition 2. Dorsiflexion ≥ 10 degrees (measured in prone with knee 2. Address contributing factors (footwear/
and rehabilitation extended) (Riddle, Pulisic, Pidcoe, and Johnson, 2003), or inserts, posture, gait, neuro-dynamic or
3. Improve dorsiflexion symmetrical dorsiflexion to uninvolved side proximal impairments)
3. Exercise* – stretch/mobilization
4. Night splint†
5. Manual therapy
6. Taping
7. Modalities
2 1. Further reduction in pain 1. Mild (< 3/10) to no pain 1. Exercise*‡ – stretch and strength
2. Restore muscle performance 2. Single leg heel raise ≥ 12 repetitions (Kulig et al., 2009), or 2. Manual therapy‡
3. Minimize gait deviations symmetrical performance to the uninvolved side 3. Gait training
4. Enhance basic function(s) 3. Walking items on FAAM ≤ “slight difficulty”
3 1. Enhance higher level function Discharge when: 1. Progression of exercise
(s) including sport and Understanding of condition management and prevention and (a) 2. Sport/recreation specific training
recreational activities patient-specific goals met, (b) GRC ≥ “quite a bit better,” or (c) 3. Education on condition management and
2. Prevent recurrence plateau evident in GRC or FAAM scores prevention
*Included a home program with less than five exercises (Henry, Rosemond, and Eckert, 1999).
†
Night splint use considered for patients that had significant concern regarding their pain with the first step in the morning and were willing to wear
consistently for at least 1 month (Martin et al., 2014).
‡
Manual therapy during phase 2 will address residual impairments from phase 1 but phase 2 treatment will reflect greater volume of exercise interventions
than manual therapy compared to phase 1.
FAAM, foot and ankle ability measure; GRC, global rating of change scale.

changes to dorsiflexion and knee extension interven-
tions, her home program emphasized dorsiflexion
active range of motion, calf trigger point mobilization
with dorsiflexion, knee extension, and neurodynamic
exercises emphasizing knee extension followed by
dorsi-/plantar flexion (Appendix B). As she progressed
to phase 2 of her program, strengthening exercises
emphasized correction of her dynamic valgus tenden-
cies to reduce the potential influence of PHP due to
knee dysfunction.
Initial interventions in all cases were directed at the
foot, ankle, and lower leg but suspected contributing
factors from proximal areas were considered when
supported by the history, examination, and/or modula-
tion of PHP with treatment or testing of proximal
impairments. For example, at the second visit, after
initial management focused on manual therapy and
exercise for dorsiflexion and calf limitations, case 7
reported a history of lumbosacral pain ipsilateral to
her PHP. Further examination of the lumbosacral
region and peripheral nerves was performed based on
evidence of peripheral neuropathic contributions to
PHP (Alshami, Souvlis, and Coppieters, 2008;
Klingman, 1999; Meyer, Kulig, and Landel, 2002;
Schon, Glennon, and Baxter, 1993), high prevalence of
LBP in individuals with PHP (McClinton, Weber, and
Heiderscheit, 2018; Schon, Glennon, and Baxter, 1993;
Were, 2013), and changes in foot plantar pressure dis-
tribution during gait following lumbosacral manipula-
tion (Grassi et al., 2011; Méndez-Sánchez, González-
Iglesias, Sánchez-Sánchez, and Puente-González, 2014)
considering individuals with PHP commonly demon-
strate abnormal plantar pressure during gait (Phillips
and McClinton, 2017). Abnormal tibial neurodynamics
were found during supine tibial-bias straight leg raise
and limited mobility with tenderness on the involved
side at L4 and L5. Following lumbar rotation non-
thrust and thrust manipulation (Appendix C), greater
symmetry in neurodynamic testing was observed that
prompted including lumbar and neurodynamic inter-
ventions into her treatment plan. Initially, manipula-
tion/mobilization of the lumbar spine and
neurodynamic mobilization interventions was per-
formed in isolation, but was progressed to combined
lumbar/neurodynamic mobilization (Klingman, 1999;
Petersen and Scott, 2010) As treatment progressed to
phase 2, lumbar muscle performance impairments were
integrated along with exercises to improve foot and
lower leg muscle performance based on involved-side
weakness demonstrated during side plank performance.
Similarly, proximal interventions were included in the
treatment of cases 3–5. Lumbar and hip interventions
were integrated into treatment in case 3 based on a
history of back and hip injury combined with lumbar
and hip impairments that demonstrated additional
within- and between-session improvements to foot
and lower leg interventions. In case 4, lumbar and
posterior thigh interventions were integrated into treat-
ment based on response to interventions in the low
back and thigh that were informed by evidence of a
relationship between PHP and the low back
(McClinton, Weber, and Heiderscheit, 2018; Schon,
Glennon, and Baxter, 1993; Were, 2013) or posterior
thigh (Bolívar, Munuera, and Padillo, 2013; Labovitz,
Yu, and Kim, 2011). Low back and hip strengthening to
help reduce dynamic valgus (Figure 2) was performed
 PHYSIOTHERAPY THEORY AND PRACTICE 7

in case 5 informed by the relationship between PHP,

Figure 2. Example of increased dynamic knee valgus/medial
collapse (hip internal rotation and adduction with tibial internal
rotation, foot pronation, and foot abduction) observed during
squatting in cases 5 and 8.
hip weakness (i.e., control of adduction and internal
rotation), dynamic valgus, and pronation (Kamonseki,
Gonçalves, Yi, and Júnior, 2016; Khamis and Yizhar,
2007; Powers, 2003; Santos et al., 2016). In contrast,
lumbar intervention was not included with case 6 even
though he had a history of lumbar radiculopathy con-
tralateral to the involved PHP side. Lumbar interven-
tion was excluded because there were no impairments
identified in the lumbar region on examination
although he did have signs of abnormal tibial neurody-
namics that was hypothesized to be due to increased
pronation since increased pronation has demonstrated
increased tibial nerve tension in cadaver studies
(Daniels, Lau, and Hearn, 1998; Lau and Daniels,
1998). Therefore, tibial neurodynamic intervention
was integrated into treatment along with tape- and
exercise-based interventions to reduce pronation (e.g.,
short foot and heel raise resistance training [Appendix
B]) including attention to pronation during heel raise
training (Figure 3). Although local impairments were
addressed in cases 3, 4, 6, and 7, each of these cases
demonstrated proximal impairments known to be asso-
ciated with PHP that produced positive short-term
responses when treated. A positive short-term response
to proximal intervention prompted addition of proxi-
mal-based intervention to the initial primary focus on
local treatment.
All phases of treatment included education about
factors contributing to their PHP based on the exam-
ination including elevated body weight, that PHP is
responsive to treatment but can take up to a year to

