Plantar Heel Pain: How you treat it may not be evidence based
Plantar heel pain (PHP) is by far the most common condition presenting to podiatrists and physios, so much so that many are now calling it an “epidemic”.
Well, enough with the catastophising, and I am not about to delve into the numbers because you have heard it all before. But, everyone of us has our favorite way to treat PHP, and we swear by its efficacy, “I use X and it works for me” or “I use Y and ALL my cases get better”. The problem is, there is a very fair chance that the treatment you use to bring relief to that patient with the sore heel, probably has no evidence base at all and probably is no better than placebo.
In fact, the amount of folklore, opinion and witchcraft associated with this most troubling of conditions is frankly staggering.
This is the first of a series on common sports injury, Achilles tendinopathy, Anterior knee pain, “shin splints” and more, that really puts the blowtorch under the common methods of treating MSK pain.
Read on, because it may shock you to learn that you might need to change the way you treat Plantar Heel Pain.
First we should set out the hard cold facts.
- despite the extreme commonness of plantar heel pain, there is great confusion over what the condition actually is.
- of course PHP is not a diagnosis, it is a catch all label, and without a diagnosis, how can we treat the condition effectively.
- we continue to label all PHP as plantar fasciitis, which certainly IS a diagnosis, but, is it really what you are seeing, and if not, how can you treat it properly?
- There are literally dozens of proposed treatments for PHP, but there appears to not be one single reliable treatment
- Many of the mainstay treatments, for example taping and orthoses have very mixed efficacy based on the evidence
- New treatments, for example platelet rich plasma (PRP) or autologous blood, have promised miracle cures, but have not withstood scientific scrutiny.
The fact is, that although clinical guidelines and clinical trial data support a general approach to management, the current literature is limited in case-specific descriptions of PHP management that addresses unique combinations of pathoanatomical, physical, and psychosocial factors that are associated with PHP.
The term PHP encompasses a variety of pathoanatomical features including plantar fascia inflammation, degeneration or thickening, heel fat pad pathology, nerve irritation, and heel spurs.
Additionally, individuals with PHP may present with impairments in foot posture/mobility, ankle or hallux dorsiflexion, weightbearing duration, lower leg/foot muscle performance, and neurodynamic function, as well as comorbidities including stress, depression, obesity, and low back pain.
Where does that leave us?
Well, the goal of this series on common MSK injury is to uncover what really does work, according to the evidence, and thereby equip you to get better clinical outcomes for your patients with PHP. Here we go.. let’s begin with a favorite quote
“Great things are not accomplished by those who yield to trends and fads and popular opinion” – Jack Kerouac
I shall start with some of the sketchier, shall we say “experimental” treatments that might be trendy, or even seem financially attractive, but which in fact offer little or no evidence of efficacy, at this time.
This is part one, and explores what almost certainly does not work, and if you are using these therapies, you should stop.
Part 2 will explore the therapies with stronger evidence of efficacy, therefore those you might consider using, and part 3 will look at those therapies that almost certainly do work and are backed up by strong evidence base. These you most certainly should be considering
Part 1: These therapies do not work for PHP
Mesenchymal Stem Cell Therapy (MSC)
The Australasian College of Sports Physicians position statement 2017 immediately cuts to the chase and states
- That MSCs are experimental and are not proven safe or effective for clinical use.
- The long-term harms from the use of MSCs have not been determined.
- That the patient is being offered a therapy that has not been validated through reliable research methods.
So, if you are considering delving into the very murky world of MSC Therapy, don’t.
Low Level Laser
What is it?
- LLLT is the application of red and near infra-red light within the band width of 600-1000 nanometers.
- LLLT is purported to improve wound and soft tissue healing, reduce inflammation and relieve both acute and chronic pain.
The actual therapy may be either Laser Diode or LED with the laser diode machines commonly utilising either a gallium arsenide (GaAs) diode or a gallium aluminum arsenide (GaAlA) diode.
So, does it work? Well, there have been 2 quite strong studies on the therapy, one showing reduced migration of inflammatory cells and improved quality of repair while reducing the functional limitations. (Casalechi et al Lasers in Medical Science; November 2013) and LLLT decreased Achilles tendon’s inflammatory process. De Jesus et al, Lasers in Medical Science; July 2014
The unfortunate caveat is that both these studies were on rats, and there is no convincing study at all showing any reliable efficacy for LLLT in the treatment of PHP.
