Treatment

Guidelines

There are two primary existing clinical practice guidelines from the past decade relative to heel pain:

• ‘The diagnosis and treatment of heel pain: a clinical practice guideline – revision 2010‘ from the American College of Foot and Ankle Surgeons
• ‘Heel pain-plantar fasciitis: revision 2014’ from the American Physical Therapy Association

No contemporary guidelines for managing plantar heel pain exist in the public domain.

Fortunately, a team of researchers and experts in plantar heel pain, including  from La Trobe University, have created a best practice guide to meet this gap. ‘Management of plantar heel pain: a best practice guide synthesising systematic review with expert clinical reasoning and patient values’ (Morrissey et al., 2019) is currently awaiting publication. The systematic review included only high quality RCT’s with of a score of at least 8/10 on the PEDRO scale. A meta-analysis also features in the guide.

Unlike the above examples, this guide is truly best practice as it incorporates not only high quality evidence and expert opinion but also the patient voice.

Clear recommendations for management are provided, and these recommendations include patient preferences. Information is easily applicable to clinical practice and includes a core approach, as well as a stepped approach in situations where people with heel pain are slow to improve. A summary is provided below.

 

Treatment approach

Core

The core approach includes three elements:

1. Stretching
   • plantar fascia 
   • calf
2. Taping
3. Education, tailoring elements to the patient such as:
   • load management
   • pain education, including self-monitoring
   • influence of co-morbidities, body weight
   • footwear

The graphic below may assist with patient education

 

A period of six weeks trialling the core approach is recommended before progressing to the stepped approach (Morrissey et al., 2019).

Stepped

When people with plantar heel pain have little to no improvement after trying the core approach, the stepped approach to management should be employed. Extracorporeal shockwave therapy (ESWT) (whether radial or focussed) is recommended as the next line of treatment, due to its strong evidence. This is only recommended after the core approach, as evidence shows stretching has a greater effect on acute symptoms, compared to ESWT (Morrissey et al., 2019).

If the core approach plus ESWT has been tried and there is still no satisfactory improvement, custom orthoses are the next line of treatment. The final feature of the stepped approach is injection therapy.

It is suggested that if the person is still experiencing symptoms, repeating the core treatment and focussing on compliance, is a suitable approach. However, adjunct therapies can also be considered at this point (Morrissey et al., 2019).

 

 

Treatment snapshot

People with plantar heel pain want to know the risks and benefits of proposed treatments, as well as how they are hypothesised to work. A clear and recurring theme has emerged: practitioners need to work harder to explain this better to the people they treat (Morrissey et al., 2019; Cotchett et al., 2019).

To assist with this task, an overview of common treatments for heel pain is provided below as a starting point.

Exercise programs

A recent RCT by Riel, Jensen, Olesen, Vicenzino & Rathleff (2019) conducted a 12 week exercise program of standing heel raises, either self-dosed, or pre-determined, for people with plantar fasciopathy. Outcomes included pain and patient acceptable symptom state (where patients felt they did not need any additional treatment). All participants were also provided with silicone heel cups and education. 

There were no differences between the group who chose their own exercise dose, and those who completed the pre-determined regime, in terms of actual exercise dosage completed. Interestingly, the authors found that the majority of participants did not feel their symptoms were at an acceptable state at the conclusion of the 12 weeks – only 6% of participants met this criteria. In other words, most people felt they needed additional treatment for their heel pain at the conclusion of the exercise program. Furthermore, the authors compared findings for the outcome of pain and found similar results as taping, steroid injection and orthoses, as well as sham orthoses and placebo (Riel, Jensen, Olesen, Vicenzino & Rathleff, 2019). 

A recent systematic review by Osborne, Menz, Whittaker and Landorf (2019) assessed muscle function and muscle size differences in people with and without plantar heel pain. The strength of the evidence was low but they found no differences in calf muscle endurance between groups. However, they did find that size and strength of foot musculature in those with heel pain was less when compared to those without heel pain. In particular, strength of toe flexors. Regardless, once again it could not be established that weaker foot muscles cause plantar heel pain.

Babatunde et al. (2019) highlights that there is currently no clear evidence on effective exercise prescription for plantar heel pain. Their review found that exercise alone does not appear to help in the short term for pain and function, although they suggested it does long-term. Similarly, although the best practice guide by Morrissey et al. (2019) noted an absence of trials where the direct impacts of strength programs could be clearly identified, most experts appear to believe in the value of exercise for people with heel pain.

Strength-based programs for plantar heel pain may target areas such as the lower limb, foot intrinsics and hip region but should be based on objective assessment findings. 