Figure 3. Example of limited plantar flexion range (lower height of the medial malleolus on the right leg illustrated by the dashed
line) and increased external rotation and medial collapse of the right leg (illustrated by the apparent out-of-plane movement
between the foot and lower [solid lines]) on the right (involved) side during heel raise observed in cases 1, 4, 5, and 7 that was
corrected using short foot training during heel raise training. This example demonstrates the natural movement of the involved side
despite starting with both feet parallel to the wall and efforts to keep the pelvis facing the wall during the heel raise.
8 S. MCCLINTON ET AL.
fully resolve (DiGiovanni et al., 2006; Martin, Irrgang,
and Conti, 1998; Wolgin, Cook, Graham, and Mauldin,
1994), and pain neuroscience education (PNE). The
extent of PNE differed based on patient presentation
and an abbreviated PNE approach was used that inte-
grated education during manual therapy and exercise
interventions (Louw, Puentedura, and Mintken, 2012;
Zimney, Louw, and Puentedura, 2014). Abbreviated
PNE emphasized the role of pain as the body’s alarm
system that can remain sensitive even after tissues heal
and that pain is influenced by many factors including
failed treatments, uncertainty about why they have
pain, stress, concern for/lack of exercise, and job or
family issues (Louw, Puentedura, and Mintken, 2012).
Weight management was encouraged through efforts to
reduce PHP and achieve the patient’s exercise goals, but
limited dietary advice was provided. Patients were seen
by the PT 1 time per week, on average, and the time
between appointments was lengthened as the patient
demonstrated independence in self-directed manage-
ment in phases 2 and 3 (Table 4). Exercise interven-
tions were performed as a home program with initial
instruction, reassessment of performance, and progres-
sion occurring during clinic visits with the PT.
Individualized interventions according to the primary
impairments identified in the examination are found in
Appendix A with specific details of the manual therapy
and exercise interventions in Appendices B and C,
Figure 4. Outcomes of each case. FAAM, foot and ankle ability measure; GRC, global rating of change scale; NPRS, numeric pain
rating scale.
respectively. To achieve functional goals related to
walking and exercise, a graded activity approach was
used that progressed activities by approximately 10% of
the prior week’s volume including duration, frequency,
or intensity if it did not flare-up the patient’s symp-
toms. When possible, patients were given specific para-
meters to self-assess their progress relative to the
uninvolved side (where applicable) and the ankle
lunge test (Bennell et al., 1998), number of heel raises,
perceived flexibility of the foot, calf, or posterior thigh,
and duration of walking were used the most frequently.
Adherence to medication, footwear recommendations,
foot orthoses, and exercises prescribed by the DPM or
PT were reported by patients at each follow-up using a
numeric rating scale where 0 = no treatment completed
and 10 = completed all treatment as instructed.
Outcomes
All patients demonstrated clinically meaningful
improvements in NPRS, FAAM, and GRC that were
maintained at the 1–2-year follow-up (Figure 4).
Changes in NPRS ranged between 3–8.67/10 and
between 14–70% for the FAAM. Meaningful improve-
ment was achieved by 6 months after the first visit with
the DPM although cases 1, 2, 3, 4, and 7 demonstrated
meaningful improvement in 6 weeks. Patient adherence
to the interventions varied, but adherence to the

exercises prescribed by the PT was good (Table 2). All
cases achieved their individual goals following
treatment.
Positive within-session responses (defined as at least
a 2-point reduction in NPRS (Cook, Showalter, Kabbaz,
and O’Halloran, 2012)) during walking were observed
in response to specific interventions but varied between
patients and over the course of treatment. Every case
demonstrated a positive response to soft tissue (includ-
ing trigger point) mobilization of the calf and/or foot.
Cases 1, 2, 3, 5, and 8 also demonstrated positive
responses to ankle and/or rearfoot mobilization. Cases
4 and 6 had equally positive responses to neurodynamic
mobilization as they did calf/foot soft tissue mobiliza-
tion and case 7 had an equally positive response to low
back versus calf/soft tissue mobilization. Case 4, 5, and
7 reported positive reactions to heel raise training in
phases 2 and 3 of treatment. Cases 5–7 reported
reduced PHP with augmented low-Dye taping even
though they were already using foot orthoses.
Discussion
The cases in this series presented with a variety of local
and proximal impairments that is representative of the
multifactorial nature of PHP that frequently compli-
cates clinical management decisions. Meaningful
improvement that lasted 1–2 years was achieved in
individuals with a variety of impairments and prog-
nosis-limiting factors related to PHP such as obesity
and a long duration of symptoms (5/8 cases had a BMI
greater than 33 kg/m2 and symptoms from
90–360 days) (McClinton, Cleland, and Flynn, 2015;
Ortega-Avila et al., 2016; Wolgin, Cook, Graham, and
Mauldin, 1994). Treatment provided by the PT varied
between cases, but each case’s multimodal treatment
program was specifically structured using a clinical
decision-making framework (Figure 1) to select and
progress treatment from a core set of evidence-
informed interventions (Appendices B and C). Even
though cases were participants in a clinical trial, the
treatment program and circumstances were consistent
with contemporary PT practice, which is recommended
to improve generalizability to the “. . . real-world com-
plexity of providing physical therapy to individual
patients” (Bennell et al., 2011).
Treatment phases
An important part of the PT clinical decision-making
framework was the three phases used to help guide
progression of treatment (Figure 1, Table 4). The initial
phase of treatment used manual therapy, stretching,
PHYSIOTHERAPY THEORY AND PRACTICE 9
taping, and/or a night splint to modulate symptoms
based on evidence of short-term improvement with
these interventions (Ajimsha, Binsu, and Chithra,
2014; Looney, Srokose, Fernandez-de-las-Penas, and
Cleland, 2011; Martin et al., 2014; McPoil et al.,
2008). Phases 2 and 3 were directed at improved load
tolerance of involved tissues and graded return to activ-
ity (Rathleff et al., 2015; Rathleff and Thorborg, 2015).
Recently, significant improvements have been demon-
strated with a graded plantar fascia high-load resistance
training program at 3 months but improvements did
not extend to 1 year (Rathleff et al., 2015). Long-term
outcomes may be improved when a graded tissue load-
ing program is phased in with symptom modulation
interventions as illustrated in this case series. Further
investigation is needed to determine if an individua-
lized program that is progressed in phases is effective
and if such a program can lower PHP recurrence rates.
Individualized intervention
Interventions were selected based on individual impair-
ments and goals and progressed or modified based on
treatment response. In some cases, primary impair-
ments and consequently, the interventions were in
regions proximal to the foot and lower leg. For exam-
ple, case 5 responded well to inclusion of intervention
to the pelvis, hip, and knee (Appendix A) in her treat-
ment after not responding to treatment focused on
local impairments during a prior episode of physical
therapy treatment. Cases 3, 4, 6, and 7 also improved
with integration of proximal intervention to local inter-
ventions. Although there is evidence of regional inter-
dependence between PHP and proximal impairments,
only a few studies were found that included interven-
tions for mobility and/or strength directed at the knee
and hip in the management of PHP (Cleland et al.,
2009; Kamonseki, Gonçalves, Yi, and Júnior, 2016;
Santos et al., 2016) and no studies that demonstrate
benefit isolated to low back, hip, or knee intervention.
Proximal factors that may be important considerations
in individualized PHP management include evidence of
concomitant low back pain (Hagen et al., 2006;
McClinton, Weber, and Heiderscheit, 2018; Menz
et al., 2013; Schon, Glennon, and Baxter, 1993; Were,
2013), hamstring tightness (Bolívar, Munuera, and
Padillo, 2013; Labovitz, Yu, and Kim, 2011), increased
knee flexion during gait (Harty, Soffe, O’Toole, and
Stephens, 2005), hip weakness (Santos et al., 2016),
increased central sensitivity (Fernandez-Lao et al.,
2016), and influence of the pain neuromatrix on PHP
(Concerto et al., 2016). While the outcomes of this case
series cannot be directly attributed to an impairment-
10 S. MCCLINTON ET AL.
based approach informed by evidence of local factors
and regional interdependence, consideration of impair-
ments proximal to the lower leg in PHP management is
warranted.
Short-term patient response to guide treatment
Another important part of the clinical decision-making
framework in this case series was selection and mod-
ification of intervention based on the patient’s response
to treatment. A 2-point change in the NPRS was used
to determine a meaningful short-term change and this
amount of change has demonstrated association with
successful treatment at discharge (Cook, Showalter,
Kabbaz, and O’Halloran, 2012). Soft tissue mobilization
including trigger point of the calf and/or foot reduced
PHP during weightbearing in all cases and cases 1, 2, 3,
5, and 8 demonstrated positive responses to ankle and/
or rearfoot mobilization. Patient education was pro-
vided immediately following this response to treatment
to reinforce the potential for PHP to improve and the
importance of the phase 1 and 2 goals including the
home program. Response to augmented low-Dye tap-
ing was used to decrease symptoms and pronated foot
posture in cases 5–7. In addition, taping was used to
demonstrate the benefit of foot and lower leg resistance
training by teaching patients that improved muscle
strength will replace the need for tape. The decision
to use tape was influenced by static foot posture, foot
mobility during squat (e.g., pronation and foot external
rotation illustrated in Figure 2) or gait assessment, and
the potential for tape to modulate symptoms (e.g.,
reduce irritation of nervous and soft tissue structures
of the medial heel). Cases 5–7 demonstrated a pronated
foot posture identified by scoring between 6 and 9 on
the FPI (Redmond, 2005). Case 5 also demonstrated
excessive pronation during squatting (Figure 2). Cases
5 and 6 had excessive pronation during gait, and case 7
had abnormal tibial neurodynamics with reduced pain
during heel raise once tape was applied. Augmented
low-Dye taping has been suggested to inform the deci-
sion to use foot orthoses (Vicenzino, 2004), but all cases
in this series were prescribed foot orthoses by the DPM
or were already using orthoses. Therefore, short-term
benefit of taping was used by the PT to emphasize heel
raise training and foot exercises designed to improve
foot arch function and foot/lower leg muscle perfor-
mance (Appendix B) (Jung, Koh, and Kwon, 2011;
Kelly, Kuitunen, Racinais, and Cresswell, 2012; Lynn,
Padilla, and Tsang, 2012; Mulligan and Cook, 2013).
This approach may help to counteract loss of muscle
performance and altered muscle activity levels asso-
ciated with foot orthoses use (Dedieu et al., 2013;
McClinton, Collazo, Vincent, and Vardaxis, 2016;
Murley, Landorf, and Menz, 2010). In addition to
reduced symptoms, initial response to treatment was
used to confirm the relevance of impairments identified
in the examination. Improved PHP following interven-
tion directed at neurodynamic or low back mobility
impairments prompted inclusion of neurodynamic
(cases 4 and 6) and lumbar (case 7) interventions in
the treatment plan. Case 8 responded to knee mobiliza-
tion that prompted inclusion of knee intervention in
her treatment.
Patient education
Patient education provided by the PT may have influ-
enced outcomes and adherence. Education was pro-
vided at every phase of treatment and included
information about the diagnosis, prognosis, and PNE.
Every patient except for case 1 demonstrated elevated
fear-avoidance beliefs related to physical activity based
on the screening questions that may have affected base-
line activity levels and confidence in exercise interven-
tions (Hart et al., 2009). Pain-related fear of movement
has demonstrated a greater impact on disability in
individuals with foot and ankle conditions than other
risk factors including age, BMI, pain intensity, motion
limitations, or duration of symptoms (Lentz, Sutton,
Greenberg, and Bishop, 2010). Consequently, fear-
avoidance beliefs leading to decreased activity and
increased disability may contribute to increased depres-
sion, anxiety, and stress that has been associated with
PHP (Cotchett, Whittaker, and Erbas, 2015). Education
to improve the patient’s understanding of the problem
and reduce fear-avoidance beliefs may have helped to
achieve the relatively good adherence to exercise pre-
scribed by the PT and the outcomes. Pain neuroscience
concepts were integrated throughout treatment, which
may have added to any effects related to education.
PNE can decrease pain ratings, disability, and catastro-
phization, therefore contributing to improvement in
psychosocial factors related to PHP and treatment out-
comes (Cotchett, Munteanu, and Landorf, 2016;
Cotchett, Whittaker, and Erbas, 2015; Louw, Diener,
Butler, and Puentedura, 2011; Louw, Zimney,
Puentedura, and Diener, 2016).
Limitations
The cases in this uncontrolled case series were selected
(i.e., nonconsecutive) to demonstrate a variety of clin-
ical presentations in patients who completed an episode
of treatment directed by a PT. Therefore, the outcomes
and adherence ratings are not representative of the

