Hello! Today we are going to learn about heel pain and plantar fasciitis. One of our most recent learning rounds at the clinic was all about this condition and reviewing what the current evidenced-based, best practice is for rehabilitating this painful condition!
We know plantar fasciitis, or what is also referred to now as plantar fasciopathy, is the most common musculoskeletal disorder in the foot.(1) Fasciitis means there is an active inflammatory response occurring and it is considered an acute presentation. Plantar fasciopathy means the condition is not acute but chronic. It is a degenerative condition caused by repetitive stress or microtrauma to the fascia but is not actively inflamed. Often tissue degenerates because of weakness of intrinsic foot muscles and decreased ankle and big toe range of motion.
Plantar fasciitis is characterized by medial plantar heel pain with tenderness at the medial calcaneal tubercle and symptoms that are most noticeable with weight-bearing first thing in the morning or after a period of rest.(2)
We are going to review what we learned from the 2023 Heel Pain – Plantar Fasciitis Clinical Practice Guideline (CPG).(3) The Academy of Orthopaedic Physical Therapy creates evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability and Health (ICF).(3) The purposes of these clinical guidelines are to “describe evidence-based physical therapy practice, including diagnosis, prognosis, intervention, and assessment of outcomes for musculoskeletal disorders commonly managed by orthopaedic physical therapists”.(3) That’s us! We are here to help you manage this condition.
Let’s jump into the information from the CPG now and review (3):
1. Risk factors – For heel pain and plantar fasciitis
2. Diagnosis – What needs to be present to be diagnosed with plantar fasciitis
3. Differential Diagnosis – The other conditions we screen for (as heel pain is not always plantar fasciitis!)
4. Outcome Measures
5. Intervention Strategies
1. Risk Factors
Clinicians will assess the presence of limited ankle dorsiflexion range of motion (ROM), high body mass index in nonathletic individuals, running, and work-related weight-bearing activities, particularly under conditions with poor shock absorption, as risk factors for the development of heel pain/plantar fasciitis.
2. Diagnosis
Physiotherapists diagnose plantar fasciitis using the following history and physical examination findings:
- Pain on bottom and inside part of heel (plantar medial heel pain): most noticeable with initial steps after a period of inactivity, but also worse following prolonged weight-bearing
- Heel pain precipitated by a recent increase in weight-bearing activity
- Pain with palpation of the proximal insertion of the plantar fascia
- Positive windlass test
- Negative tarsal tunnel tests
- Limited active and passive talocrural joint dorsiflexion
- Abnormal Foot Posture-6 (FPI-6) score
- High body mass index in nonathletic individuals
*You don’t need to remember/know all these tests but these are some of the things we are screening for!
Imaging studies are usually not indicated for patients that meet clinical examination criteria for plantar fasciitis until they fail conservative interventions.(2)
3. Differential Diagnosis
We will assess for other things like spondyloarthritis, fat-pad atrophy, and proximal plantar fibroma during your assessment, when your activity limitations or impairments of body function and structure are not consistent with those presented in the Diagnosis/Classification of the CPG, or when your symptoms are not resolving with interventions aimed at improving your impairments.
We will assess your lumbopelvic and legs to assess for referred or radiating pain from your back.
4. Outcome Measures
Outcome Measures: There are outcome measures we use (questionnaires you fill out) that help us diagnose and track your progress.
Physical Impairment/Activity Limitations/Participation Measures: There are a lot of tests we do in the clinic to assess your foot, ankle and leg range of motion, strength of your feet, ankles, legs and core, and your movement patterns (to see how you move when we put that all together!). We will look at your control and strength when both feet are on the ground and when you are single leg stance (on one foot).
5. Intervention Strategies That Are Recommended In CPG
A. Therapeutic Exercises:
- Plantar fascia stretching
- Gastrocnemius/soleus stretching
Evidence Synthesis
- The evidence supports the effectiveness of plantar fascia- specific and gastrocnemius/soleus stretching exercises for improving pain, function, and disability, with treatment times ranging from 1 week to 12 months.
- There were no serious side effects or adverse events reported within any of these studies.
- The only reported side effects were mild to moderate increase in pain while stretching, which ceased at the conclusion of the stretch.
Gaps in Knowledge
Future research should investigate long-term outcomes (>3 months) and isolate the effects of stretching other muscles in conjunction with plantar fascia and gastrocnemius/soleus stretching, such as the hamstring and fibularis. Studies should specify stretching parameters, duration, and frequency of treatment.
