A New Protocol for Plantar Heel Pain

Original Editor - Merinda Rodseth based on the course by Bernice Saban


Top Contributors - Merinda Rodseth, Jess Bell and Rucha Gadgil  

Introduction[edit | edit source]

The previous literature reviews on the risk factors, evaluation and management of plantar heel pain (PHP) identified a lack of support for any of the commonly used assessment and treatment options for this condition.[1][2][3][4] This highlighted that there was a need for appropriate methods to assess and manage PHP and led to the development of a new tool for PHP.[5] This protocol involves:

  • an assessment tool
  • manual therapy and
  • exercises

Assessment Tools for Plantar Heel Pain[edit | edit source]

A comprehensive physical examination is essential for the effective diagnosis and management of plantar heel pain syndrome (PHPS) and effective assessment tools are required. Assessment tools have, over time, become more sophisticated and technologically advanced, but even these advancements have not enhanced the assessment of PHP. Historically, physical examination tests have been an essential part of clinical assessments as they are more readily available and less expensive than diagnostic imaging methods.[6]

In an attempt to find an accurate means of assessing PHP, two tests were found to reproduce the heel pain experienced by an individual with PHPS during a regular foot and ankle evaluation. These were the:[5]

  • Single leg heel raise
  • Single leg mini squat (half squat) (Figure 1)

PHPS reproduction exercises.jpg

Figure 1. Two clinical tests that reproduce PHP

This raised the question of why these tests would provoke pain in the heel (Figure 2).[5] Considering that PHPS is associated with weight-bearing, could the reproduction of the pain be attributed to an increase in weight-bearing? Yet during these movements, the weight is shifted from the heel to the forefoot, thus reducing weight-bearing on the heel.

If not because of increased weight-bearing, could these tests be causing increased stress in the plantar fascia? But once again, when analysing these motions, this does not seem likely.[5] During the single-leg heel raise, the increased extension of the toes might increase tension in the fascia, but plantarflexion at the heel reduces this tension. Similarly, during the single leg mini squat, dorsiflexion of the ankle increases fascial tension, but this is reduced by flexion of the knee.[5] Thus, if there is an increase in fascial tension, it will be minimal considering how these movements cancel each other out.

Figure 2. Proposed reasons for pain provocation in the heel

Based on these findings, Saban and Masharawi[4] investigated if these tests were able to reproduce heel pain in a larger population, and conducted a clinical trial involving 40 patients with a typical presentation of PHP (Figure 3).[5]

Inclusion criteria for study by Saban and Masharawi 2017.jpg

Figure 3. Inclusion criteria for participants in the trial assessing the reliability of three clinical tests for assessing PHP[4][5]

Three tests were included in the study - the single leg static stance test, single leg half squat and the single leg heel raise. The test measures are described in Figure 4.[4][5]



Description of clinical tests used for Ax of PHPS.jpg

Figure 4. Description of the clinical tests used[4][5] (P1 refers to the appearance of pain)

The measures used to assess the tests included (Figure 5):[4][5]

  • The appearance of the first painful sensation (P1) assessed with the visual analogue scale (VAS). The performance (i.e. repetitions / seconds) was also recorded
  • The functional status of the patient, measured using a computerised version of the Lower Extremity Functional Scale (LEFS)


Outcome measures in Saban and Mashawari 2017.jpg

Figure 5. Outcome measures utilised [4][5]

The aims of this study were to investigate whether:

  • These tests were reliable and valid in patients with PHPS
  • Combining the three tests would enhance the possibility of a positive test response from each patient[4][5]

The study procedure was as follows:

  • The patient was interviewed and completed the functional status questionnaire
  • This was followed by an assessment of the patient by Rater 1 using the three clinical tests
  • These same tests were re-assessed 30 minutes later by Rater 2 as a measurement of the interrater reliability of the tests
  • The patient was then reassessed by Rater 1 one week later in order to establish the intrarater reliability of the clinical tests (Figure 6)[4]

Study procedure Saban and Masharawi 2017.jpg

Figure 6. The procedure of the clinical trial[4][5]

Moderate to high levels of interrater and intrarater reliability were reported for all the tests and a correlation was reported between the level of pain (VAS) and the functional scale (LEFS) (Figure 7).[4]

Reliability of the measures used in Saban and Masharawi 2017.jpg

Figure 7. Reliability indices for the clinical tests[4][5]

Figure 8 illustrates the frequency of a positive pain response for each individual test and combination of tests.[4][5]

Frequency of positive pain response Saban and Masharawi 2017.jpg

Figure 8. Frequency of a positive pain response for the clinical tests

It is important to also mention that some of the patients only experienced pain towards the end of the testing protocol, which indicates that many repetitions might be needed to reproduce the patient’s pain.

