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A new treatment pathway has been suggested for plantar heel pain (stabbing pain at the bottom of the foot). Existing guidelines lack clear, high-quality recommendations for how best to manage the condition. This study included published research, expert interviews and survey data from people with lived experience. Based on the best available evidence, the researchers set out a management guide for plantar heel pain.

Plantar heel pain (plantar fasciitis) is common, and its causes are poorly understood. It can indirectly cause long-term harm to people’s physical and mental health.

The new guide advises on which treatments should be offered first (core treatment), and which should be offered later, in a stepped approach, if earlier treatments are not effective.

The core approach is a 6 week package combining daily stretching exercises, daily foot taping, and education (about suitable footwear, for example). The 3 elements are all needed for the whole period. People with resistant plantar heel pain may then be offered shockwave therapy (energy waves directed at the affected area), followed by customised insoles. Education is critical to achieve good outcomes and prevent recurrence. People need to know that while treatment is likely to be successful, it may take several weeks or months for their symptoms to improve.

This guide could be immediately useful for both clinicians and people with the condition. Future research should evaluate its effectiveness and investigate the treatments that currently have insufficient evidence to support their routine use.

Further information on plantar heel pain is available on the NHS website.

What’s the issue?

Plantar heel pain commonly causes stabbing pain at bottom of the foot, near the heel. The pain is usually most intense during the first steps after waking up, when people say it feels like walking on broken glass. It can also be triggered by long periods of standing or inactivity. It can be debilitating and often reduces people’s quality of life.

Plantar heel pain is caused by degeneration of the band of tissue (fascia) that connects the heel bone to the base of the toes. The condition can affect people who are either sedentary or physically active. Risk factors include exercise that places excessive stress on the heel, poor footwear, being overweight and having an occupation that involves a lot of walking or standing. People aged between 40 and 60 are most at risk. It is estimated to affect 4% of the general population, and accounts for around 8% of all running injuries.

Treatments for plantar heel pain include rest, taping (wearing special tape around foot and ankle to support the arch of the foot), wearing supportive shoes, oral painkillers, and regular stretching exercises. Other potential interventions include muscle strengthening exercises, customised insoles, injections to help reduce inflammation (such as steroids), shockwave therapy or even surgery.

The most effective way of sequencing treatments is currently not well-defined. Current guidance from the National Institute for Health and Care Excellence (NICE ) was last revised in March 2020. It is based on variable quality evidence and does not recommend one treatment over another.

Researchers aimed to develop a best practice guide for the management of plantar heel pain.

What’s new?

The researchers pooled data from 51 studies, involving 4,351 participants in all. They then interviewed 14 specialists. In addition, 40 people with lived experience completed a survey on their experiences and expectations.

Published evidence, expert opinions, and the values of those with lived experience were largely in agreement. The researchers developed a best practice guide, which recommends a stepwise approach.

The guide recommends :

  • core (first-line) treatment combining daily taping, stretching, and tailored education for 6 weeks (strong evidence)
  • shockwave therapy if core treatment is not effective after approximately 6 weeks (strong evidence)
  • customised insoles if the shockwave therapy is not effective after approximately 8 weeks (moderate evidence)
  • steroid injection if customised insoles are not effective after approximately 6 weeks (weak evidence).

Clinicians highlighted the importance of education, since people often have a poor understanding of their condition. Clinicians can help people by setting out realistic expectations, which emphasise that, while treatment is likely to work, it may take time. Content needs to be tailored to individuals.

The guide suggests that clinicians provide people with advice on:

  • changing position to distribute bodyweight through the foot in different ways (load management); this can break up long periods of standing still, or help manage rapid changes to training in more athletic people
  • pain, including methods of self-monitoring, and an explanation of the pain response to address fears of long-term consequences
  • managing related long-term conditions, such as type 2 diabetes and increased body weight
  • wearing footwear that is supportive, comfortable and holds the heel higher than the ball of the foot; avoiding walking barefoot.

Why is this important?

The best practice guide produced by this study will help clinicians take a stepwise approach when treating people with plantar heel pain. The researchers hope their results will also help people with the condition who are searching for information on treatments; they often come across inconsistent advice online. Healthcare commissioners will also be interested in the guide as it suggests which approaches to support, including shockwave therapy.

What’s next?

Further work is needed to ensure education is delivered as effectively as possible. Guidance is needed on how to best ensure information is understood and acted on, and to make sure that fears are allayed.

The overall quality of research in the field is low. Many studies are small; and of the 362 trials assessed, only 51 were of high enough quality to include in this review. Well-designed trials are needed to evaluate the effectiveness of interventions. These include dry needling (using very thin needles to enter the skin and tissue), steroid injections and exercises to strengthen the leg muscles. Strong evidence for these approaches is currently lacking.

You may be interested to read

This Alert is based on: Morrissey D, and others. 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 2021;55:19

Information on heel pain from the Royal College of Podiatry.

NICE Clinical Knowledge Summary on plantar fasciitis: which provides primary care practitioners with guidance on best practice for its management.

Funding: This study was part-funded by the Higher Education England/NIHR Integrated Clinical Academic Programme.

Conflicts of Interest: Three of the study authors conducted trials evaluated in this review.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

As a physiotherapist, I treat people with musculoskeletal injuries and, in general, strengthening exercises work well for most conditions. But stretching appears to be more beneficial than strengthening for plantar heel pain. I was also surprised by the lack of good clinical trials of injections as this intervention is used a lot and it should be easy to test.

I’ve treated many patients who’ve had a series of different traditional treatments and not had good outcomes. A lot of them have got better with this combined core approach.

A long-held assumption is that plantar heel pain is a self-limiting condition (and resolves by itself). But this is not true, and people have had to suffer for a long time. This should no longer be the case.

Dylan Morrissey, Clinical Professor and Consultant Physiotherapist, William Harvey Research Institute, Queen Mary University of London 

Royal College of Podiatry 

The complexity of plantar heel pain management provides a challenge for most podiatrists. This research starts to address gaps in understanding. It collates evidence from multiple sources and promotes best practice in the management of plantar heel pain.

Care plans often need to be tailored to each individual. Guidance, informed by research, allows for judgement and reasoning to be at the centre of discussions with patients. This paper is a useful starting point in the conversation on the management of heel pain and will provide primary care and GPs with additional knowledge around the complexity of this complaint.

The key points should be digested and applied to existing knowledge. Further experimental research is still required to examine interventions used for heel pain and the Royal College of Podiatry welcomes continued study of this condition.

Helen Branthwaite, Musculoskeletal Project Lead, Royal College of Podiatry, and Senior Lecturer in Clinical Biomechanics, Staffordshire University 

Physiotherapist 

This study provides a useful stepped care approach allowing sound evidence-based practice to be applied to the management of plantar heel pain. It provides confidence in early assessment, encourages people to actively self-manage their condition – and it is easy to follow.

It will improve the standard of care delivered.

Shane Collins, Senior Physiotherapist, Health Service Executive (HSE) 

Lived experience

My late father had this condition for many years. I also sometimes have plantar heel pain so this research is relevant to my family.

The findings will hopefully lead to greater awareness of the condition. Existing local and national policies need to be updated. We need a greater range of services and more flexibility in the support available and how it is accessed.

There should be more emphasis on prevention of plantar heel pain. But once people have the condition, they need more person-centred care. People want to know whether NHS services are provided locally. They need assistance that is easily accessible, and available at minimum cost and minimum inconvenience.

Manoj Mistry, Public Contributor, Greater Manchester

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