Management of Plantar Heel Pain

Plantar heel pain rehab

Morrissey et al. (2021)

Introduction

Plantar heel pain (PHP) predominantly affects sedentary middle-aged and older adults. About 4-7% of the population suffers from it. In runners, it’s considered the cause of 8% of the complaints. PHP is characterized by pain on the heel with first-step pain and pain during weight-bearing tasks; particularly after periods of rest.

The literature is dominated by systematic reviews and meta-analysis including low-quality trials. A clear answer thus remains elusive. This best practice guide aims to guide management of PHP with high-quality trials, expert clinical reasoning and patient values.

Methods

This trial followed PROSPERO guidelines without deviations from the protocol. Only high-quality RCT’s were included with at least 2 weeks of follow-up and at least one outcome measure defining patient-reported pain, first step pain, or foot-related function. High-quality was defined with a PEDro score of ≥ 8/10 and subsequent Cochrane Risk of Bias tools (RoB). Experts were invited via mail to participate in an interview regarding the management of PHP. Furthermore, patient voices were added to look for recurrent themes within these three sources. 

Results

The core approach for plantar heel pain consists of plantar stretching, low-dye taping, and an individualized education approach. 

At least 4 to 6 weeks are needed to evaluate the effects of the abovementioned interventions before adjunctive modalities such as shockwave therapy and or orthoses are considered. 

Fig1 morrissey plantar heel pain management
From: Morrissey et al (2021), BJSM

Although education has never been tested in isolation for this condition, it was much appreciated by patients and recommended by experts. Therefore, it’s recommended as first-line intervention. 

Key issues that could be targeted with load management are breaking up long periods of standing and/or reducing stretch-related dynamic loading such as running. Other educational topics are explaining pain and setting realistic expectations for recovery which could take months. However, the prognosis is favorable. Information regarding footwear includes a supportive and comfortable rearfoot to forefoot drop with specific advice to avoid barefoot walking or walking on flat, unsupportive footwear until symptoms resolve. Comorbidities such as a high BMI and/or type 2 diabetes should be addressed.  

Adjunct therapies are recommended based on the strength of the quantitative evidence and expert reasoning. Such adjuncts are radial or focused shockwave therapy and should be applied if people with plantar heel pain are not deriving optimal benefit from the previously mentioned core approach.

A final modality after unsuccessful shockwave therapy might be custom orthoses and/or a return to the core approach with good accuracy and a focus on adherence.

Interventions without proven efficacy such as injections are discouraged.

Reference

Morrissey et al (2021): https://pubmed.ncbi.nlm.nih.gov/33785535/

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