Heel pain is quite common, especially in the older, non-sporting population. It’s one of those problems that everyone you meet seems to have a different solution for, which can leave you wondering where to go and what to do. We thought we’d give you a step by step process to help restore a pain-free step.
Step 1: Know what you’re dealing with – get a diagnosis
The first essential step to take with plantar heel pain, is to establish a diagnosis. There are multiple structures that may contribute to pain, besides the most frequently blamed – plantar fascia. That includes diagnoses such as abductor digiti nerve entrapment, lumbar spine referral, tarsal tunnel syndrome, fat pad atrophy, tibialis posterior tenosynovitis, retro calcaneal bursitis, calcaneal stress fractures, inflammatory arthropathies, subtalar arthritis and many other big words. It can even be caused by the use of particular antibiotics. However, roughly one in every ten people will develop plantar fasciopathy.3 Development of this pain can usually be attributed to an increase in walking or running load, changes in footwear or a high body mass index. Plantar fasciopathy is typically characterised by severe heel pain during the first few steps of the morning when getting out of bed.3
Typically, ultrasound studies are sufficient to confirm a diagnosis of plantar fasciopathy as well as exclude irritation to the heel fat pad. MRI may be more sensitive in visualising any particular tears within this structure as well as determine if any fluid has started to accumulate in the bony elements, which can be a particularly painful symptom of more chronic cases.
What actually is the plantar fascia?
The Plantar Fascia is a band of connective tissue that spans the bottom of your foot connecting the front of the heel to the base of all 5 toes. It has a static role in stabilising the long arch of the foot as well as a dynamic role during gait to assist with leverage and propulsion. Plantar fascioapthy is essentially degeneration of this structure resulting in reduced mechanical integrity and pain. Rarely, unless in more chronic instances, are inflammatory processes at play, which means your usual nurofen and a wait and see type approach is generally not going to be effective.
Step 2: Get going with a plan
The second step is to determine an individualised treatment plan that addresses the underlying contributing factors to injury. This initially may include modalities to reduce pain, such as ice, stretching, insoles and manual therapy. Research has concluded that injections of corticosteroids are successful in treating pain, but tend to only be efficacious in the short term (< 4 weeks).1 Another study comparing corticosteroid to platelet rich plasma (PRP) injections has found PRP to be superior at the 3 month mark4. It has been suggested that exercise based training is more beneficial in the longer term (>12 weeks), such as heavy slow resistance training of the calf muscles.1 Further research is being conducted with combinations of patient advice, injections, exercise and insoles to determine if there is a superior treatment combination.3
Step 3: Get strong and get active
The third step, once your pain has appropriately reduced, is to implement strategies to return to activity/performance and reduce recurrence. During walking and running the foot dissipates, recycles and produces mechanical energy. This involves contributions from both the passive structures (plantar fascia, fat pad, ligaments and bone) and active structures (intrinsic and extrinsic foot muscles) of the foot.2 The significant contribution of the intrinsic foot muscles to the energetic function of the foot suggests that intrinsic foot muscle weakness is important to address in the management of plantar fasciopathy – and preventing further episodes of injury and pain.2
Seeking assistance from a Physiotherapist with experience in the holistic management of plantar heel pain, will hopefully make these three steps feel like a walk in the park.
APA Sport & Exercise Physiotherapist
- Babatunde, O. O., Legha, A., Littlewood, C., Chesterton, L. S., Thomas, M. J., Menz, H. B., … & Roddy, E. (2019). Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. British journal of sports medicine, 53(3), 182-194.
- Franettovich Smith, M. M., Collins, N. J., Mellor, R., Grimaldi, A., Elliott, J., Hoggarth, M., … & Vicenzino, B. (2020). Foot exercise plus education versus wait and see for the treatment of plantar heel pain (FEET trial): a protocol for a feasibility study. Journal of foot and ankle research, 13, 1-14.
- Riel, H., Vicenzino, B., Olesen, J. L., Jensen, M. B., Ehlers, L. H., & Rathleff, M. S. (2020). Corticosteroid injection plus exercise versus exercise, beyond advice and a heel cup for patients with plantar fasciopathy: protocol for a randomised clinical superiority trial (the FIX-Heel trial). Trials, 21(1), 1-13.
- Singh, P., Madanipour, S., Bhamra, J. S., & Gill, I. (2017). A systematic review and meta-analysis of platelet-rich plasma versus corticosteroid injections for plantar fasciopathy. Int Orthop, 41(6), 1169-1181. doi:10.1007/s00264-017-3470-x