In conclusion on the assessment tools, the study by Saban and Masharawi[4] indicates the existence of simple, relevant and reliable clinical tests that are performance-based, easily applied and appropriate for the assessment of PHPS.

Considering the presence of pain in the heel with PHPS, the source of pain has often been assumed to be at the level of the heel. This is a prime example of the thought distortions described by Daniel Kahneman when he posed his quiz question described in Figure 9.[7] If one opens his / her mind and looks further, it becomes clear that the pain experienced in PHPS might not be in the heel after all.[5]

Quiz question Daniel Kahneman.jpg

Figure 9. Quiz question by Daniel Kahneman[5][7]

Treatment Protocol for PHP[edit | edit source]

No definite conclusions have been made about the treatment of PHPS due to a lack of high-quality evidence.[1][2][3][4][8] Hence, following the above discussion on the assessment of PHP, it is necessary to consider how to progress to the treatment of this condition. If the heel pain provoked during testing is not caused by an increase in weight-bearing or fascial stress, could it be due to a contraction of the calf muscle? This should be considered given that the:

  • Heel raise test incorporates concentric contraction of the calf muscles
  • Half-squat test involves eccentric contraction of the calf muscles

Manual palpation of the plantarflexor muscles in the posterior calf on the affected leg in patients with PHPS revealed stiff, non-compliant and painful soft tissue.[9] Thus, a treatment protocol directed at the posterior calf muscles was proposed by Saban et al.[9] The aim of their study was to compare deep soft tissue massage of the posterior calf to a more common treatment approach directed at the heel (Figure 10).[9]

Aim of study posterior calf treatment for PHPS Saban 2014.jpg

Figure 10. Aim of the study by Saban et al [9]

In this study, participants were divided into a study and a control group. The control group received a stretching protocol and ultrasound with commonly used settings while the study group received the same stretching protocol combined with deep tissue massage of the posterior calf muscles and a neural stretch (Figure 11).[9]

Study protocol Saban et al 2014.jpg

Figure 11. Study protocol of the study by Saban et al.[9]

The primary outcome measure in this study was a functional status questionnaire (computerised version of LEFS). The secondary measure was the level of first-step pain in the morning (VAS).[9] A visual representation of the flow of patients through the study can be found in Figure 12.[9]

Flow of patients through study by Saban et al 2014.jpg

Figure 12. Flow of patients through the study by Saban et al[9]

The characteristics of the patients at baseline were also compared by groups to look for similarities between groups at baseline. No statistically significant differences were found between groups at baseline (i.e. similar age, chronicity of heel pain and similar scores on the functional scale and VAS scale at intake) (Figures 13 and 14).[9]

Baseline characteristics gender .jpg

Figure 13. Baseline patient characteristics by treatment group [5][9]

Baseline characteristics outcomes.jpg

Figure 14. Baseline patient characteristics by treatment group [5][9]

Completion rates were similar between groups and also corresponded to those of two other studies investigating similar aspects to the study (Figure 15).[9][10][11]

Completion rates of study by Saban et al 2014.jpg

Figure 15. Treatment completion rates[9][10][11]

The results on the primary outcome of the study indicated that even though both groups improved on the functional scale, the deep massage group (DMS) improved by 15 points compared to the 6 point improvement in the ultrasound / control (USS) group (Figure 16).[9] Wang et al.[12] indicated that a change of 8 points is needed for any change to be clinically significant. Thus, even though the USS group improved statistically, there was no real clinical change whereas the DMS group improved both statistically and clinically (Figure 16).[9]

Results of study by Saban et al 2014.jpg

Figure 16. Results of the functional scale scores [5][9]

The level of first-step pain in the morning (VAS) decreased similarly in both groups with no significant difference (Figure 17).[9] This could indicate that the complaint of first-step pain in the morning might only be one part of PHPS and that patients have other functional limitations that were picked up by the functional scale score (LEFS).[5]

Results of VAS in Saban et al 2014.jpg

Figure 17. Results of VAS for first-step pain in the morning [5][9]

In the study by Saban et al.,[9] deep massage therapy to the posterior calf muscles and neural mobilisation combined with stretching exercises had superior short-term functional scale outcomes compared to ultrasound treatment with stretching exercises. This treatment protocol is easy to use and effective for PHP and could therefore be recommended for individuals with PHPS.[5][9]

