What a pain in the heel!

The alarm clock goes off and you begrudgingly roll out of bed to start another Monday, but as you begin to walk across the room you experience sharp pain in your heel. Plantar heel pain, more commonly called plantar fasciitis, affects approximately 10% of the American population during their lifetime.1,2 Due to the high prevalence, there are many risk factors that predispose an individual to developing this condition. Common risk factors are:

  • limited ankle dorsiflexion range of motion (ROM)
  • running
  • high BMI
  • increased weight bearing activities related to work.1

Plantar heel pain may start as an inconvenient pain that only occurs after prolonged inactivity and improves as we “walk it off,” but can quickly become a severe pain that disrupts an individual’s ability to participate in their functional or recreational activities. Several treatment interventions have been suggested over the years and here we will discuss which ones have the most potential to help our patients.

Does foot support matter?

The previously stated risk factors provide a good starting point for our treatment via patient education regarding activity modification, exercise for weight loss, and footwear.1It is recommended that individuals with plantar heel pain make the following modifications to their footwear habits:

  • rotating shoes during the week when expected to stand for extended durations, and
  • utilization of rocker-bottom shoes with orthotics.1

Orthotics are designed to provide support to the foot and improve alignment.  They are recommended for individuals that respond well to anti-pronation taping in order to support the longitudinal arch and cushion the heel.1

What effect does this have on the foot musculature now that an external support is doing the “heavy lifting” of supporting the arch? McClinton et al found that individuals with plantar heel pain had weaker ankle plantar flexors than individuals without plantar heel pain and that longer duration of orthotic use was correlated with increased plantar flexor weakness.3 Is the ‘weakness’ in the foot the chicken or the egg? What if the weakness is dysfunction that is feeding the plantar heel sensitivity? Orthotic use does not have to be a long term solution and clinicians should consider incorporating plantar flexor strengthening into the exercise regimen for these individuals. Prefabricated orthotics from the store are a great cost saving alternative for patients (especially if intended for short-term use) because they have been found to be just as effective as custom orthotics in treating plantar heel pain.1

While we do not administer corticosteroid injections, patients often ask our opinion of them when they are considering their treatment options.  A randomized controlled trial compared corticosteroid injection to foot orthoses for treating plantar heel pain.  They found that at 4 weeks, the injection was more effective at reducing pain, however at 12 weeks the orthotics resulted in greater improvement in pain levels.  Unfortunately, the 12 week measurements did not demonstrate a significant enough difference between interventions to be perceived by patients.5 Based on this information, we can inform them that the injection can provide quick relief initially, but it is an invasive procedure that comes with its own risks (injection site pain, fat pad atrophy, infection, nerve damage, plantar fascia rupture, and muscle damage1). Orthotics can provide the same or greater relief in a more gradual fashion without the procedural risks.

Can stretching and taping help?

A popular treatment for plantar heel pain is stretching of the calf musculature to increase available dorsiflexion and taping the foot and ankle.  Current recommendations indicate that stretching of the gastrocnemius and/or soleus is appropriate for short term relief of plantar heel pain. 1 Additionally, a comparison of 3 groups (foot exercise only, foot and hip exercise, and stretching only) found that the stretching group demonstrated the same amount of improvement as the other two groups. 2

Prolonged stretching is the premise behind utilization of night splints, however many patients complain that they interfere with sleep and so they are non-compliant. Are the results worth the discomfort?  A case-series study investigated the effectiveness of tension night splints in chronic plantar heel pain and found that they were beneficial in decreasing pain and improving function.6 Thus, it may be worthwhile to encourage our patients and educate them on the rationale behind splinting.

As mentioned earlier with regards to orthotics, taping can also be utilized to support the longitudinal arch and predict response to orthotic support. A comparison of stretching versus kinesio-taping found that taping was more effective at reducing pain than stretching for short term results.7 The type of taping implemented will depend on the goal for your taping treatment (i.e. joint position, muscle inhibition, muscle activation, etc.), however a 2016 study found that calcaneal taping resulted in a greater reduction of pain and calcaneal eversion angle than the windlass taping technique.8

What about manual therapy?

Manual therapy can also be an effective treatment approach for the plantar heel pain population, including both soft tissue manipulation and joint mobilizations.  The research concerning joint mobilizations for plantar heel pain supports the use of subtalar mobilizations, however the superiority of it compared to “conventional treatment” (ultrasound and stretching) is a bit conflicting. Three different studies looked into this as a treatment for plantar heel pain and two of them found significant improvements in their patients that received mobilizations. The three are outlined below:

  • Comparison: conventional treatment vs. conventional treatment plus mobilization (anterior/posterior talocrural for dorsiflexion, subtalar joint for inversion/eversion, and midtarsal for supination/pronation)
    • Results: No differences between groups with regards to pain, ROM, or function.9
  • Comparison: Conventional treatment vs. conventional plus subtalar joint mobilization (which also included subtalar joint distraction manipulation)
    • Results: Joint mobilization was more effective at improving pain levels and function than conventional treatment alone.10
  • Comparison : Conventional treatment vs. mobilization alone (lateral glide, hind foot distraction, and anterior/posterior talo-crural)
    • Results: Both groups improved significantly, but the mobilization group had greater improvements that were achieved more quickly.11

Combining this information with your assessment of your patient can give you good rationale for providing manual therapy interventions for your patients with plantar heel pain.

What about the nerves?