entire pool of participants from the clinical trial or the
general population of individuals with PHP. Adherence
ratings were for all the exercises prescribed by the PT
and adherence to specific types of exercise such as
stretching versus resistance training are unable to dif-
ferentiated. The exact contribution or interaction of
DPM- and PT-directed interventions to the outcome
is unable to be determined by this case series. All
patients were treated by the same PT and it is unknown
if individualized treatment decisions or outcomes are
reproducible.
Conclusion
This case series describes a multimodal PT manage-
ment approach in individuals with diverse impairments
related to PHP. Although treatment varied between
individual cases, treatment was guided by an evi-
dence-based clinical decision-making framework that
included consideration of both local and regional influ-
ences on PHP and progressed treatment from a focus
on symptom modulation initially to increased load
tolerance of involved tissues and graded activity.
Education was intertwined with all phased of treatment
and included abbreviated PNE. Although the case series
design is unable to draw direct cause and effect con-
clusions, this case series illustrates that individuals with
a variety of local and regional impairments who fully
participated and completed an episode of treatment
with a PT achieved meaningful improvements in pain
and function for up to 1–2 years after treatment.
Further research is warranted to see if these results
are reproducible and effective compared to other treat-
ment approaches.
Acknowledgments
Thank you to the Des Moines University Foot and Ankle and
Physical Therapy Clinics, Sharon Johansen, Adam Phillips,
Ellen Barton, and Alec Standiford for their essential contri-
butions. Portions of this work was completed as part of PhD
dissertation research through Rocky Mountain University of
Health Professions.
Declaration of Interest
The authors report no conflicts of interest.
Funding
This work was supported by the Orthopaedic Section,
American Physical Therapy Association [not applicable];
Iowa Osteopathic Education Research Fund at Des Moines
University [09-16-03], Des Moines, IA.
PHYSIOTHERAPY THEORY AND PRACTICE 11
ORCID
Shane McClinton http://orcid.org/0000-0002-8655-2564
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 PHYSIOTHERAPY THEORY AND PRACTICE 15

Appendix A. Patient goals and presentation considered by the PT to tailor interventions to each
patient. Interventions listed were performed in addition to standardized treatment that included
treatment from the DPM (medication, orthotics [Table 3], plantar fascia/calf stretching handout)
and the PT (education, individualized instruction in plantar fascia and calf/dorsiflexion stretching).
Interventions are described in further detail in Appendices B and C and were progressed according
to the details provided in Table 4. Impairments listed below are of the involved side(s) unless
stated otherwise

