Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values

Key Points

1. Plantar heel pain can be a chronic condition characterized by first-step pain, pain after weight bearing following periods of rest or pain during weight bearing activities performed for longer duration.
2. The first line of treatment should comprise of plantar fascia stretching, taping and patient education followed by shockwave therapy, then custom orthoses and other adjunctive interventions in that order.
3. Patient education should address four main aspects, which are load management (sedentary versus athletic population), pain monitoring, addressing related comorbidities and advice on appropriate footwear.

BACKGROUND & OBJECTIVE

The management of plantar heel pain (PHP) is difficult due to its varying causes and contributing factors, making it challenging to choose the most appropriate intervention (1). Each person experiences PHP in a different manner, and what is effective for one person may not be effective for another. This, along with the lack of quality evidence, can lead to confusion about which interventions are the most effective for PHP and when to use them.

This review aimed to establish a systematic treatment guideline for the management of PHP based on high-quality evidence, expert clinical reasoning and patient experiences.

The management of plantar heel pain is difficult due to its varying causes and contributing factors.

It is important to base treatments on symptom change using patient-reported outcome measures.

METHODS

• This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and screened nine electronic databases and reference lists of relevant studies.

• The studies included in the review were randomized controlled trials (RCTs) that evaluated the effectiveness of interventions for PHP and were conducted until October 2019.

• Participants in the studies were over 16 years of age and experienced pain on the plantar aspect of their heel during weight bearing after rest or prolonged weight bearing.

• The included studies compared different interventions for PHP with another intervention, placebo, sham, or a wait-and-see approach and had a minimum follow-up of two weeks.

• The studies were included if they used one of the three outcome measures: patient-reported pain, first-step pain, or foot-related function.

• Studies with participants who had PHP due to fracture, tumors, infections, or conditions with rheumatological, neural, vascular, or dermatological origins were excluded.

RESULTS

• A review was conducted on 51 studies, with 4,351 participants, 49% of whom were female.

• The plantar heel pain best practice guideline (BPG) was created by combining high-quality RCTs, input from 14 international expert clinicians, and surveying 40 patients.

• The BPG suggests starting with daily taping, stretching, and education (core treatment) for six weeks, with patient-reported outcomes to track symptoms. If core treatment is ineffective, shockwave therapy or customized orthoses may be used. A steroid injection may be considered after 6 weeks if other treatments fail.

• Clinicians should prioritize education and offer advice on pain management, related health issues, and proper footwear. Supportive, comfortable shoes with a higher heel are recommended. Walking barefoot or wearing flat shoes should be avoided until symptoms improve.

• The results, expert opinions, and patient experiences were in agreement.

LIMITATIONS

• There is a low quality of research in the field of PHP; this study found that only 51 out of 362 trials evaluating interventions for PHP met the inclusion criteria. This highlights a low overall quality of research in the field.

• There was a limited number of trials included: the same review that was used did not include 35 studies that were included in the more comprehensive review, reducing the number of trials that could be evaluated.

CLINICAL IMPLICATIONS

For the management of PHP, available evidence does not support the superiority of any of the commonly available treatments over another (2). This study provides a guideline on the interventions and timelines for a tailored approach to manage PHP, considering each patient's specific needs (see Figure 1). This study emphasizes the significance of basing treatments on symptom change using patient-reported outcome measures to promote better evidence translation and treatment.

Participants in the study reported gaps in the understanding of their condition, including the underlying pathology, causal factors, and efficacy of various treatments. The study findings provide clarity for those seeking information about treatments and to reduce the confusion caused by conflicting advice.

The recommended interventions have moderate to strong evidence for their effectiveness in pain management in the short-term. The expert interviews also suggested to consider the repeat application of the core treatment approach as the fourth line of treatment (if the adjunct interventions are ineffective). The study recommends refraining from incorporating ineffective interventions in clinical practice other than for research purposes.

+STUDY REFERENCE

Morrissey D, Cotchett M, Said J'Bari A, Prior T, Griffiths I, Rathleff M, Gulle H, Vincenzino, B, Barton C (2021) Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British Journal of Sports Medicine, 55, 1106 – 1118.

SUPPORTING REFERENCE

1. Latt LD, Jaffe DE, Tang Y, Taljanovic MS. Evaluation and Treatment of Chronic Plantar Fasciitis. Foot & Ankle Orthopaedics. 2020;5(1).
2. Babatunde OO, Legha A, Littlewood C, Chesterton LS, Thomas MJ, Menz HB, van der Windt D, Roddy E. Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. British journal of sports medicine. 2019 Feb 1;53(3):182-94.