It is important that during the objective exam you investigate the cause for any limited ROM that you find.  What may appear to be “tight calves” may actually be related to neurological limitations.  Assessment of the tibial and sural nerves may reveal entrapment or poor neurodynamics, leading to plantar heel pain.12,13,14 If this is the case, then static stretching may further irritate the patient’s symptoms due to prolonged tension on the nerve. Implementation of joint mobilization, soft tissue mobilization at common entrapment sites, and nerve mobilization techniques (passive and active) would be appropriate in order to decrease the sensitivity of the nerve.12,13,14

Is strengthening going to aggravate their pain?

Many of the studies mentioned so far have indicated that passive treatments may be just as effective, if not better than, exercise for plantar heel pain.  In 2014, with the revision of the Clinical Practice Guidelines for plantar heel pain they added recommendations for exercise and neuromuscular re-education (2008 CPG had no recommendation), specifically focusing on muscles that control pronation and influence force/load throughout the foot during weight-bearing.1  Rathleff et al investigated the effects of high-load strength training on pain levels and recovery of function and found that the high-load group had quicker reduction in pain and improvements in function compared to the stretching group.15

There are several other interventions available to therapists and other specialists, however many of them lack sufficient research to support their implementation (i.e. electrotherapy, laser therapy, phonophoresis, and dry needling) or are outside of the physical therapy scope of practice (i.e. extracorporeal shockwave therapy, corticosteroid injections, and autologous blood injections). Interestingly, ultrasound is one intervention that the 2014 CPG indicated they could not recommend based on current evidence, however many of these studies considered it part of “standard conventional treatment.”  The current research gives us several options for individualizing our treatment to each unique case that comes into our clinics.  We should feel confident in the utilization of orthotics, stretching, taping, manual therapy, and exercise with our patients experiencing plantar heel pain.  Lastly, we cannot forget that patient education throughout treatment is essential to ensuring our patients become active participants in their care and long-term success.

References:

  1. Martin RL, Davenport, TE, Reischl SF, et al. Heel pain – plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014;44(11):A1-A33. doi: 10.2519/jospt.2014.0303
  2. Kamonseki DH, Gonçalves GA, Yi LC, Júnior IL. Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomized controlled single-blind clinical trial. Man Ther. 2016;23:76-82. doi:10.1016/j.math.2015.10.006
  3. McClinton S, Collazo C, Vincent E, Vardaxis V. Impaired foot plantar flexor muscle performance in individuals with plantar heel pain and association with foot orthosis use. J Orthop Sports Phys Ther. 2016;46(8):681-688. doi:10.2519/jospt.2016.6482
  4. Moyne-Bressand S, Dhieux C, Dousset E, Decherchi P. Effectiveness of foot biomechanical orthoses to relieve patients suffering from plantar fasciitis: Is the reduction of pain related to change in neural strategy?. Biomed Res Int. 2018;2018:3594150. Published 2018 Dec 12. doi:10.1155/2018/3594150
  5. Whittaker GA, Munteanu SE, Menz HB, Gerrard JM, Elzarka A, Landorf KB. Effectiveness of foot orthoses versus corticosteroid injection for plantar heel pain: The SOOTHE randomized clinical trial. J Orthop Sports Phys Ther. 2019;49(7):491-500. doi:10.2519/jospt.2019.8807
  6. Wheeler PC. The effectiveness and tolerability of tension night splints for the treatment of patients with chronic plantar fasciitis – A case-series study. Int Musculoskeletal Med. 2014;36(4):130-136. doi:10.1179/1753615414y.0000000032
  7. Singh AK, Kumar S, Sharma A. A comparison between kinesiotaping and tissue specific plantar fascia stretching exercise treatment in planter fasciitis. Indian J Physiother Occup Ther. 2017;11(4):6-10. doi:10.5958/0973-5674.2017.00111.3
  8. Aishwarya N, Sai K. Immediate effect of calcaneal taping versus windlass taping on calcaneal angle in subjects with plantar fasciitis. International Journal of Therapeutic Applications. 2016;33:28-32. doi:10.20530/ijta_33_28-32
  9. Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: A randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-272. doi:10.2519/jospt.2015.5155
  10. Heggannavar A, Gupta RK. Effectiveness of subtalar joint mobilization in plantar heel pain. Indian J Physiother Occup Ther. 2015;9(2):75-79. doi:10.5958/0973-5674.2015.00057.x
  11. Kumar S, Motimath B. Effect of short duration targeted manual therapy approach in plantar fascitis – a randomized control trial. Indian J Physiother Occup Ther. 2015;9(1):193-197. doi:10.5958/0973-5674.2015.00038.6
  12. Butler, D. The neurodynamic techniques: A definitive guide from the NOI team. Adelaide, Australia: van Gastel Printing; 2005.
  13.  Moroni S, Zwierzina M, Starke V, Moriggl B, Montesi F, Konschake M. Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter’s neuropathy in recalcitrant heel pain syndrome: part I. Surg Radiol Anat. 2019;41(1):29-41. doi:10.1007/s00276-018-2124-z
  14.  Alshami AM, Souvlis T, Coppieters MW. A review of plantar heel pain of neural origin: differential diagnosis and management. Man Ther. 2008 May;13(2):103-11. doi: 10.1016/j.math.2007.01.014. Epub 2007 Mar 30. PMID: 17400020.
  15. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2014;25(3):e292-e300. doi:10.1111/sms.123