Plantar heel pain is an umbrella term used to describe pain on the under surface of the heel. Historically, we have tended to relate this pain to the plantar fascia, and hence the term ‘plantar fasciitis’ was coined. The plantar fascia is a thick fibrous band of tissue originating from your heel and extending towards your toes. Its primary function is to maintain the position of your foot’s arch and transfer load.
We now know that the plantar fascia may not be the only tissue involved in heel pain. Hence, plantar heel pain is now the more accepted term used when describing pain on the under surface of the heel (Riel et al, 2017).
Plantar heel pain affects approximately 10% of adults during their lifetime, making it difficult for them to put weight through their heel (Babatunde et al, 2019). This makes activities such as walking, playing sport, and work increasingly difficult to complete.
Causes of Plantar Heel Pain
Plantar heel pain often has a slow and gradual onset with no specific cause or event. It often starts as pain on the first couple of steps getting out of bed that warms up. As it progresses, the severity and duration of the pain increases, and weight-bearing activities in day to day life start to become painful. Plantar heel pain does not discriminate and can affect both athletes and sedentary people.
There are certain risk factors associated with plantar heel pain and these include:
- Pronated foot type (flat feet)
- Reduced ankle and big toe range of motion
- Prolonged weight-bearing
- Obesity
Some specific causes of plantar heel pain include:
- A calcaneal spur with fracture diagnosed via x-ray
- Plantar fasciopathy. This is a thickening of the plantar fascia, usually diagnosed via ultrasound
- Plantar fascia tear diagnosed via MRI
- Calcaneus stress reaction diagnosed via MRI with bone marrow oedema
Treatment of Plantar Heel Pain
Good evidence now shows that in the treatment of plantar heel pain traditional approaches such as the wait and see approach and over the counter anti-inflammatories generally show less beneficial effects (Babatunde et al, 2019). Treatment should address several factors and be specific to the individual. This makes it important to seek expert assessment and management for plantar heel pain. Below are some common treatment options your physiotherapist can use for the management of plantar heel pain.
Load Management
Managing the load going through an individual’s foot, who is suffering with plantar heel pain, is particularly important. The aim is to try and find a balance between putting enough load through the foot to improve strength so the foot can handle more load, but not putting to much load through the foot so it remains painful and aggravated. Individuals will be able to physically complete a lot of exercises, but it doesn’t mean that they should if it is aggravating the plantar heel pain. Your physiotherapist will be able to guide you regarding how much you should and shouldn’t be doing so your plantar heel pain can begin to settle whilst still making improvements in strength.
Manual Therapy
Manual therapy can include joint mobilisation, soft tissue therapy, and dry needling. Based on assessment findings manual therapy can be used to put your foot in the best possible environment to function and allow it to cope with more load. This is done by loosening up tight muscles and stiff joints. Joint mobilisation is particularly beneficial in improving ankle and big toe range of motion, thus limiting that risk factor. Manual therapy is also beneficial as a pain management strategy as well.
Exercise Therapy
The way to improve your capacity to handle load going through the foot is by making it stronger. The way to make you stronger is through exercise. Your physiotherapist will be able to implement a progressive home exercise based on deficits found in your assessment. This will then be guided by your capacity to handle load so that your foot is not continued to be overloaded. Your physiotherapist will be able to progress your home exercise program as your pain begins to settle and you become stronger. This will mean that you will continue to see benefits and improvements, and hopefully prevent plantar heel pain from re-occurring.
Orthotic Devices
Orthotic devices used in the management of plantar heel pain can include off the shelf orthotics or heel raises. Both aim to reduce or change the load going through the foot by correcting biomechanics. These devices will not be suitable for everyone, but your physiotherapist will be able to determine your suitability during their assessment. In some cases where the pain is severe a CAM boot may be recommended. This should make weight bearing and walking easier to complete.
Alternative Treatment
Both corticosteroid injection and extracorporeal shockwave therapy can be used in the management of plantar heel pain. Both options have shown promising effects on decreasing pain and improving function at least in the short term (Babatunde et al, 2019). Neither option will fix plantar heel pain but may allow a short period of time to load the tissues involved so improvements in strength can be made. Corticosteroid injections in particular do have some potential negative side effects that need to be considered first. You can discuss these with your physiotherapist of GP if an injection is being considered.
References
- Babatunde, B. B., Legha, A., Littlewood, C., Chesterton, L. S., Thomas, M. J., Menz, H. B., Van der Windt, D., Roddy, E. (2018). ‘Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis’. British Journal of Sports Medicine, 53, 182-194
- Riel, H., Cotchett, M., Delahunt, E., Rathleff, M. S., Vicenzino, B., Weir, A., Landorf, K. B. (2017). ‘Is ‘plantar heel pain’ a more appropriate term than ‘plantar fasciitis’? time to move on’. British Journal of Sports Medicine, 51