Plantar heel pain and plantar fasciitis

Abstract

Introduction

Plantar heel pain, also known as plantar fasciitis, causes soreness or tenderness of the sole of the foot under the heel, which sometimes extends into the medial arch. Pain associated with the condition may cause substantial disability and poor health-related quality of life. The prevalence and prognosis are unclear, but the symptoms seem to resolve over time in most people.

Methods and outcomes

We conducted a systematic overview, aiming to answer the following clinical questions: What are the effects of conservative treatments for plantar heel pain? What are the effects of non-conservative treatments for plantar heel pain? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2013 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review).

Results

At this update, searching of electronic databases retrieved 162 studies. After deduplication and removal of conference abstracts, 84 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 39 studies and the further review of 45 full articles. Of the 45 full articles evaluated, five systematic reviews and nine RCTs were included at this update. We performed a GRADE evaluation for 30 PICO combinations.

Conclusions

In this systematic overview, we categorised the efficacy for 12 interventions based on information relating to the effectiveness and safety of corticosteroid injection alone (both short-term and longer-term effects), corticosteroid injections plus local anaesthetic injection (both short-term and longer-term effects), customised foot orthoses, extracorporeal shock wave therapy, heel pads and cups, local anaesthetic injection alone, night splints, stretching exercises, surgery, and taping.

Key Points

Plantar heel pain causes soreness or tenderness of the sole of the foot under the heel, which sometimes extends into the medial arch.

• Pain associated with the condition may cause substantial disability and poor health-related quality of life.

• Those affected can experience significant limitations in their activities of daily living, ability to exercise, and work-related activities.

• The prevalence and prognosis are unclear, but in most people the symptoms seem to resolve over time, although in some cases this can take years.

Conservative treatments for plantar heel pain:

Customised foot orthoses may be more effective than sham orthoses at improving function at up to 12 months in people with plantar heel pain, but we don’t know whether they are more effective at reducing pain.

• Customised foot orthoses may be equally effective as prefabricated orthoses at reducing pain or improving function in people with plantar heel pain.

• We don’t know whether customised foot orthoses (alone or with taping) are more effective than night splints at reducing pain or improving function or health-related quality of life in people with plantar heel pain as the evidence is weak.

We don't know whether heel pads and heel cups are effective in people with plantar heel pain as we found no evidence from RCTs meeting our inclusion criteria.

Taping may be more effective than no taping or sham taping at reducing pain in the short term (at 1 week) in people with plantar heel pain. However, we don’t know whether it is effective in the longer term or whether it is effective at improving function.

We don't know whether stretching exercises are more effective than no treatment or taping at reducing pain or improving function in people with plantar heel pain as the evidence is weak and inconsistent.

Non-conservative treatments for plantar heel pain:

Corticosteroid injections may be more effective than placebo at reducing pain in the short term (4 and 6 weeks) in people with plantar heel pain, but we don’t know whether they are more effective at reducing pain in the longer term (8 and 12 weeks). However, this is based on weak evidence.

• We don’t know whether corticosteroid injections are more effective than placebo at improving function in the short or long term in people with plantar heel pain.

• We don't know whether corticosteroid injection plus local anaesthetic injection are more effective than local anaesthetic injections alone at reducing pain in the short or long term in people with plantar heel pain.

• There is limited evidence that ultrasound-guided corticosteroid injection may be more effective that palpation-guided corticosteroid injection.

• Corticosteroid injections may be associated with a high rate of plantar fascia rupture and other complications, which may lead to chronic disability in some people. However, this is likely related to the solubility and duration of action of the corticosteroid being used.

Extracorporeal shock wave therapy (ESTW) may be more effective than placebo at reducing pain at 12 weeks in people with chronic heel pain, but this is based on limited evidence.

• We don’t know how low-dose ESWT compares with high-dose ESWT or how ESWT (with or without local anaesthetic injections) compares with corticosteroid injection plus local anaesthetic injection, as the evidence is weak.

Surgery with endoscopic plantar fasciotomy (partial release) may be equally effective as ESWT at reducing pain and improving function at 1 year in adults with recalcitrant heel pain, but this is based on weak evidence.

Clinical context

General background

Plantar heel pain, also known as plantar fasciitis, causes soreness or tenderness of the sole of the foot under the heel, which sometimes extends into the medial arch. Pain associated with the condition may cause substantial disability and poor health-related quality of life. Those affected can also have significant limitations in activities of daily living, ability to exercise, and work-related activities. The prevalence and prognosis are unclear, but the symptoms seem to resolve over time in most people.