Case 1: 46-year-old female with bilateral PHP for 360 days, BMI = 33.3 kg/m2, normal foot posture (FPI: right = 3, left = 5)* and low fear avoidance beliefs
(PA = 0, work = 1)†.
Goal: return to walking program with running intervals for weight loss.
Primary impairments: myofascial trigger points‡ in medial calf and plantar foot, decreased DF with rearfoot inversion, increased pronation bilaterally
during single leg squat, single leg heel raise and side plank weakness bilaterally.
Individualized interventions (six visits with the PT over 6 weeks): manual trigger point and myofascial mobilization of the calf followed by instrumented
mobilization, ankle dorsiflexion mobilization with rearfoot inversion bias, rearfoot lateral glide with rearfoot inverted, self-directed rearfoot lateral glide,
short foot training with progression to single leg heel raise, side plank progression, and screen of running form followed by graded walk with run
interval program.
Case 2: 41-year-old male with left PHP for 243 days, unknown onset but a history of left ankle sprain 15 years ago, BMI = 33.9 kg/m2, left-sided pronated
foot posture (FPI: right = 5, left = 7)*, and slightly elevated PA fear avoidance beliefs (PA = 2, work = 1)†.
Goal: increase tolerance to standing and walking required of coaching football.
Primary impairments: limited ankle dorsiflexion range of motion (ankle lunge test:(Bennell et al., 1998) right = 9 cm, left = 5 cm) and limited dorsiflexion
at terminal stance phase of gait.
Individualized interventions (three visits with the PT over 6 weeks): manual trigger point and myofascial mobilization of the calf and peroneals followed
by instrumented mobilization, ankle mobilization, ankle distraction thrust manipulation, dorsiflexion mobilization with movement in lunge position,
rearfoot medial glide, increased emphasis of calf/dorsiflexion stretching, regular dorsiflexion active range of motion, self-directed dorsiflexion lunge
mobilization with movement, use of ankle lunge test to assess dorsiflexion progress, and gait training to increase dorsiflexion during ankle rocker.
Case 3: 62-year-old female with right PHP for 60 days that she thinks was due to limping because of a fall that injured her right hip, knee and low back
2 years ago, BMI = 35 kg/m2, normal foot posture (FPI: right = 0, left = 3)*, and moderately elevated fear avoidance beliefs (PA = 3, work = 2)†.
Goal: walk for exercise 30–45 min, 3 days per week.
Primary impairments: myofascial trigger points‡ in right calf and right posterior gluteus medius/minimus, limited ankle dorsiflexion mobility bilaterally,
limited multi-segmental flexion (fingertips to 6 inches from ankle with standing toe touch attempt) and posterior thigh tightness (supine straight leg
raise right = 56°, left = 61°), increased contralateral pelvic drop and ipsilateral trunk side-bend during right stance phase of gait, limited mobility and
discomfort with passive physiological intervertebral mobility of right rotation/side-bend of the pelvis/low back in right side-lying, limited mobility of
right hip and knee extension.
Individualized interventions (five visits with the PT over 6 weeks): manual trigger point and myofascial mobilization of the calf and gluteal region, ankle
dorsiflexion and rearfoot lateral glide mobilization, side-lying low back rotation mobilization, side-lying hip extension mobilization with hold-relax
anterior hip stretching, supine posterior thigh stretching, low back stretching (seated hip/back flexion with sidebending), single leg stance short foot
training with specific emphasis of gluteal activation to keep the pelvis level progressed to band-resisted contralateral hip abduction, hip strengthening
(prone hip extension with knee extended and side-lying hip abduction), and gait training (anterior to posterior resisted gait with band around pelvis,
cued to “walk tall”) including graded walking program.
Case 4: 48-year-old male with left PHP for 40 days that started after running in dress shoes when late to work and weight gain (13.6 kg in 9 months),
BMI = 35 kg/m2, supinated foot posture on the right and normal on the left (FPI: right = −3, left = 3)*, and moderately elevated PA fear avoidance beliefs
(PA = 3, work = 1)†.
Goal: walk 30–45 min, 3 days per week for exercise; maybe get back into a little running.
Primary impairments: limited multi-segmental flexion (fingertips to mid-shin with standing toe touch attempt), low back pain improved with prone
active extension exercises, myofascial trigger points‡ in left calf which was 6 mm smaller than right, decreased height with left heel raise performance
relative to right (Figure 3), covert abnormal tibial neurodynamics (greater calf sensation on the left without reproduction of PHP during supine straight
leg raise with ankle dorsiflexion) that improved with neurodynamic mobilization.
Individualized interventions (four visits with the PT over 7 weeks): manual trigger point and myofascial mobilization to the calf and plantar foot, tibial-bias
neurodynamic mobilization progressed to include nerve massage at the medial heel/ankle, reinforced abbreviated PNE information (Louw, Puentedura,
and Mintken, 2012), self-directed tibial-bias neurodynamic mobilization, self-directed manual or ball-assisted trigger point treatment to the calf and foot,
low back and hamstring stretching (back rotation in side-lying, seated hip/back flexion with side-bending, “jack-knife” (Sairyo et al., 2013), anterior and
posterior pelvic tilt), low back strengthening (prone extension to neutral), heel raise training, and screen of running form followed by graded walk with
run interval program that emphasized foot strike close to his center of mass.
Case 5: 64-year-old female with right PHP for 180 days that she thinks was due to 4 months of working on her feet at a retail warehouse that also led to
low back/buttock/posterior thigh pain on the contralateral side (left); previously treated with foot/calf stretches and ultrasound unsuccessfully by
another PT 3 months ago, BMI = 26.2 kg/m2, normal foot posture on the involved side (right) and pronated on the left (FPI: right = 9, left = 4)*, and
severely elevated PA fear avoidance beliefs (PA = 4, work = 1)† including concern about pain with the first few steps in the morning.
Goal: walk for exercise 30–45 min, 4–5 days per week.
Primary impairments: myofascial trigger points‡ in right calf and foot, limited forefoot eversion mobility, dynamic valgus (hip internal rotation and
adduction with tibial external rotation, foot pronation and foot abduction) during squatting (Figure 2), decreased heel raise performance (heel raise test
(Ross and Fontenot, 2000), right = 17, left = 23), delayed right heel rise at terminal stance of gait.
Individualized interventions (nine visits with the PT over 15 weeks): manual trigger point and myofascial mobilization to the calf and plantar foot, ankle
dorsiflexion mobilization, mid-foot posterior to anterior mobilization, forefoot eversion mobilization, night splint (nightly for 2 weeks, then tri-weekly for
2 weeks), reinforced abbreviated PNE information (Louw, Puentedura, and Mintken, 2012), augmented low-Dye tape (Vicenzino, 2004), short foot
training progressed to squat and heel raise (bilateral then unilateral) training using bands to encourage reduced dynamic valgus, side plank progression,
and graded return to walking.
(Continued )
16 S. MCCLINTON ET AL.

