WHAT’S THE EVIDENCE FOR TREATING PLANTAR HEEL PAIN?

Plantar Heel Pain (PHP) will be a hot topic at this year's Biomechanics Summer School, with Trevor Prior presenting findings regarding the management of this condition which are, yet unpublished. This month we look at a comprehensive paper very recently published in the British Journal of Sports Medicine which provides a thorough overview of the treatment options for PHP and their effectiveness in clinical practice. 

Overview:

This study reports that 10% of adults are affected with PHP during their lifetime. PHP also accounts for 25% of all foot disorders in athletes. The exact causes are poorly understood but it is likely to be multifactorial. There is plenty of research looking at treatment options for PHP but a lack of “robust evidence to inform the choice of treatment.” The study concluded that no one treatment method is better than any other overall.

What it all means:

The main treatment modalities used to treat PHP are scrutinised in this review.

Key points:

• 31 RCT’s were included in the study comprising a total of 2450 patients with PHP.

• All studies included adults, 18 years and older, with PHP. This included plantar fasciitis, plantar fasciopathy and plantar fasciosis as diagnosed by clinical examination and/or diagnostic imaging.

• Treatments investigated included:
  1. Corticosteroid injection
  2. Non-steroidal anti-inflammatory drugs
  3. Therapeutic exercise
  4. Orthoses
  5. Extracorporeal shockwave therapy (ESWT)

• The primary outcome measures for this review were pain and functional disability.

• Corticosteroid injections (alone or in combination with exercise) were most likely to be effective for the management of short-term pain or function, although cortisone did have potential side effects.

• ESWT also looked beneficial from the evidence, but not significantly greater than other treatments in the study for reducing pain and improving function.

• Exercise appeared to be beneficial for long term pain and function but there is a lack of evidence regarding the most effective exercise method.

• NSAIDs were generally the least effective treatment option.

• “Foot orthoses (prefab or custom), were not found to be effective as a stand-alone treatment for PHP, but were mostly effective in combination with ESWT”.

• Overall - “Available evidence does not suggest that any of the commonly used treatments for the management of PHP are better than any other”.

Putting it into practice:

1. In the discussion, the authors state that their findings support other research regarding foot orthoses: “foot orthoses are better than sham/placebo and may be effective for reducing pain in the medium term”. Although the paper does not make any suggestions regarding how or why they may be effective. Try using a cheaper prefab orthotic first to see if it's beneficial for your patient before considering the customised route. Bio Advanced is a good starting point.

2. The authors also state that “Foot orthoses were not found to be effective as a stand-alone treatment” If you decide to use foot orthoses as part of your management plan, consider other treatment modalities which may compliment orthoses, such as ESWT or exercises.

3. The evidence suggests that foot exercises are beneficial for long term pain and function but there is no clear evidence for specific exercises or dosage suggesting that different clinicians have different preferences for different reasons! If you are new to prescribing foot exercises, read through the LBG Medical “Guide to Core Foot Exercises".