Focus of the review

In this overview, we look at commonly used conservative and non-conservative interventions that patients may receive.

Comments on evidence

This overview contributes to the evidence base for treating plantar heel pain by providing a summary of evidence that is of high quality. Importantly, many weak studies have been filtered out by our inclusion criteria, ensuring that estimates of treatment effectiveness and adverse effects are as accurate as possible.

Search and appraisal summary

The update literature search for this overview was carried out from the date of the last search, January 2007, to November 2013. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. Searching of electronic databases retrieved 162 studies. After deduplication and removal of conference abstracts, 84 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 39 studies and the further review of 45 full articles. Of the 45 full articles evaluated, five systematic reviews and nine RCTs were included at this update.

Additional information

The condition has for many years been known as 'plantar fasciitis', but there was a move away from this name about 10 years ago because research indicated that it wasn't an inflammatory condition. Hence, the term 'plantar fasciosis' was suggested, which means 'degeneration' of the plantar fascia. Since then, some authors have also referred to it as 'plantar fasciopathy', which simply means pathology of the plantar fascia. However, recent imaging studies are increasingly demonstrating that the condition affects more than just the plantar fascia (e.g., the heel bone and surrounding tissues), so the general term 'plantar heel pain' is more appropriate. Medical imaging may subsequently allow use of specific terms that relate to the tissues/structures involved (e.g., delamination of the plantar fascia, a tear of the plantar fascia, bone marrow oedema of the calcaneus).

About this condition

Definition

Plantar heel pain, also known as plantar fasciitis, is soreness or tenderness of the heel that is restricted to the sole of the foot. It often radiates from the central part of the heel pad or the medial tubercle of the calcaneus, but may extend along the plantar fascia into the medial longitudinal arch of the foot. Severity may range from tenderness at the origin of the plantar fascia, which is noticeable on rising after rest, to an incapacitating pain. This overview excludes clinically evident underlying disorders (e.g., calcaneal fracture and nerve entrapment, which may be distinguished clinically [a calcaneal fracture may present after trauma, and calcaneal nerve entrapment gives rise to shooting pains and feelings of 'pins and needles']). The condition has for many years been known as 'plantar fasciitis', but there was a move away from this name about 10 years ago because research indicated that it was not an inflammatory condition, particularly in its chronic form. As a result of this research, the term 'plantar fasciosis' was suggested, which means 'degeneration' of the plantar fascia. Since then, some authors have also referred to the condition as 'plantar fasciopathy', which simply means pathology of the plantar fascia. However, recent imaging studies are increasingly demonstrating that the condition affects more than just the plantar fascia (e.g., the heel bone and surrounding tissues), so the general term 'plantar heel pain' is more appropriate. Medical imaging may subsequently allow use of specific terms that relate to the tissues/structures involved (e.g., delamination of the plantar fascia, a tear of the plantar fascia, bone marrow oedema of the calcaneus). In this overview we have used the term 'plantar heel pain'; although, when referring to particular studies we have used the authors' terminology

Incidence/ Prevalence

The incidence and prevalence of plantar heel pain are uncertain. However, it has been estimated that 7% of people aged over 65 years in the US report tenderness in the region of the heel, and that plantar heel pain accounts for a quarter of all foot injuries relating to running. In the North West Adelaide Health Study, a population-based study of 3206 people aged 20 years or older, about 4% of the sample indicated that they had pain underneath their heel. A further study from the UK that collected data from 12 primary care settings found that plantar fasciitis accounted for about 8% of musculoskeletal foot and ankle consultations in general practice. In the US from 1995 to 2000, the diagnosis and treatment of plantar heel pain accounted for more than 1 million visits per year to physicians. The condition affects both athletic and sedentary people, and does not seem to be influenced by sex.

Aetiology/ Risk factors

Aetiology is largely unknown. Suggested risk factors include being overweight, older age, prolonged standing, and having a reduced range of motion in the ankle and first metatarsophalangeal joint. A pronated foot posture has also been linked with the condition, but this has not been consistently found to be a risk factor.

Prognosis

One systematic review found that almost all of the included trials reported an improvement in discomfort regardless of the intervention received (including placebo), suggesting that the condition is at least partially self-limiting. A telephone survey of 100 people treated conservatively (average follow-up 47 months) found that 82 people had resolution of symptoms, 15 had continued symptoms but no limitations of activity or work, and three had persistent bilateral symptoms that limited activity or changed work status. Thirty-one people said that they would have seriously considered surgical treatment at the time that medical attention was sought. In addition, one RCT has observed marked improvement in pain and function over time in 45 people with plantar fasciitis who were randomised to a sham intervention. Notwithstanding these findings, some people who have plantar heel pain can experience pain and disability for long periods (i.e., years), and these cases are frustrating to treat both from the patient's and practitioner's perspective.