(Continued).
Case 6: 68-year-old male with left greater than right PHP for 30 days with unknown onset and history of left lumbar radiculopathy with the last episode
3 years ago, BMI = 25.1 kg/m2, pronated foot posture bilaterally (FPI: right = 9, left = 6)*, and slightly elevated PA fear avoidance beliefs (PA = 2,
work = 0)†.
Goal: return to walking for exercise for 1–1.5 h, 5–6 days per week.
Primary impairments: limited dorsiflexion on the left greater than the right, myofascial trigger points‡ in the left greater than the right calf and abductor
hallicus, left calf 2 cm smaller than the right, increased foot abduction and relative thigh internal rotation on the left greater than the right throughout
the gait cycle and reduced heel rocker on the left, abnormal left tibial neurodynamics (increased PHP only when dorsiflexion added to supine straight
leg raise), pain with heel raise test that was reduced with augmented low-Dye tape (Vicenzino, 2004)
Individualized interventions (11 visits with the PT over 10 weeks): manual trigger point and myofascial mobilization to the calf and plantar foot, ankle
dorsiflexion mobilization, rearfoot lateral glide with rearfoot inverted, tibial-bias neurodynamic mobilization progressed to include nerve massage at the
medial heel/ankle, reinforced abbreviated PNE information (Louw, Puentedura, and Mintken, 2012), regular dorsiflexion active range of motion, self-
directed tibial-bias neurodynamic mobilization, self-directed rearfoot lateral glide, supine bridge with no abduction of the feet and band resisted thigh
abduction/external rotation, heel raise training (bilateral then unilateral), initial reduction of walking replaced with cycling and then graded return to
walking.
Case 7: 62-year-old female with right PHP for 249 days that started after a mission trip where she rode in a truck with prolonged inversion of the foot and
was bedridden after contracting the chikungunya virus, BMI = 29.7 kg/m2, pronated foot posture on the right greater than the left (FPI: right = 8,
left = 6)*, and slightly elevated PA fear avoidance beliefs (PA = 2, work = 1)†.
Goal: be able to walk for exercise 1 h 6 days per week, weight train for 40 min, 4 days per week, and be able to go on the same mission trip next year.
Primary impairments: myofascial trigger points‡ in right calf, decreased heel raise performance relative to left (rocker board plantar flexion test
(McClinton, Collazo, Vincent, and Vardaxis, 2016): right = 10 repetitions, left = 18 repetitions), decreased toe flexor strength (modified paper grip test
[hallux] (McClinton, Collazo, Vincent, and Vardaxis, 2016): right = 2.3 kg, left = 4 kg), limited posterior to anterior mid-foot and ankle dorsiflexion
mobility; covert abnormal tibial neurodynamics (greater calf sensation on the left without reproduction of PHP during supine straight leg raise with
ankle dorsiflexion) that improved with low back mobilization, limited and tender unilateral posterior to anterior mobilization of L4 and L5 on the right,
weak right side plank.
Individualized interventions (seven visits with the PT over 23 weeks): manual trigger point and myofascial mobilization to the calf and plantar foot, ankle
dorsiflexion mobilization, mid-foot posterior to anterior mobilization, side-lying low back rotation mobilization and thrust manipulation, neurodynamic
combined mobilization of L4 and L5 in modified prone straight leg raise position (Klingman, 1999; Petersen and Scott, 2010), supine tibial-bias
neurodynamic mobilization, self-directed tibial-bias neurodynamic mobilization, self-directed manual or ball-assisted trigger point treatment to the foot
and calf, plantar foot stretching in kneeling, augmented low-Dye tape (Vicenzino, 2004) and use of compressive foot/heel/ankle stocking temporarily,
short foot training progressed to squat and heel raise (bilateral then unilateral) training, foot muscle training; side plank progression, and graded return
to walking and weight training programs.
Case 8: 57-year-old female with left PHP, including increased pain when sitting, for 90 days with unknown onset but she thinks she may have stepped on a
door threshold but also has a history of altered gait following incomplete recovery from knee surgery 3 years ago, BMI = 39.3 kg/m2, normal foot
posture (FPI: right = 1, left = 3)*, and moderately elevated PA fear avoidance beliefs (PA = 3, work = 0)†.
Goal: return to video-based exercises and walking for at least 30 min, 5 days per week.
Primary impairments: myofascial trigger points‡ in the calf, limited ankle dorsiflexion and tibial internal rotation mobility, knee pain and limited extension
(−7°), dynamic valgus (hip internal rotation and adduction with tibial external rotation, foot pronation and foot abduction) during squat and lunge, left
greater than right contralateral pelvic drop and ipsilateral trunk side-bend during stance phase of gait, habitual sitting posture with left knee flexed and
right knee extended, covert abnormal tibial neurodynamics (greater calf sensation on the left without reproduction of PHP during supine straight leg
raise with ankle dorsiflexion).
Individualized interventions (three visits with the PT over 4 weeks): manual trigger point and myofascial mobilization to the calf, ankle dorsiflexion
mobilization, knee extension mobilization with tibial internal rotation and knee varus bias, supine tibial-bias neurodynamic mobilization, self-directed
tibial-bias neurodynamic mobilization, self-directed manual or ball-assisted trigger point treatment to the calf, band-resisted terminal knee extension in
standing, increased left knee extension when sitting, tibial internal rotation and ankle dorsiflexion active range of motion, lunges with mirror
biofeedback to correct dynamic valgus, heel raise training (bilateral then unilateral), graded return to exercise videos.
*Foot posture category as defined by Redmond (2005), normal = 0–5, pronated = 6–9, highly pronated = 10+, supinated = −1–4, highly supinated.
†
Fear avoidance was rated on a Likert scale where 0 = completely disagree and 4 = completely agree with screening questions for physical activity (PA), “I
should not do physical activities which (might) make my pain worse,” and work, “I cannot do my normal work with my present pain.” Scores ≥2/4 indicate
elevated fear avoidance beliefs (Hart et al., 2009).
‡
Trigger points were identified by the presence of a “hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut
band” (Simons, Travell, and Simons, 1999) that produced local or referred pain.
FPI, foot posture index; PA, physical activity; PNE, pain neuroscience education.
 PHYSIOTHERAPY THEORY AND PRACTICE 17

Appendix B. Exercise interventions utilized in this case series. Frequency of cases that used each
intervention is listed in Appendix D. Stretching and self-directed mobilization was performed daily
until symptoms were gone and then 2–3 times per week or as needed after that. Resistance
training was performed daily for 1–2 weeks at 40–70% maximum effort, then 3–4 times/week at
≥ 70% effort, and after that patients were encouraged to continue indefinitely or integrate into
their usual resistance training program

Stretching/mobilization interventions
Plantar fascia stretch: The involved leg is crossed over the non- A B
involved leg and fingers are placed over the ball of the toes and the
pad of the hand over the tips of the toes (A). This hand is used to
extend the toes and dorsiflex the ankle until a stretch is felt in the
bottom of the foot. The opposite hand is used to mobilize/massage the
bottom of the foot parallel to foot and squeezing the plantar foot
tissues between the fingertips and palm of the hand. This is performed
for a total of 3-5 minutes per day performed in 1-3 bouts at an intensity
near the patient’s pressure-pain threshold or adjusted so that
symptoms are improved following mobilization. Alternate positioning
for the stretch/mobilization is in kneeling (B). Also, if preferred, the stretch is performed for 2
repetitions of 30 seconds, 2-3 times/day standing with the foot inclined on a wall and the knee flexed (see C and D of
the calf/dorsiflexion stretch below).
Calf/dorsiflexion stretch: In standing, the A B C D
involved foot is placed furthest from the wall
pointed straight ahead and in neutral arch/foot
(i.e., short foot) position. The patient leans
forward while keeping neutral arch/foot
position and heel on the floor with, A) the back
knee straight or B) the back knee bent until a
stretch is felt in the calf and/or Achilles region.
Each position is held for 30 seconds, 2
repetitions, 2-3 times per day. If preferred, the
stretch can be performed with the foot inclined
on a wall using shoes to get traction on the
wall (C and D). In this stretch, the toes are extended during the stretch with the knee extended (C) and flexed (D).
Dorsiflexion active range of motion: In seated or standing with foot in the air A B
(A) or heel on the ground (B), the ankle is dorsiflexed as much as much as
possible. A 5 second hold is performed and repeated 10 times. This is
performed before getting out of bed, before rising from a chair, or after
calf/dorsiflexion stretches at least 4 times daily.

