Plantar Heel Pain Summary of Important Questions

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Top Contributors - Merinda Rodseth and Kim Jackson  

Introduction

Plantar heel pain (PHP) is a complex and multifactorial condition with many factors proposed to be associated with it (Sullivan 2020, Thomas 2019). The aetiology of PHP is generally not well understood which causes uncertainty regarding the most effective management thereof, making the condition difficult to effectively treat (Sullivan 2020, Thomas 2019). Following this, many questions arose during this series on PHP, which will can now be answered, based on the literature discussed.

Why Call it Plantar Heel Pain Syndrome?

Many terms have been used to describe pain under the plantar aspect of the heel but the majority of these terms are related to specific pathologies, even when the actual underlying pathology of pain under the heel remains largely unknown (Riel 2017, Cotchett 2020). Many clinicians have focused on the plantar fascia when presented with complaints of pain under the heel, but sufficient evidence now exists to indicate that the plantar fascia is not the only culprit (Riel 2017). The descriptive term “Plantar Heel Pain Syndrome” (PHPS) was hence proposed to describe the condition of pain under the heel where no differential diagnosis exists (Riel 2017, Rios-Leon 2019).

Why are Stretches to the Posterior Calf Muscles Helping Patients with PHPS?

Manual palpation of the plantar flexor muscles in the posterior calf on the affected leg in patients with PHPS revealed stiff, incompliant and painful soft tissue (Saban 2014). These myofascial restrictions of the posterior calf muscles have been implicated in the development of PHP as it interferes with the extensibility of the muscles and fascia, impeding optimal muscle functioning (Pollack 2017, Saban 2014). Damage to the muscle during injury prevents optimal contraction (widening) and relaxation (lengthening) of the muscle and healing of the muscle tissue is through scar tissue, which is less elastic and more fibrous than muscle tissue.

Deep Friction Massage (DFM) supports the muscle to contract and widen effectively as it breaks the adhesions between the muscle fibres limiting the contraction (Chaves 2020, Farooq 2019). It is the stretches, however, that will enable the muscle to recover its full length, improving its ability to relax and narrow (Pollack 2017).

Why was the Central Heel Area More Sensitive to Pressure During the Pressure Pain Threshold Studies?

It is not completely clear why the central heel area was so sensitive during the Pressure Pain Threshold (PPT) study performed by Saban & Masharawi (2016)(Figure 1), especially considering that there are almost no soft tissues in the heel area . No conclusive evidence exists that the fat pad can be a source of pain (Saban 2021). Anatomically, the medial calcaneal branch of the tibial nerve enters the heel from the medial side adn terminates in the skin of the heel, providing sensory innervation to the skin of the heel (Zhang 2021), which might explain the increased sensitivity to the pressure in this area (Figure 1). Figure 1.  PPT test sensitivity and the neural anatomy (Saban 2016)

Which Risk Factors are Associated with PHPS?

The literature review on risk factors associated with PHPS found no particular risk factors for the development of PHPS. However, individuals who were:

• Overweight
• Under exercising/sedentary
• Over exercising

could be at a slightly higher risk for developing PHPS. (Menz 2019, Saban 2014, Van Leeuwen 2016)

Which Treatment Techniques are Effective for the Management of PHPS?

Following the literature review on the treatments for PHPS, it is clear that many of the commonly used treatments for PHP are not effective or any better than placebo for the management of PHPS (Babatunde 2018, martin 2014). Saban et al (2014), however, found the use of deep massage therapy combined with stretching exercises and neural mobilisation an effective treatment for PHPS. As other commonly used techniques have not been proven effective for PHPS, they only serve to mislead patients, making them more passive in their treatments (Saban 2021). The “new protocol” for PHPS: (Saban 2021)

• Relies on our existing physiotherapeutic skills
• Upgraded our assessment and treatment skills
• Is a low tech and low cost intervention
• Is simple, but not easy as it demands a wide scope of knowledge of
  • what we are doing
  • why we are doing it (clinical reasoning based on anatomical knowledge)
  • dealing with different patients
  • how to build and manage the treatment sessions

Conclusion

In summary, the key concepts introduced and explored in this course included:

• Basic information about PHPS - the function of the heel in the gait cycle, pain location and behaviour, prevalence of PHPS
• Indepth literature review on the risk factors for PHPS and the assessment and treatment thereof (Figure 2)
• Clear identification of the need for a different approach for the effective management of PHPS

Figure 2. Known variables from the literature reviews on risk factors, assessment and treatment of PHPS (Saban 2021) The “new protocol” started with the observation of a poorly understood reaction to two commonly used assessment tests - the heelrise test and the minisquat test. Ultimately, it provided the means for the enhanced management of PHPS, through the use of the:

• Assessment tool (Figure 3)(Saban 2017)
• Manual therapy (Figure 4)(Saban 2014)
• Exercises (Figure 4) (Saban 2014)

Figure 3. Clinical tests in the assessment tool (Saban 2017)

Figure 4. Treatment following the New Protocol (Saban 2021)

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