There are, however, some limitations to this study, including:[9]

  • No record of daily self-exercise compliance
  • Short-term results only
  • DMS group performed one additional exercise (SLR with dorsiflexion) thereby introducing an additional variable into the trial

This treatment approach is also supported by two other studies performed by Renan-Ordine et al.[13] (Figure 18) and Ajimsha et al.[14] (Figure 19). Renan-Ordine et al.[13] suggested myofascial trigger point therapy of the calf for PHP, but the results of the study are not that clear and the clinical effect is unknown (Figure 18). Amjisha et al.[14] investigated the effect of myofascial release of the calf in PHP and found a clear difference between groups with the myofascial release group performing much better compared to the control sham ultrasound group (Figure 19).

Results of study by Renan Ordine 2011.jpg

Figure 18. Results of the study by Renan-Ordine et al.[13][5]

Results of study by Ajimsha et al 2014.jpg

Figure 19. Results of the study by Ajimsha et al. [14][5]

Conclusion[edit | edit source]

This new protocol for the assessment and treatment of PHP is showing promising results for the management of PHPS.[9][13][14][15] The next course in this series will investigate the anatomical features behind this protocol followed by details on how to apply this technique and manage a treatment session with a patient.

References[edit | edit source]

  1. 1.0 1.1 Morrissey D, Cotchett M, J'Bari AS, Prior T, Griffiths IB, Rathleff MS, Gulle H, Vicenzino B, Barton CJ. 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 Mar 30. 
  2. 2.0 2.1 Salvioli S, Guidi M, Marcotulli G. The effectiveness of conservative, non-pharmacological treatment, of plantar heel pain: a systematic review with meta-analysis. The Foot. 2017 Dec 1;33:57-67.   
  3. 3.0 3.1 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.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Saban B, Masharawi Y. Three single leg standing tests for clinical assessment of chronic plantar heel pain syndrome: static stance, half-squat and heel rise. Physiotherapy. 2017 Jun 1;103(2):237-44. 
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 5.23 5.24 Saban B. A New Protocol for Plantar Heel Pain Course. Physioplus. 2021.
  6. Schwieterman B, Haas D, Columber K, Knupp D, Cook C. Diagnostic accuracy of physical examination tests of the ankle/foot complex: a systematic review. International journal of sports physical therapy. 2013 Aug;8(4):416.    
  7. 7.0 7.1 Kahneman D. Thinking, fast and slow. New York: Farrar, Straus & Giroux. 2011.
  8. Rasenberg N, Bierma-Zeinstra SM, Bindels PJ, van der Lei J, van Middelkoop M. Incidence, prevalence, and management of plantar heel pain: a retrospective cohort study in Dutch primary care. British Journal of General Practice. 2019 Nov 1;69(688):e801-8.     
  9. 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 9.18 9.19 9.20 9.21 9.22 Saban B, Deutscher D, Ziv T. Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial. Manual Therapy. 2014 Apr 1;19(2):102-8.   
  10. 10.0 10.1 Bezalel T, Carmeli E, Katz-Leurer M. The effect of a group education programme on pain and function through knowledge acquisition and home-based exercise among patients with knee osteoarthritis: a parallel randomised single-blind clinical trial. Physiotherapy. 2010 Jun 1;96(2):137-43.
  11. 11.0 11.1 Deutscher D, Horn SD, Dickstein R, Hart DL, Smout RJ, Gutvirtz M, Ariel I. Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice. Archives of physical medicine and rehabilitation. 2009 Aug 1;90(8):1349-63.
  12. Wang YC, Hart DL, Stratford PW, Mioduski JE. Clinical interpretation of a lower-extremity functional scale–derived computerized adaptive test. Physical therapy. 2009 Sep 1;89(9):957-68.
  13. 13.0 13.1 13.2 13.3 Renan-Ordine R, Alburquerque-SendÍn F, Rodrigues De Souza DP, Cleland JA, Fernández-De-Las-Penas C. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2011 Feb;41(2):43-50.   
  14. 14.0 14.1 14.2 14.3 Ajimsha MS, Chithra S, Thulasyammal RP. Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Archives of physical medicine and rehabilitation. 2012 Apr 1;93(4):604-9.   
  15. Pollack Y, Shashua A, Kalichman L. Manual therapy for plantar heel pain. The Foot. 2018 Mar 1;34:11-6.