Dorsiflexion lunge mobilization with movement: Standing with the involved foot on a chair or
bench, the hands are placed just above the ankle with the inner elbow tucked into the abdomen.
A forward lunge is performed to maximum dorsiflexion while a posterior to anterior force is
applied just above the ankle using the body and arms. The goal is to achieve dorsiflexion
without pinching in the anterior ankle. Each lunge is held for 5 seconds and repeated for 2 sets
of 10 repetitions. The posterior to anterior force is applied constantly for the entire set.
18 S. MCCLINTON ET AL.

Rearfoot lateral glide: While seated, the involved leg is crossed and stabilized with the arm
on the same side. The other hand grasps the heel of the foot and pushes towards the floor
until a stretch is felt along the inside of the heel/ankle. This is performed for 3 sets of 30
oscillations at approximately 100-120 oscillations/minute, 2-3 times/day.

Calf/Foot mobilization: In sitting, or if more effective, in standing, the A B

bottom of the foot is slowly mobilized/massaged using a ball (A), foam
roller, frozen water bottle or rolling pin for three to five minutes. If a
tender nodule within a tight band (i.e., a trigger point) is found,
pressure is maintained at the pain-pressure threshold for up to 90
seconds or until the knot goes away or becomes less tender. While
holding the pressure on the trigger point, the patient has the option to
wiggle and spread the toes. Similarly, trigger points in the calves can
be worked in the same way seated with the leg straight and the calf placed over a ball that is targeting a trigger point
(B). Pressure is maintained at the pain-pressure threshold for up to 90 seconds with the option of plantar- and
dorsiflexing the ankle at a rate of 30-60 repetitions/minute. This is repeated on other trigger points found that are
different from the tother side for 3-5 minutes/day. Over time and as the patient improves, the patient is encouraged to
decrease frequency of this activity to avoid hypervigilence about these trigger point areas.
Neurodynamic mobilization: While seated (A) or supine with A B C
the hip flexed 90°, the ankle is dorsiflexed and then the knee is
extended (seated version: B, supine version: D) until
tension/stretch is in the back of the thigh, knee, or leg and held
for 2 seconds. Then tension is released by bending the knee and
this is repeated for 10-15 repetitions. Another set of 10-15
repetitions is performed by changing the sequence of movement;
first the knee is straightened, then the ankle
F
D E
dorsiflexed (B and D). This is performed 2-3
times/day. A strap can be added to assist if
preferred by the patient (C and E). An
alternate position is in standing, with ankle
dorsiflexion and then swinging the leg like a
pendulum from hip flexion to extension with
the knee extended (F).
Low back stretch: To stretch the right low back, lie on the left A B
side and hook the right foot behind the left knee (A). Then rotate
the pelvis to the left by sliding the right knee away from the body
while the left arm assists. Keeping the pelvis rotated, place the
right hand on the lower right rib cage and rotate the trunk to the
right. Continue to rotate the trunk and pelvis in opposite directions
until a stretch is felt in the lower back. Reverse the position to stretch the opposite side. If
preferred, the low back stretch can be performed seated (B). Seated at the edge of the
chair with legs spread, flex the low back by reaching hands towards the floor until a stretch is felt in the low back. To
target the left side of the low back, the hands walk around the right foot until a stretch is felt in the left side of the low
back. To target the right low back, the hands walk around the left foot. Low back stretches are held for 30 seconds, 2
repetitions, 2-3 times per day.
 PHYSIOTHERAPY THEORY AND PRACTICE 19

Posterior thigh stretch: Starting in B C D

standing with knees bent and grasping A
the arches with both hands (A), the
knees are straightened without losing the
grip on the arches until a stretch is felt in
the back of the legs (B). This is held for 5
seconds, then tension released by
bending the knees and repeated 5 times.
Then return to upright stance and the
process is repeated with both feet slightly turned in and then
with both feet turned out (C). This is also known as the “jack-knife” stretch
(Sairyo et al, 2013). If preferred, an alternate position is standing with involved foot on a chair, stool or step and the
back foot and hips pointed towards the foot on the chair/step/stool (D). Hinge at the hips while keeping the back straight
until a stretch is felt in the back of the leg. Hold for 30 seconds, and repeat 2 more times; one with the foot on the
chair/step/stool pointed in and another with the foot pointed out. Repeat 2-3 times/day.
Resistance training
Short foot: With the foot on a flat surface (A), the arch of A B C
the foot is lifted including active approximation of the head
of the first metatarsal towards the heel (B). Emphasis is
placed on keeping the first metatarsal-phalangeal joint
firmly on the ground and avoiding toe flexion. If excessive
toe flexion is observed, the short foot is maintained while
lifting the toes off the ground and then gently resting the toes back on the ground. The lower
leg, thigh, and pelvis are aligned during short foot performance including external rotation of
the lower leg and thigh, and assuring a level pelvis if the patient demonstrates dynamic valgus.
The short foot is held for 5 seconds, 3 sets of 5 repetitions, 2 times per day. The exercise is
progressed from sitting to bilateral stance and then to unilateral stance once completion of the
previous level for the target repetitions is achieved with good technique. Once unilateral stance
is achieved, then longer holds of 30 seconds are performed and balance or resistance training (e.g., short foot with
band resisted contralateral hip extension/abduction [C]) activities are added.
Heel raise: Stand so that the closest part of the body is 1 fist width
A B C D
away from the wall to prevent excessive forward lean during the
exercise (A). Place fingertips on the wall for balance and perform
the short foot with both feet. Perform a heel raise using the calf
muscles without letting the body run into the wall. The foot, lower
leg, thigh, and pelvis are aligned during heel raise performance
including adduction of the foot, external rotation of the lower leg
and thigh, and assuring a level pelvis if the patient demonstrates
dynamic valgus. The exercise is progressed from bilateral (A) to
unilateral (B) with an emphasis on achieving full plantar flexion
and achieving similar performance between the involved and
uninvolved sides. Slow repetitions are performed at the pace of 1
repetition every 3 seconds including a brief pause at the top of the
heel raise. Up to 20 repetitions are performed, 3 sets, 1 times/day. A pain monitoring model (Silbernagel, Thomeé,
Eriksson, and Karlsson, 2007) is used to assess tolerance to training and decreased frequency (i.e., every 2 nd or 3rd
day), sets, and repetitions is recommended if pain increases more than 5 out of 10 on a numeric pain rating scale
during, or 24 hours following exercise, or pain and perceived stiffness is progressing from 1 week to the next. For
additional correction of rearfoot eversion/medial ankle collapse, a single leg heel raise is performed against the
resistance of a band placed just below the lateral malleolus that is pulling the ankle into eversion (C). For additional
correction of pelvic drop, a band is placed around the knees and the patient encouraged to abduct the hips and lift the
pelvis contralateral to the weightbearing leg (D).
20 S. MCCLINTON ET AL.

