Treatment of Plantar Heel Pain - A Literature Review
Introduction[edit | edit source]
Plantar heel pain (PHP) is regarded as a multifactorial condition with a number of proposed associated factors. It is generally viewed as a self-limiting condition and for the majority of individuals with PHP, the symptoms resolve within one year without any therapeutic intervention. Twenty percent of individuals, however, continue to experience PHP beyond a year.
Because the aetiology of PHP is generally not well understood, there is uncertainty about its management. There is a lack of high quality evidence regarding optimal treatment. This leaves clinicians with a variety of treatment options, but no clear guidance on what works best and no firm, evidence-based advice about the optimal management of PHP.
This lack of guidance prompted Grieve et al to conduct a survey asking UK-based physiotherapists to identify which interventions they used to treat PHP (Figure 1).
The results of this survey highlighted the need to search the available research in order to establish which treatment options are available and effective in the management of plantar heel pain syndrome (PHPS).
When considering the research, it is important to keep in mind that the term “significant difference” is a statistical value and not always reflective of a difference / change that would be meaningful for the patient. It is, therefore, also important to consider the “minimal important difference” (minimal clinically important difference / change) or the “smallest change in treatment outcome that an individual patient would identify as important, and which would mandate a change in the patient’s management”.
Which treatments should then be used for patients with PHPS? The physiotherapy and medical treatments shown in Figure 2 will be discussed in this review, with the aim of identifying treatment options supported by high-quality research studies.
Figure 2. Treatment options proposed for PHPS 
Physiotherapy Treatments[edit | edit source]
A large variety of physiotherapy treatment options for PHPS have been discussed in the literature and will be reviewed in the following section (Figure 3).
Figure 3. Physiotherapy treatment options proposed for PHPS 
Ultrasound[edit | edit source]
Therapeutic ultrasound is one of the electrical devices most widely used by physiotherapists despite the fact that there is not sufficient high-quality evidence to support its use in musculoskeletal conditions. Many studies investigated the use of ultrasound and found therapeutic ultrasound to be ineffective for the treatment of PHP. Its use is, therefore, not recommended for individuals with PHPS (Figure 4). 
Figure 4. Studies investigating the treatment of PHP by ultrasound
Stretching[edit | edit source]
Stretching of the triceps surae muscles has been proposed in many studies as an essential part of the management of plantar fasciitis. The aim of stretching is to release tension in the Achilles tendon and plantar fascia, both of which attach to the calcaneus. Many studies have investigated the use of stretching for the treatment of PHPS, often with conflicting results. Several studies compared the use of various stretches for PHPS and generally found that all groups improved. Barry et al also reported a shorter recovery time with the use of night splinting (Figure 5).
Some studies compared stretching to various other treatment interventions (sham US, ESWT, strengthening) and generally found no differences between groups, and that all groups improved. Stretching was therefore not found to be superior to other forms of treatment (Figure 6). 
In a systematic review analysing the effectiveness of manual stretching for PHPS, Sweeting et al reported:
- Conflicting results
- One study showed placebo to be equally effective to stretching
- Another study showed stretch to be more effective than EWST
- Intermittent or sustained methods of stretching were equally effective
- A non-weight bearing stretch of the plantar fascia could be more effective than a weight bearing dorsiflexion stretch
Strengthening[edit | edit source]
Weakness of the intrinsic foot muscles, as well as the ankle plantar flexors have been proposed as risk factors for the development of PHPS and prompted the use of strengthening as a treatment for PHPS. Several studies investigated the effect of strengthening on PHPS and reported improvement in all groups with no advantage to strengthening in the management of PHPS, except after 3 months of plantar-specific strengthening (Figure 6).
Manual Therapy[edit | edit source]
Physiotherapists often use manual therapy to improve joint mobility, mobilise soft tissue and reduce pain. Current literature on the use of manual therapy for patients with PHP is, however, sparse and often of lesser quality. Cleland et al conducted a study on the efficacy of manual therapy and exercise (MTEX) compared to electro-physical agents and exercise (EPAX) in the management of PHPS (Figure 7). Both treatment groups, however, received multiple different interventions - this is problematic when attempting to interpret which intervention made the difference (Figure 8). The authors concluded that all patients improved with statistically significant differences between groups regarding pain and global improvement favouring MTEX (Figure 9). There is, however, not enough information about the clinical effects of the treatment.
Shashua et al also investigated the effect of manual therapy on plantar fasciitis (Figure 10) with the treatment group receiving manual therapy, ultrasound and stretch exercises and the control group only ultrasound and stretch exercises (Figure 11). They reported an improvement in both groups with no difference between groups, indicating no additional advantage to manual therapy for PHPS (Figure 12).
Taping[edit | edit source]
Taping is proposed to be associated with pain reduction, increased circulation and improved proprioception, all of which would be beneficial for the management of PHPS. Radford et al applied standardised leukotape to the plantar skin of patients and kept it in situ for 7 days. This group was compared to a control group. Both groups improved and there was no significant reduction in heel pain intensity in the taping group compared to the controls. First step pain, however, was significantly better in the taping group compared to the controls (Figure 13).
Tsai et al compared the use of kinesiotape for plantar fasciitis, applied over the gastrocnemius and plantar fascia and kept in situ for one week, to a control group (Figure 14). Both groups reported a significant reduction in pain and there was a significant difference in pain reduction between the groups, but this was also reported before the intervention. No differences in plantar fascia thickness were found between groups. This study, however, had insufficient information to accurately interpret its measurements and come to a final conclusion about the treatment effects (Figure 15).