B. Manual Therapy
- Joint mobilization to improve identified restrictions in joint mobility of the lower extremity, with an emphasis on improving talocrural dorsiflexion (this is bringing your toes up towards you and moving your ankle joint).
- Soft tissue mobilization of the plantar fascia, and calf muscles -> specifically targeting trigger points and soft tissue restrictions.
Evidence Synthesis
- Overall, recent studies add to the body of evidence supporting the use of manual therapy directed at the joints and soft tissue structures of the lower extremity to improve pain, function, and disability.
- There was 1 additional level I study and 3 level II studies, supporting joint mobilization, identified since the previous update.
- Four additional level II studies supported techniques directed at soft tissue.
- No new side effects or adverse events were reported. Therefore, based on the low risk and the consistent likely benefits of improved pain and function, the preponderance of evidence continues to support manual therapy.
Recommendation
Clinicians should use manual therapy directed at the joints and soft tissue structures of the lower extremity to address relevant joint and flexibility restrictions, decrease pain, and improve function in individuals with plantar heel pain/plantar fasciitis.
C. Taping
- Rigid or elastic, in conjunction with other physical therapy treatments for short-term use only (one to ≤ six weeks) .
- Clinicians should use antipronation taping for immediate (up to 3 weeks) pain reduction and improved function for individuals with heel pain/plantar fasciitis.
- Additionally, clinicians may use elastic therapeutic tape applied to the gastrocnemius and plantar fascia for short-term (1 week) pain reduction.
Gaps in Knowledge
Studies are needed to compare rigid versus elastic taping, as well as methods of tape application that may be influenced by foot shape (supination and pronation). Additionally, studies investigating long-term outcomes (>6 weeks) are needed.
D. Night Splints
- Utilization of a night splints for a 1 to 3 month period for those who consistently have heel pain with the first step in the morning.
E. Low Level Laser Therapy (LLLT)
- We can treat two to three points with a minimum dose of 2 J/point with a 904 nm wavelength laser or 4 J/point with 780–860 nm wavelength.
Gaps in Knowledge
The optimal LLLT treatment parameters, including wave- length, energy dosage, duration, and frequency need to be further studied. Also, higher-quality research is needed to further investigate the effect of LLLT on foot function.
2023 Recommendation
Clinicians should use LLLT as part of a rehabilitation program in those with acute or chronic plantar fasciitis to decrease pain in the short term.
F. Dry Needling (DN)
- 1-6 sessions treating myofascial trigger points (MTrP) in the gastrocnemius, soles and plantar muscles.
Gaps in Knowledge
Further research is needed to determine if the addition of electrical stimulation and specific parameters of stimulation adds any additional benefit to DN. Currently, only 1 study has compared standard DN to percutaneous needling electrolysis with equivocal results.
2023 Recommendation
Clinicians should use DN to MTrP in the gastrocnemius, soles, and plantar muscles of the foot for short- and long-term pain reduction, as well as long-term improvements in function and disability.
G. Strengthening and Neuromuscular Re-education
- Resistance training for the musculature of the foot and ankle.
- There is strong evidence that combined interventions of manual therapy, client education, stretching, resistance training, and neurodynamic interventions improve pain at 6 weeks (short term) and 1 year (long term), and functioning at 6 months.
- There is weak evidence that isolated strengthening interventions such as isotonic, isometric, or self-paced walking during 3 sessions over 2 weeks provide clinically important pain reduction. There was insufficient evidence to identify a superior type of strength training or exercise.
Gaps in Knowledge
Additional research is needed to determine the dose and timing of exercise interventions. There appears to be an additive effect when exercise is combined with other interventions. Additional research is also needed to determine which combinations are best and at which dosages.
H. Foot Orthoses
- Combine with other treatments and not as a stand-alone intervention
- Use of over-the-counter/pre-fabricated or a custom foot orthoses that support the medial arch and/or provide cushion to the heel region, especially in individuals with excessive pronation (when the arch collapses inwards) and/or positively respond to anti-pronation taping.
- A use of an over-the-counter heel cushion, footwear modification that provides heel cushioning, especially in individuals with decreased shock absorption capacity indicated by a Foot Posture Index-6 score that indicates excessive supination.
Evidence Synthesis
- The evidence from 4 meta-analyses suggest a small to no effect of the use of custom or prefabricated orthoses as a stand-alone treatment for the short term (<3 months) management of plantar fasciitis.
- New studies investigating the additive benefit of orthoses to a multimodal program on long-term outcomes are limited. When combined with other interventions, such as stretching and extracorporeal shockwave therapy (ESWT), the outcomes on pain are positive.