Foot training: Spend 3-5 minutes per day A B E

working on the coordination, control, and strength
of the feet. Pick from any of the following
exercises:

1) Toe dissociation: With foot on a flat

surface or in the air, raise your big toe C D
while pressing all the other toes down (A).
Hold for 10 seconds, then reverse
direction – press the big toe down while
raising all the other toes (B).
2) Toe spreading: Spread your toes as much as possible and hold for 10 seconds (C). A band can be placed around
the toes for added resistance (D).
3) Object pick-up: Use your feet to repetitively pick up marbles, small stones, small balls, cotton balls, socks, etc.
Objects can be placed in a target, such as a container and use of variable objects to get a range of difficulty is
encouraged (E).
Squatting: Perform a squat as if you were sitting into a chair. Assure good alignment A B
while squatting by performing the short foot, keep the pelvis level and square, and keep
the knees aligned. Squat depth is no deeper than chair height but dependent on the
depth that can be performed with correct technique. The exercise is progressed from
bilateral (A) to unilateral (B) with an emphasis on proper squat technique including foot
posture. For additional correction of dynamic valgus/medial knee collapse, the squat is
performed against the resistance of a band placed above or below the knees that is
pulling the knees into dynamic valgus (A and B). Perform 3 sets of 10-15 repetitions, 1
time/day.

Knee extension: Stand facing a door with a resistance band around the involved A B
knee and anchored in the door. From a knee bent position, straighten the knee as
far as possible against the resistance of the band. Hold 10 seconds and repeat 3
sets of 10 repetitions, 2 times/day.

Hip extension and abduction: Starting A B

position for hip extension is prone with a
pillow under the abdomen to achieve neutral
lordosis (A). From this position, straighten the
knee and extend the hip. Emphasis is on
gluteal activation to lift the leg without arching the lower back. The hand can be placed in
the small of the back to monitor position (A). For hip abduction, the shoulder blades,
buttocks and heel of the top leg is placed against a wall with the low back in neutral (B).
The top leg is lifted while keeping the heel, buttocks, and shoulder blades against the
wall and a neutral low back. Emphasis is on posterior/lateral gluteal activation. Perform 3 sets of 10-15 repetitions, 1
time/day.
Low back extension: Lying with a pillow under the stomach so
that the low back is slightly flexed, extend the trunk using the
back muscles until the low back is neutral. Hands are placed in
the low back to monitor position and avoid hyperextension. Hold
for 10 seconds and perform 3 sets of 10 repetitions 1 time/day.
 PHYSIOTHERAPY THEORY AND PRACTICE 21

Side plank: To exercise the A B

right side, lie on the right side
supported by your forearm with
the low back in neutral, pelvis
perpendicular to the floor, and
the knees bent 90°. Next, tighten
the abdominals and lift pelvis
from the floor until it is level with
an imaginary line drawn between the knees and the chin (A). Work up to C
holding this position for 3 sets of 30 seconds, 1 time/day. The exercise
is progressed in the following sequence once completion of the previous
level for the target set and hold time is achieved with good technique:
1) lift the top leg up and down slowly at a frequency of 1 repetition every
3 seconds during the 30 seconds (B).
2) full plank position the legs extended (C).
3) full plank position while lifting the top leg up and down slowly at a
frequency of 1 repetition every 30 seconds.
Bridging: In supine hook-lying with the feet and knees in line with the hips,
lift the pelvis without arching the lower back. Emphasis is placed on using the
gluteal muscles to lift the pelvis and short foot position of the feet. Additional
thigh abduction and external rotation can be encouraged using a resistive
band placed around the knees. Hold for 10 seconds and perform 3 sets of 10-
15 repetitions 1 time/day.
22 S. MCCLINTON ET AL.

Appendix C. Manual therapy interventions utilized in this case series. Frequency of cases that used
each intervention is listed in Appendix E

Trigger point and myofascial-bias mobilization

Calf mobilization: First, trigger point(s) in the calf are identified and A B
the therapist applies pressure over the trigger point until an increase
in muscle resistance is perceived and up to the patient’s pain-
pressure threshold. Pressure is increased as the tension in the
muscle releases for up to 90 seconds for each point. To enhance the
mobilization, the patient is asked to slowly dorsiflex and plantar flex
the ankle at a frequency of 1 repetition every 3 seconds while the
pressure is maintained. Next, the therapist applies 3-8 longitudinal
strokes over the taught bands in the posterior lower leg using slow-absorbing lubricant (A).
The distal aspect of the taught band is compressed using one hand while the thumb or fingers of the opposite
hand compress and stroke along the taught band using pressure at the patient’s pain-pressure threshold. Finally,
in select cases, the edge of a metal soft tissue mobilization tool and slow-absorbing lubricant is used parallel to the
muscle fibers at a rate of approximately 6-8 inches/second (B). The entire width of the calf is mobilized using the
tool from the heel towards the head and from the head towards the heel. Strokes are applied for 30-90 seconds or
until minor redness (depending upon skin tone and tolerance) and, in some cases, the first appearance of
petechiae.
Foot mobilization: With the patient prone or supine and the foot off the edge of the plinth, therapist
identifies and treats trigger points, performs longitudinal strokes along the plantar aspect of the foot
and, in select cases, uses a metal instrument to mobilize the soft tissues of the plantar foot in the
same manner as described for the calf.

Gluteal region mobilization: With patient in the side-lying position with hips flexed
45° and the knees flexed 90°, therapist identifies and treats trigger points, performs
longitudinal strokes in the direction of the gluteus medius/minimus fibers and, in
select cases, uses a metal instrument to mobilize the soft tissues of the gluteal region
in the same manner as described for the calf. Enhancement of the trigger point
sequence is performed by hip abduction and external rotation (i.e. clamshell motion).
Joint-bias mobilization
Ankle dorsiflexion: The involved foot is placed on the therapist’s thigh which is used to A
dorsiflex the ankle. Therapist stabilizes the distal lower leg with one hand and the other hand
grasps the foot taking up skin slack until the 1st and 2nd digit webspace is over the superior
aspect of the talus (A). An anterior to posterior oscillatory mobilization at a frequency of 100-
120 oscillations/minute at the therapist-perceived restrictive barrier is applied to the talus. Up
to 3 sets of 30-60 oscillations are performed or until improved mobility is perceived and the
therapist uses his/her thigh to increase dorsiflexion as able during the procedure. To address
dorsiflexion impairments that are exaggerated with the rearfoot inverted, the B
foot is held in inversion during the anterior to posterior mobilizations. Following
oscillations, a non-weightbearing mobilization with movement is performed by
dorsiflexing the ankle as far as possible using therapist’s thigh while an
anterior to posterior glide is sustained. Up to 4 sets of 10 repetitions are
performed or until improved mobility is perceived. In select cases a
weightbearing mobilization with movement is performed in a lunge position
with the involved foot on the plinth or a chair (B). A belt is placed at the level
just above the malleoli and around the therapist’s pelvis. The therapist holds
the patient’s foot in neutral pronation/supination while a sustained posterior to anterior force is applied to the distal
lower leg using the belt and the patient dorsiflexes the ankle by lunging forward bringing the knee over the toes as
far as possible. Up to 4 sets of 10 repetitions are performed or until improved mobility is perceived.
 PHYSIOTHERAPY THEORY AND PRACTICE 23

Ankle distraction thrust manipulation: Therapist grasps the dorsum of the foot and
traction, eversion, and dorsiflexion of the ankle is introduced while the therapist radially
deviates the hands to fine-tune the perceived restricted barrier. A high-velocity, low-
amplitude thrust in a caudal direction is applied up to 2-3 times or until improved ankle
mobility is perceived.

