Plantar heel pain, or simply ‘heel pain’, is pain felt on the sole of the foot, frequently at the origin of the plantar fascia on the calcaneus (Landorf, Simons, Jordan & Rathleff, 2017). First-step pain of insidious onset is characteristic of the condition (Landorf, Simons, Jordan & Rathleff, 2017; Morrissey et al., 2019).
Heel pain is more commonly known by its previous name, plantar fasciitis, but has also been called plantar fasciosis, plantar fasciopathy and heel spur syndrome.
The condition is common, affecting approximately 1 in 10 adults throughout their lifespan (Landorf, 2015). The only proven risk factor for developing heel pain is a high body mass index (Irving, Cook, Young & Menz, 2008) and with Australia’s population becoming increasingly obese (Australian Bureau of Statistics, 2019), it is likely the condition will become even more prevalent in future.
Given the above, clinicians such as physiotherapists and podiatrists will presumably see numerous patients with heel pain during their career.
Purpose of this resource
This resource has been designed to help clinicians who manage plantar heel pain by providing a user-friendly, trustworthy, engaging and central point of evidence-based information.
It aims to provide:
- an overview of the condition, including who it commonly affects, associated factors and current understanding of pathophysiology
- management principles for plantar heel pain
- guidance on how to conduct a subjective and objective assessment, with clues for recognising how a patient with heel pain will commonly present
- an outline of differential diagnoses, including when imaging is appropriate
- a snapshot of current evidence on common treatment approaches
- a selection of relevant outcome measures
- information in a mixture of mediums to cater to differing learning styles
Impacts of heel pain
Treating plantar heel pain is a burden to the economy with projected costs as high as $376 million in the United States (Tong & Furia, 2010). Heel pain impacts people’s quality of life, with those affected more likely to experience stress, anxiety and depression (Cotchett, Munteanu & Landorf, 2016). The pain experienced is often debilitating and limits function during daily activities such as walking, running and going to work (Irving, Cook, Young & Menz, 2008). At its most severe, people with the condition may be unable to walk and require periods of non-weight bearing (M. Cotchett, personal communication, 31 October, 2019).
Patient population
Plantar heel pain is the most common foot disorder and affects both active and sedentary members of the population (Martin et al., 2014; Taunton et al., 2002). It commonly affects sedentary people in middle and older age groups, however it is also the third most common running injury (after patellofemoral pain and iliotibial band friction syndrome), with eight per cent of runners impacted (Taunton et al, 2002; Dunn, Link, Felson, Crincoli, Keysor & McKinlay, 2004).
Other sporting populations commonly affected include dancers, soccer players and gymnasts, where heel pain again features in the top three conditions treated (Sobhani, Dekker, Postema & Dijkrstra, 2013). Plantar heel pain accounts for 1 in 4 foot issues in the athletic population (Dunn, Link, Felson et al., 2004).
Associated factors
People with heel pain may have one or more of the following characteristics: (Irving, Cook, Young & Menz, 2008; Riddle, Pulisic, Pidcoe & Johnson, 2003; Landorf, Simons, Jordan & Rathleff, 2017)
- high body mass index
- standing occupational work
- high levels of repetitive activity involving weight bearing on the heel
- poor footwear
- pronated foot type
- decreased ankle joint range of motion
- inflexibility in the lower limb and hip
- reduced toe plantarflexion strength
- calcaneal heel spur
- plantar fascia thickness more than 4mm
- depression, anxiety, stress
- pain related fear, catastrophising
It is important to note that of these, only overweight or obesity is a proven risk factor for heel pain. Other listed factors are only associated with the condition, with current evidence not supporting a causal relationship.
More importantly, these factors do not determine pain severity.
Pathophysiology
Changing nomenclature over the years reflects evolving knowledge regarding the pathophysiology of plantar heel pain. This more modern term recognises the condition is often not simply inflammation of the plantar fascia (Riel, Cotchett, Delahunt, Rathleff, Vicenzino, Weir & Landorf, 2017). Other potential sources involved in a person’s experience of heel pain may include: perifascial oedema, calcaneal bone marrow abnormalities (oedema, lesions) and plantar fascia tear, thickening or fragmentation (Grasel, Schweitzer, Kovalovich, Karasick, Wapner, Hecht & Wander., 1999).
Unless a specific cause is able to be determined, experts now suggest the term plantar heel pain. (Riel, Cotchett, Delahunt, Rathleff, Vicenzino, Weir & Landorf, 2017). Plantar heel pain can be conceived as an umbrella term where varied or multiple tissues may be involved, and when combined with psychosocial factors, lead to an overall experience of heel pain.
Ultimately, it is unlikely that knowing which specific tissues are involved in a person’s heel pain will change the treatment approach (Chimutengwende-Gordon, O’Donnell & Singh, 2010). Management should follow best practice principles, be tailored to findings from the subjective and objective examination, incorporate the core treatment approach and consider patient goals and preferences.
Statement of intent
These resources are not intended to serve as a prescribed standard of medical care. Standards of care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These resources have been developed to inform practice and should be considered guidance only. Following advice on this site will not ensure a successful outcome in every patient, nor should it be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the clinician, based on clinician experience, expertise and in light of the clinical presentation of the patient, the available evidence, available diagnostic and treatment options, and the patient’s values, expectations, and preferences.