Orthoses

Foot orthotics help to reduce pain by redistributing load in the foot in the medium term (around 3 months post prescription), and are more effective than sham or placebo (Babatunde et al., 2019). Orthoses may be custom, pre-fabricated or semi-custom. Customised orthotics tend to be expensive, so it is worthwhile trying pre-fabricated orthotics prior to making a larger investment (Morrissey et al., 2019). Also consider that for some patients, cost will be a deciding factor.

Taping

Taping of the foot helps to minimise plantar heel pain for up to one month and forms part of the best practice core approach (Morrissey et al., 2019). It is inexpensive, easy to apply and patients can be taught to do it themselves. Similar to orthotics, taping helps to offload forces on the foot and provide support.

A common taping method for heel pain can be found in the video below.

Corticosteroid injection

A 2017 Cochrane systematic review (David, Sankarapandian, Christopher, Chatterjee & Macadan) analysed injected corticosteroids for treating plantar heel pain in adults. The majority of trials included had a high risk of bias and evidence of very low quality. Compared to placebo or nothing, there is evidence of low quality that steroid injections can have a small influence (less than the MCID) on pain in the short term (less than 1 month). Benefits greater than one month were not found. Although not frequent, risks of steroid injection include plantar fascia rupture, infection, erythema, fat pad atrophy and nerve damage (David, Sankarapandian, Christopher, Chatterjee & Macadan, 2017; Babatunde et al., 2019).

Non-steroidal anti-inflammatories (NSAIDs)

A review by Babatunde et al. (2019) found that NSAIDs conveyed minimal benefit to pain and function for people with plantar heel pain and was similar to placebo.  In addition, adverse events reported in previous trials for plantar heel pain include gastritis, oesophagitis, bloating and pruritis (David, Sankarapandian, Christopher, Chatterjee & Macadan, 2017).

Extracorporeal shockwave therapy (ESWT)

There is strong evidence for the effectiveness of ESWT as a treatment to improve pain and function in people with heel pain at all time points (short, medium, long-term). However, it is recommended as part of the stepped approach because it is not as effective as stretching when symptoms are in the acute stages (Rompe et al., 2010). Adverse events are rare, however some studies have reported severe migraine or headache as a result (David, Sankarapandian, Christopher, Chatterjee & Macadan, 2017). Generally, people may find the treatment experience uncomfortable (Morissey et al, 2019).

If you are unfamiliar with the therapy, have a look at this video.

Dry needling

Dry needling is another option which can be used as an adjunct to treatment, in addition to the core approach. An RCT in 2014 by Cotchett, Munteanu and Landorf assessed the effectiveness of trigger point dry needling for plantar heel pain. They found that although dry needling helped to minimise heel pain and was statistically significant, effects were not clinically significant.

Dry needling is thought to work by influencing the central nervous system, reducing substance P, improve endorphin levels at local tissue sites and provide short-term pain relieving effects (Gerber et al., 2015; Cotchett, Munteanu & Landorf, 2014; Hsieh, Yang, Yang & Chou, 2012).

Adverse events from dry needling include pain at the needle site (Cotchett, Munteanu & Landorf, 2014).

Stretching

Evidence shows that plantar fascia stretching is superior to calf stretching. Stretching and taping together works better than stretching on its own (Hyland, Webber-Gaffney, Cohen & Lichtman 2006).

Education and advice

Education and advice needs to be tailored to each patient but may include discussion and consideration of the following elements:

Activity modification

• For athletic individuals, this may involve changing training regimes, whether that is frequency, distance, intensity or training surface. Are there other activities the person can complete which do not place as much load on the heel, such as swimming?
• Has the person’s heel pain resulted from a sudden change in load?
• In people with standing occupational work, can their day be broken up with periods of sitting or modified duties? Is a workplace ergonomic assessment indicated?
• In instances where people are in a lot of pain, it is important to reinforce that pain does not always equate to tissue damage and that complete rest is not recommended
• Self-monitoring for pain should form part of activity modification, and will help to empower the patient to manage their own symptoms.  A graded approach to exercise should be incorporated.

Footwear

• Does the person have supportive cushioned footwear, properly fitted to their foot? Barefoot walking or walking in thongs is not recommended when people have heel pain.
• Referral to a podiatrist should be considered when expert input on footwear is required.

Bodyweight

• As carrying excess weight is the only proven risk factor for plantar heel pain, a discussion around weight may be warranted. Although not easy to modify, maintaining a healthy weight has numerous additional health benefits.
• Therapists could broach the conversation by explaining the role weight may have on the experience of heel pain (increased load) and ask if the person is willing to try and address this.
• Referral to a dietician or GP may also be indicated.