Plantar fasciitis or heel pain, is a condition often described as being worse when walking first thing in the morning or after periods of rest. Heel pain most commonly affects people aged 40-60, people who are overweight and 10% of runners. It accounts for between 11-15% of foot complaints that require professional treatment such as podiatry (1).
With heel pain being so common, the services that the professionals provide is based on evidence from clinical trials. There’s also services that are the result of clinical experience within their field of expertise.
‘Evidence based treatment’ means it is based on repetitive outcomes of clinical trials. ‘Anecdotal treatment means’ “in my experience people have responded well to this”. The blow example explains both.
As an experienced podiatrist, I offer soft tissue manipulation and dry needling of the plantar fascia and soleus muscle, to reduce stress on the Achilles tendon. Thanks to these methods I’ve seen benefits to my patients while treating their heel pain. I also strap peoples feet at initial consultation and prescribe stretching of the calf muscle and plantar fascia. These treatments are evidence based.
A good health care professional will fully inform you of the reason for why they recommend a particular treatment but should also follow evidence based methods when treating your heel pain. Treatment steps are listed below.
- The first step to heel pain management in all cases is to identify the repetitive aggravating factor and reduce it. This means rest from running and standing. This can improve heel pain symptoms in 25% of cases (2).This should be combined with stretches that target both the calf muscle and plantar fascia. The current guidelines suggest a sustained (3 minutes) or alternating (20 seconds) stretch repeated 3 times over and at 3 different times a day (3). One study has reported heel pain symptom improvement in 96% of cases because of this targeted stretching (4).
- Strapping has been shown to offer short term relief of heel pain (7-10 days). Although the evidence is weak, guidelines recommend it remains a primary initial therapy at first session (3). Low dye taping is the method most supported by evidence but expert techniques will differ to allow for taping to be applied by patients at home.
- Orthotics have been shown to improve plantar fascia heel pain and improve foot function in the first 3 months of treatment (5). Many orthotic types exist (out of a packet and custom made) and there’s no clinical evidence that proves one is better than the other. As your podiatrist, though, I can advise based on my clinical experience that a custom orthotic made from semi-rigid plastic will last longer (up to 10 years). Orthotics are not always needed for the treatment of heel pain.
- Physical therapies such as dry needling, acupuncture and manual therapies, although popular, have little clinical evidence for their use in heel pain management on their own. One reason is they relieve a symptom and do not address the cause.For example, if you come to my clinic and I provide a dry needle session for your heel pain, your symptoms will immediately improve. It’ll return, though, if not used with other steps because the source of the pain hasn’t been addressed. Think of it as being issued morphine because you trod on a nail and the nail isn’t removed. These therapies should always be offered in addition to steps 1 and 2.
- Anti-inflammatory medication can be effective in the short term (up to 4 weeks) but must be taken regularly. Cortisone injections can be considered but only after initial therapy has failed (6-12 months) (3).
- Surgery should always remain a last resort for the treatment of heel pain. Guidelines suggesting after 12 months or more of failed conservative treatment (1). Please note, the evidence for effective treatment from surgery in the management of heel pain is lacking. Patients may experience symptoms of surgery for up to 2 years. Symptoms range from fractures, nerve damage and a change in foot shape.
References
- Buchbinder R. Plantar fasciitis N Eng J Med. 2004; 350: 2159-2166.
- Wolgin M, Cook C, Graham C, et al. Conservative treatment of plantar heel pain: long-term follow up. Foot Ankle Int. 1994; 15: 97-102
- Mcpoil TG, Martin RL, Cornwall MW, et al. Heel pain – plantar fasciitis: Clinical practice guidelines linked to the international classification of functioning, disability, and health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008:38(4).
- DiGiovanni BF, Nawoczeneski DA, Malay DP, et al. Plantar Fascia-Specific Stretching Exercise Improves Outcomes in Patients with Chronic Plantar Fasciitis: a prospective clinical trial with two year follow up. J Bone Joint Surg Am. 2006; 88:1775-1781.
- Landorf KB, Kreenan AM & Herbert R. Effectiveness of Foot Orthoses to Treat Plantar Fasciitis: a randomized trial. Arch Intern Med. 2006;166:1305-1310
