Plantar Heel Pain: How you treat it may not be evidence based

Plantar heel pain (PHP) is by far the most common condition presenting to podiatrists and physios, so much so that many are now calling it an "epidemic".

Well, enough with the catastophising, and I am not about to delve into the numbers because you have heard it all before. But, everyone of us has our favorite way to treat PHP, and we swear by its efficacy, "I use X and it works for me" or "I use Y and ALL my cases get better". The problem is, there is a very fair chance that the treatment you use to bring relief to that patient with the sore heel, probably has no evidence base at all and probably is no better than placebo.

In fact, the amount of folklore, opinion and witchcraft associated with this most troubling of conditions is frankly staggering.

This is the first of a series on common sports injury, Achilles tendinopathy, Anterior knee pain, "shin splints'' and more, that really puts the blowtorch under the common methods of treating MSK pain.

Read on, because it may shock you to learn that you might need to change the way you treat Plantar Heel Pain.

First we should set out the hard cold facts.

  • despite the extreme commonness of plantar heel pain, there is great confusion over what the condition actually is.
  • of course PHP is not a diagnosis, it is a catch all label, and without a diagnosis, how can we treat the condition effectively.
  • we continue to label all PHP as plantar fasciitis, which certainly IS a diagnosis, but, is it really what you are seeing, and if not, how can you treat it properly?
  • There are literally dozens of proposed treatments for PHP, but there appears to not be one single reliable treatment
  • Many of the mainstay treatments, for example taping and orthoses have very mixed efficacy based on the evidence
  • New treatments, for example platelet rich plasma (PRP) or autologous blood, have promised miracle cures, but have not withstood scientific scrutiny.

The fact is, that although clinical guidelines and clinical trial data support a general approach to management, the current literature is limited in case-specific descriptions of PHP management that addresses unique combinations of pathoanatomical, physical, and psychosocial factors that are associated with PHP.

The term PHP encompasses a variety of pathoanatomical features including plantar fascia inflammation, degeneration or thickening, heel fat pad pathology, nerve irritation, and heel spurs.

Additionally, individuals with PHP may present with impairments in foot posture/mobility, ankle or hallux dorsiflexion, weightbearing duration, lower leg/foot muscle performance, and neurodynamic function, as well as comorbidities including stress, depression, obesity, and low back pain.

Where does that leave us?

Simon Bartold
Director of Bartold Clinical