- Additionally, a level II study found that long-term (24-28 weeks) follow-up favored custom orthoses over ESWT on pain and function.
Gaps in Knowledge
Evidence on the type, materials, and design of foot orthoses is limited, while evidence clearly finds a similarity in outcomes between custom and prefabricated orthoses. Studies looking at the additive benefit of orthoses to a multimodal program on long-term outcomes are needed.
I. Phonophoresis with ketoprofen gel
- Phonophoresis with ketoprofen gel to reduce pain in individuals with heel pain/ plantar fasciitis.
- This is when ultrasound units are used with an anti-inflammatory agent incorporated into the ultrasound gel. The ultrasound helps the topical anti-inflammatory be absorbed into the tissue at a greater rate.
J. Patient Education and Counseling
- Strategies to modify relevant weight bearing loads during occupational, recreational, or daily activities.
- Footwear options to mitigate commonly occurring weight loading stresses
- Strategies to gain or maintain optimal lean body mass, especially in nonathletic individuals with a high body mass index.
- Referral to appropriate health care practitioners to address nutrition issues.
Multimodal Interventions
A combination of interventions that may include education, manual therapy, neuromuscular re-education, therapeutic exercise, electrotherapeutic modalities, ultrasound (US), thermal agents, taping, orthotics, splinting, DN, or training for correction of posture and movement during functional activities can collectively be considered multimodal intervention. Education may include information about the health condition or activity modification.
Evidence Synthesis
- The evidence base for plantar fasciitis interventions is beginning to allow comparisons for combined treatments. The addition of electrical DN or ESWT to manual therapy, exercise, and US seems to result in small to moderate gains for short- and medium-term pain and function.
- Manual therapy may be supplemented with the addition of stretching, strengthening, and modalities. However, there was not enough evidence to support a specific recommendation in this area.
- One study demonstrated benefits of combined US delivered daily at 2.4 W/cm2 with cryotherapy in the same probe in those with chronic symptoms. The theoretical basis for the benefit of cryoultrasound treatment was that it allows for the potential positive mechanical effects of higher-intensity US without the associated thermal effects.
Gaps in Knowledge
Evidence is starting to include combined interventions, but controlled studies are needed to identify what particular combinations are needed.
Interventions – Other
Also included in CPG was information regarding extracorporeal shockwave therapy (ESWT) and corticosteroid injection (CSI) and platelet-rich plasma (PRP) injection:
- A meta-analysis found that ESWT was effective in the medium and long term in decreasing pain when compared to control interventions.
- The effectiveness of CSI compared to other treatments on those with plantar heel pain with some conflicting conclusions.
- A more recent comprehensive network meta-analysis found that while there is some evidence that CSIs alone or in combination with exercise and ESWT may be effective in improving short-, medium-, and long-term pain or function, the estimates of effect varied widely across trials.
- There is also some evidence to suggest that PRP can be effective in short-term pain reduction compared to control interventions.
- When looking at medium-term outcomes, ESWT was found to be effective in decreasing pain when compared to CSI. However, no difference was found among these 3 treatments in short- and long-term pain control.
- A Cochrane review noted that the evidence support for CSI was of low quality, and although serious adverse events were rare, these were underreported and a higher risk cannot be ruled out. Potential adverse effects after CSI included postinjection steroid-induced increase in pain, fat pad atrophy, nerve injury, and rupture of the plantar fascia.
We appreciate this is a lot of information – and that is why we are here! We are committed to staying up to date on best practices, and are here to help develop a plan of care that works for you.
We will diagnose, explain exactly what is going on with your heel pain, and provide treatment options that work for you and your specific goals. Heel pain can be very debilitating, but we can help get you back on track!
Sources
- Reil, H. (2023). Does a corticosteroid injection plus exercise or exercise alone add to the effect of patient advice and a heel cup for patients with plantar fasciopathy? A randomized clinical trial. Br J Sports Med ., 57(18), 106948. https://doi.org/10.1136/bjsports-2023-106948
- Martin R, Davenport T, Reisch lS,et al .Heel pain – plantar fasciitis: Revision 2014. J Orthop Sports Phys Ther. 2014;44:A1-33. https://doi.org/10.2519/ jospt.2014.0303.
- Koc, T., Bise, C. G., Neville, C., Carreira, D. S., Martin, R. L., & McDonough, C. M. (2023). Heel Pain – Plantar Fasciitis: Revision 2023. Journal of Orthopaedic & Sports Physical Therapy, 53(12), CPG1–CPG39. https://doi.org/10.2519/jospt.2023.0303