A randomized and placebo-controlled study provided evidence for using low-level laser therapy for pain reduction, but not for altering plantar fascia morphology, in individuals with heel pain/plantar fasciitis. Kiritsi and colleagues studied the effects of gallium-arsenide infrared diode laser and placebo irradiation, respectively, on VAS pain rating and sonographic measurements of plantar fascia morphology. Treatments were provided 3 times weekly for 6 weeks. Data for 25 patients who completed the entire study protocol were analyzed. Pain measurements demonstrated statistically significant but clinically small effects favouring low-level laser therapy for night rest pain.
Conversely, data from one of the very few other randomized studies failed to support the clinical effectiveness of low-level laser therapy to address symptoms in individuals with plantar fasciitis.
There is insufficient evidence in the published, peer-reviewed scientific literature to demonstrate that LLLT is effective. The question that must always be front of mind is
Is there an advantage over existing treatment modalities we use?
There is limited evidence for the efficacy of LLLT for the immediate reduction of pain in cases of PHP. However, it is my view that this is taking a sledgehammer to the nail, and that there are far simpler methods that are more cost effective and likely more effective.
My next quote?
“It has become appalling obvious that our technology has exceeded our humanity” – Albert Einstein
Why would I bother you may ask? Because, after years of evidence showing it does not work it is still being used. Many years ago, renowned Adelaide Physio Dave Butler labeled ultrasound as “ultrabullshit”, at a time when every physio practice in Australia had an ultrasound machine!
A recent review by Shanks et al concluded that:
There is currently no high-quality evidence available to support therapeutic ultrasound in the treatment of musculoskeletal conditions of the lower limb.
This review included a study by Crawford and Snaith, who found ultrasound (0.5 W/cm2 power, 3-MHz frequency, 1:4 pulsed duty cycle) delivered for eight 8-minute sessions at a frequency of twice weekly for 4 weeks no more effective than a sham treatment in treating those with heel pain.
Platelet Rich Plasma (PRP)/Autologous blood
The use of PRP / AB for the treatment of PHP can possibly be best summed up by a very recent paper which compared PRP infiltration to corticosteroid infiltration. The paper concluded:
“the treatment of plantar fasciitis with steroid or PRP injection was equally effective”
In other words, PRP is equally as effective as Corticosteroid, which, is not AT ALL effective in the management of PHP. The evidence is fairly clear that PRP / AB is not effective in the management of PHP.
The results of 2 systematic reviews failed to yield evidence favoring any substantive clinical benefit of ICSI for patients with heel pain / plantar fasciitis. (here and here)
Potential harms associated with ICSI may include injection-site pain, infection, subcutaneous fat atrophy, skin pigmentation changes, plantar fascia rupture, peripheral nerve injury, and muscle damage.
Any perceived benefit associated with infiltration of corticosteroid (understanding there is no defined mechanism of pathway or efficacy) does not offset the risk for harms, including long-term disablement.
Trigger Point and Dry Needling Therapy
It hurts me to report on this, because my own personal N=1 of experience with acupuncture and trigger point therapy has been outstanding in relation to my own PHP.
However, this is what the evidence tells us that the literature on the topic is frankly a shambles. Non randomised studies, case reviews, opinion pieces and totally inappropriate study designs.
Based on this, there is currently insufficient evidence to recommend the use of dry needling, trigger point therapy or acupuncture in the treatment of PHP
These are the therapies that we can fairly confidently say we should be discarding. With the exception of dry needling / acupuncture and CS infiltration, I doubt many of you are currently involved with these techniques. If you are, reconsider because your treatments are not evidence based, and read part 2, which covers treatments that MIGHT work.
This was originally posted on Simon Bartold’s website. You can click here to read more blogs from him.
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If you have a question, suggestion or a link to some related research, share below!
Are you going to upload Part 2 and 3on Physionetwork as well?
Please, can you upload Part II? This was very very interesting!
I suggest more research to be conducted on the effectivement of therapeutic Ultrasound on PHP . I propose this time with ; 1.5W/Cm² Power, 1MHz Frequency ( could provide a deeper penetration to the plantar fascia through the tick heel skin) and on a Continuous mode ( plantar fasciitis often being chronic ).
Are you going to upload Part II on Physionetwork as well?