Dry Needling[edit | edit source]
The presence of myofascial trigger points within the musculature of the plantar foot, as well as the muscles proximal to the foot, has been proposed to play a role in PHPS. Dry needling of these myofascial trigger points has, therefore, been proposed for the management of plantar fasciitis. Limited evidence for the effectiveness of dry needling was, however, reported in a systematic review on dry needling for PHPS and the poor quality of the studies mean it is not possible to make definite conclusions. Following this, Cotchett et al conducted a study to determine the efficacy of trigger point dry needling for PHPS (Figure 16) and compared “real dry needling” into the myofascial trigger points of a variety of muscles (Figure 17) to sham dry needling. They found that even though real dry needling provided statistically significant reductions in PHP compared to sham dry needling, the size of the effect was not clinically meaningful (Figure 18).
Cryotherapy[edit | edit source]
Ice/cryotherapy is generally considered as a basic component in the management of any injury due to its proposed effectiveness in reducing swelling and relieving short-term pain. Thus, as for many other musculoskeletal conditions, it has also been proposed as a treatment option for PHP. Costantino et al  conducted a study comparing cryoultrasound to only cryotherapy and found that all patients improved, but the ultrasound group showed a larger improvement (Figure 19).
Medical Treatments[edit | edit source]
While it varies between countries and depends on scope of practice, many of the following treatments are often not performed by physiotherapists, but rather by medical doctors. They are mostly used after failure of conservative management (Figure 20).
Figure 20. Proposed medical treatments for the management of PHPS 
Orthotics[edit | edit source]
Four high quality studies investigating the effect of a variety of foot orthoses / insoles in PHPS were identified (Figure 21 and Figure 22). They provided varied and somewhat conflicting results on the efficacy of various insoles for PHPS and generally reported improvement in all groups with no consistent benefit to any one orthosis (Figure 23).
Figure 21. Good quality studies on the use of orthoses/insoles for PHPS 
Figure 23. Results on the most effective insole for PHPS 
Winemiller et al  compared the effect of magnetic versus sham-magnetic insoles on PHP and found no benefit to magnetic insoles compared to sham-magnetic inserts (Figure 24).
Extracorporeal Shock Wave Therapy[edit | edit source]
Extracorporeal shock wave therapy (ESWT) has been used since 1976 to disintegrate kidney and gallstones (lithotripsy) and for several decades as a non-invasive pain-relief treatment option for failed conservative management of plantar fasciitis before surgical intervention. ESWT involves an electromagnetic system where a magnetic field in a surrounding fluid medium is used to produce shock waves. Abrupt, high-amplitude pulses of mechanical energy (similar to sound waves) are generated by an electromagnetic coil or a spark in water. The shock waves are proposed to stimulate angiogenesis (new blood vessels) and neurogenesis (new nerve cells). Its mechanism of action is still not well understood, but proposed to be through the destruction of unmyelinated nerve fibres with simultaneous stimulation of neovascularisation and collagen synthesis. The cells therefore appear to undergo micro trauma which promotes the inflammatory and catabolic processes associated with the removal of damaged matrix waste and stimulation of wound healing mechanisms. In short, ESWT should:
- Increase blood supply
- Improve collagen remodelling
- Enhance waste elimination
Several studies, many of poor methodological quality, explored the effect of ESWT on PHPS with conflicting results (Figure 25).
Of the studies reviewed, only Gerdesmeyer et al reported a significant improvement in pain, function and quality of life with ESWT whereas others had conflicting results. Rompe et al compared ESWT to stretching techniques and found stretching to be more advantageous than ESWT at 2 and 4 months (Figure 26).
Following the results of their systematic review, Yu et al  reported inconsistent evidence on the effectiveness of ESWT for PHPS and stated that the current evidence does not support the use of ESWT for PHPS.
Steroid Injections[edit | edit source]
Corticosteroid injections are used in multiple musculoskeletal conditions, including PHP, as a way of relieving pain. In a Cochrane review, David et al  reported low quality evidence that local steroid injections may slightly reduce PHP for up to one month, compared to placebo or no treatment (Figure 27).
Surgery[edit | edit source]
Surgical interventions are generally not considered for plantar fasciitis until conservative treatment has been thoroughly pursued and symptoms have been present for more than 6 months. Plantar fasciotomy will only be considered if conservative therapies have been ineffective and significant symptoms continue to persist. Plantar fasciotomy involves:
- an open procedure
- either a partial release of the medial one-third of the plantar fascia
- or a complete release of the fascia
The outcomes following plantar fasciotomy vary but it generally shows good early pain relief and return to function in the short term. However, many individuals experience ongoing pain and functional limitations and a retrospective study by Gibbons et al demonstrated that even though 72 percent of patients reported long-term satisfaction with the surgery, 44 percent continued to experience ongoing pain, swelling and tenderness (Figure 28).
Conclusion[edit | edit source]
From the literature explored, it seems that stretches could possibly help for PHPS and strengthening may be beneficial, but the available evidence does not support any of the commonly used treatments for PHP as significantly better than any other. At the moment, there is limited evidence upon which to base clinical practice, which poses a professional spur for clinicians as it relates to the risk factors, assessment and management of PHPS.
From the literature reviews on these topics in PHPS, it has been shown that there is some information on the risk factors associated with PHPS, no evidence for the assessment of PHPS and very little information on the management of PHP (Figure 29). This prompts us to the next course in this series, the pursuing of a new protocol for PHPS.
Figure 29. Known variables from the literature reviews on risk factors, assessment and treatment of PHPS 
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