Where’s the love?

I recently read an article from JOSPT that revealed that approximately only 7.1% (95% CI, 7.0%-7.1%) of patients who have plantar fasciitis (PF) actually receive a physical therapist (PT) evaluation. A total of 819,963 patients were diagnosed with the condition and seen by providers between 2007 and 2011. Can you believe that? Where’s the love from our colleagues? I was pretty surprised, given that the condition is treatable. Many of the problems associated with PF can be reduced/eliminated with manual therapy and exercise (MTEX) (Cleland et al., 2009). Modifiable risk factors can be eliminated with lifestyle and footwear changes (Martin et al., 2014). While the condition is usually self-limiting and resolves over time, there are a number of patients who develop chronic PF or have pain that is debilitating enough to decreased quality of life (QoL) and activities of daily living (ADL). I have a couple theories regarding why referrals are scarce:

1. It is possible that primary care providers (PCP) simply do not believe that PT is warranted for the condition. They may think it resolves over time or that simple pain medications and rest (ex. Tylenol, NSAIDs, etc.) may be sufficient to eliminate the symptoms.

2. PCPs may not be up to date on the current practices associated with PF. Hence, it may not cross their mind to even refer their patients to a PT.

3. PTs may not be educating PCPs enough about the benefits of treatment, particularly MTEX.

4. Patients may receive a referral but choose not to go to a PT due to insurance limitations or financial issues (this is the most difficult, in my opinion).

It may be a combination of these factors (or none at all), but the end result remains the same: there are not enough patients receiving treatment. PF is not unlike other conditions–there are many patients seen by their providers who have musculoskeletal conditions and they are not properly referred.

When patients come in for free injury screens, I often do not refer them to PT (that is probably to the dismay of my managers, of course). The patient may come in with a complaint of low back or foot pain that has been going on for a couple days. Obviously, pain that short in duration does not usually necessitate our services. However, pain that is on the tail end of acute (~4 weeks), sub-acute (4-8 weeks), or chronic (>12 weeks) deserves our undivided attention. When patients visit their PCPs with these issues, it is imperative that an appropriate referral is made. At the very least, refer them for a free functional injury screen (they are basically everywhere). There should not be a hold-up of services given that chronic illnesses usually take longer for recovery, cost more money, and potentially lead to worse outcomes. This goes both ways: when patients are not getting better with PT, I immediately refer them to a specialist for further consultation. I say the same thing to almost every patient I encounter: “If you do not have improved function or decreased pain in any capacity by 3-4 weeks, I will refer you appropriately to another provider. There should be some level of improvement” [obviously, this is assuming the patient is coming to PT and is adherent to their home exercise program (HEP)].

We need to continuously educate our colleagues about the benefits of PT. Likewise, consistent correspondence with providers is essential, as updating them on their progress goes a long way. If providers hear and see their patients getting better, writing a prescription for PT will become second nature.

Are you sending patients to see a PT for basic musculoskeletal conditions like PF, ankle sprains, or low back pain? If not, explain why! I would love to hear your thoughts on the subject.

Cleland, J.A., Abbott, J.H., Kidd, M.O., Stockwell, S., Cheney, S., Gerrard, D.F., & Flynn, T.W. (2009). Manual physical therapy and exercise versus electrophysiological agents and exercise the management of plantar heel pain: a multicentered randomized clinical trial. Journal of Orthopedic and Sports and Physical Therapy, 39(8), 573-585.

Fraser, J.J., Glaviano, N.R., & Hertel, J. (2017). Utilization of physical therapy intervention among patients with plantar fasciitis in the United States. Journal of Orthopedic and Sports Physical Therapy, 47(2), 49-55.

Martin, R.L., Davenport, T.E., Reischl S.F., et al. (2014). Heel pain—plantar fasciitis: revision. Journal of Orthopedic and Sports Physical Therapy, 44, A1-A33.

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