Rearfoot medial or lateral glide: The patient lies on the involved side and the therapist’s
thigh is used to control ankle dorsiflexion. Therapist stabilizes the distal lower leg while the
other hand performs a medial to lateral oscillatory mobilization to the rearfoot (by grasping the
calcaneus) at a frequency of 100-120 oscillations/minute at the therapist-perceived restrictive
barrier. Up to 3 sets of 30-60 oscillations are performed or until improved mobility is
perceived. The patient lies on the opposite side to perform medial glide rearfoot mobilization
using a lateral to medial oscillation.

Mid-foot posterior to anterior: With the patient in prone, the therapist grasps the foot with
the hands and uses the thumbs to mobilize the restricted midtarsal joints using an oscillatory
motion in a posterior to anterior direction at a frequency of 100-120 oscillations/minute at the
therapist-perceived restrictive barrier. Up to 3 sets of 30-60 oscillations are performed or
until improved mobility is perceived. The foot is maintained in slight plantarflexion and
further fine-tuning occurs through inversion or eversion of the foot.
Forefoot eversion: The patient is positioned in supine hook lying with the involved heel
placed at the edge of the plinth. The therapist’s cephalad arm is used to pinch the patient’s
lower thigh and tibia between the therapist’s arm and ribcage while inducing full rearfoot and
navicular inversion. While stabilizing with the cephalad arm and hand, the midfoot is grasped
with the other hand and the forefoot inverted at a frequency of 100-120 oscillations/minute at
the therapist-perceived restrictive barrier. Up to 3 sets of 30-60 oscillations are performed or
until improved mobility is perceived.

Low back rotation non-thrust or thrust manipulation: Patient is placed in

side-lying with the involved side up. The top leg is flexed until movement is
palpated at the selected segment interspace. The therapist uses the bottom
shoulder to side-bend and rotate the trunk until movement is palpated at the
selected segment interspace. Rotation between the patient’s pelvis and trunk
is maintained as the patient is rolled towards the therapist. A posterior to
anterior oscillatory mobilization is performed through the pelvis at a frequency
of 100-120 oscillations/minute at the therapist-perceived restrictive barrier. Up
to 3 sets of 30-60 oscillations are performed or until improved mobility is
perceived. Thrust manipulation is performed in this same position and direction
using a high velocity, low amplitude thrust through the arm on the pelvis. Up to 2 thrusts are performed or until
improved mobility is perceived.
Hip extension: The patient is positioned on the non-involved side with the
bottom hip flexed 90° and the patient’s bottom arm used to hold the hip in this
position. Therapist grasps the top leg/thigh with the left hand as pictured,
extends the hip to the restricted barrier, and applies a posterior to anterior
oscillation of the proximal femur with the right arm. The therapists right elbow is
tucked into the therapist’s body to perform the oscillations at a frequency of 100-
120 oscillations/minute at the therapist-perceived restrictive barrier. Up to 3 sets
of 30-60 oscillations are performed or until improved mobility is perceived.
Between sets 3-4 repetitions of hold-relax stretching is performed by the patient
holding for 4-6 seconds against the therapist’s effort to extend the hip followed
by the patient relaxing and the therapist extending the hip to the new restricted barrier. This is repeated 3-4 times.
24 S. MCCLINTON ET AL.

Knee extension: In supine, the involved leg is placed on 2 towel rolls as pictured. The
therapist places both hands around the proximal tibia and applies traction while anterior to
posterior oscillations are performed at a frequency of 100-120 oscillations/minute at the
therapist-perceived restrictive barrier. Up to 3 sets of 30-60 oscillations are performed or
until improved mobility is perceived. To address dynamic knee valgus where there is
increased tibial external rotation relative to the femur, the therapist internally rotates the
tibia and directs the mobilization slightly anterior/medial to posterior/lateral (varus).

Nerve-bias mobilization
Neurodynamic mobilization (tibial-bias): With the A B
patient in the supine position and the involved hip
flexed 90°, the therapist fully dorsiflexes and everts the
foot while bracing the forearms along the patient’s shin
(A). While maintaining dorsiflexion/eversion and hip
flexion, the knee is extended to the therapist-perceived
restricted barrier (confirmed by patient perception; B).
Repeated knee extension and flexion is performed
within an arc of approximately 15-30° at a frequency of
30-60 oscillations/minute for up to 3 sets of 8-15
repetitions or until improved mobility or less discomfort C D
is perceived. Nerve massage may be added to the
technique by massaging parallel to the nerve path at
the area of perceived restriction in the position of
neurodynamic dysfunction (C). Nerve massage is
performed at a rate of approximately 1 inch/second for
up to 3 sets of 8-15 strokes or until improved mobility
or decreased discomfort is perceived. In select cases
where the low back is suspected to affect
neurodynamic mobility and symptoms, combined
mobilization is performed. The patient is in a prone
straight leg raise position with the involved leg on the
floor with the knee straight and the ankle dorsiflexed/hip
flexed until tension is perceived in the back of the involved leg (D). If dorsiflexion or posterior thigh mobility is
lacking, a wedge can be placed under the foot for support (D). Next, the therapist performs unilateral posterior to
anterior mobilizations of the target ipsilateral lumbar segments at a frequency of 100-120 oscillations/minute at
the therapist-perceived restrictive barrier. Up to 3 sets of 30-60 oscillations are performed or until improved
mobility or reduced symptoms are perceived.
 PHYSIOTHERAPY THEORY AND PRACTICE 25

Appendix D. Frequency of exercise interventions utilized in this case series

Cases
1 2 3 4 5 6 7 8
Stretching/mobilization Plantar fascia stretch x x x x x x x x
Calf/DF stretch x x x x x x x x
DF AROM x x x*
Self-directed MWM x
Rearfoot lateral glide x x
Calf/Foot mobilization x x
Low back stretch x x
Post thigh stretch x x
Neurodynamic mobilization x x x x
Resistance training Short foot x x x x x
Heel raise x x x x x x
Foot training x
Knee extension x
Hip extension and abduction x
Low back extension x
Side plank x x x
Bridging x
Squat/lunges x x x
Functional training Gait training x x† x
Graded activity x x x x x x
Symptom modulation Augmented low-Dye tape x x
Foot/heel compression sock x
Night splint x
*With tibial internal rotation.
†
With posterior resistance using band around the pelvis.
AROM, active range of motion; DF, dorsiflexion; MWM, mobilization with movement.

Appendix E. Frequency of manual therapy interventions utilized in this case series

Cases
1 2 3 4 5 6 7 8
Manual therapy interventions MTrP and myofascial mobilization:
Calf and/or foot x* x* x x x x x x
Gluteal region x
Joint mobilization:
Ankle DF† x x x x x x x
Ankle distraction manipulation x
Rearfoot lateral glide x x x
Rearfoot medial glide x
Mid-foot posterior to superior x x
Low back x x
Forefoot eversion x
Hip extension x
Knee extension x
Neurodynamic mobilization x x x x
*Included instrumented mobilization.
†
Included anterior to posterior techniques and mobilization with movement.
DF, dorsiflexion; MTrP, myofascial trigger point.