Aims of intervention

To reduce pain and disability, with minimal adverse effects.

Outcomes

Pain reduction (often measured using visual analogue scales); improvement in function (e.g., walking distance); health-related quality of life; adverse effects.

Methods

Search strategy BMJ Clinical Evidence search and appraisal November 2013. Databases used to identify studies for this systematic review include: Medline 1966 to November 2013, Embase 1980 to November 2013, The Cochrane Database of Systematic Reviews 2013, Issue 10, the Database of Abstracts of Reviews of Effects (DARE), and the Health Technology Assessment (HTA) database. Inclusion criteria Study design criteria for evaluation in this review were systematic reviews and RCTs published in English, at least single-blinded, and containing more than 20 individuals (10 in each arm), of whom more than 80% were followed up. There was no minimum length of follow-up. We excluded all studies described as 'open', 'open label', or not blinded unless blinding was impossible. BMJ Clinical Evidence does not necessarily report every study found (e.g., every systematic review). Rather, we report the most recent, relevant and comprehensive studies identified through an agreed process involving our evidence team, editorial team, and expert contributors. Evidence evaluation A systematic literature search was conducted by our evidence team, who then assessed titles and abstracts, and finally selected articles for full text appraisal against inclusion and exclusion criteria agreed a priori with our expert contributors. In consultation with the expert contributors, studies were selected for inclusion and all data relevant to this overview extracted into the benefits and harms section of the overview. In addition, information that did not meet our predefined criteria for inclusion in the benefits and harms section, may have been reported in the 'Further information on studies' or 'Comment' section. Adverse effects All serious adverse effects, or those adverse effects reported as statistically significant, were included in the harms section of the overview. Pre-specified adverse effects identified as being clinically important were also reported, even if the results were not statistically significant. Although BMJ Clinical Evidence presents data on selected adverse effects reported in included studies, it is not meant to be, and cannot be, a comprehensive list of all adverse effects, contraindications, or interactions of included drugs or interventions. A reliable national or local drug database must be consulted for this information. Comment and Clinical guide sections In the Comment section of each intervention, our expert contributors may have provided additional comment and analysis of the evidence, which may include additional studies (over and above those identified via our systematic search) by way of background data or supporting information. As BMJ Clinical Evidence does not systematically search for studies reported in the Comment section, we cannot guarantee the completeness of the studies listed there or the robustness of methods. Our expert contributors add clinical context and interpretation to the Clinical guide sections where appropriate. Data and quality To aid readability of the numerical data in our overviews, we round many percentages to the nearest whole number. Mean differences taken from systematic reviews may be taken from raw data from an RCT and, as a consequence, may not exactly reflect the actual mean differences reported in that RCT if the authors of the RCT employed any adjustment (e.g., ANCOVA) when calculating between-group differences. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). BMJ Clinical Evidence does not report all methodological details of included studies. Rather, it reports by exception any methodological issue or more general issue that may affect the weight a reader may put on an individual study, or the generalisability of the result. These issues may be reflected in the overall GRADE analysis. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).

Table.

GRADE Evaluation of interventions for Plantar heel pain and plantar fasciitis.

Important outcomes	Functional improvement, Health-related quality of life, Pain relief
Studies (Participants)	Outcome	Comparison	Type of evidence	Quality	Consistency	Directness	Effect size	GRADE	Comment
What are the effects of conservative treatments for plantar heel pain?
1 (89)	Pain relief	Customised foot orthoses versus placebo/sham or no treatment	4	–2	0	0	0	Low	Quality points deducted for sparse data and weak methods
1 (89)	Functional improvement	Customised foot orthoses versus placebo/sham or no treatment	4	–2	0	0	0	Low	Quality points deducted for sparse data and weak methods
2 (at least 206)	Pain relief	Customised foot orthoses versus prefabricated orthoses	4	–1	0	–1	0	Low	Quality point deducted for weak methods (incomplete reporting of statistical analysis in one RCT); directness point deducted for use of co-interventions by some participants
1 (at least 88)	Functional improvement	Customised foot orthoses versus prefabricated orthoses	4	–2	0	0	0	Low	Quality points deducted for sparse data and weak methods
1 (25)	Pain relief	Customised foot orthoses versus night splints	4	–2	0	0	0	Low	Quality point deducted for sparse data and weak methods
1 (25)	Functional improvement	Customised foot orthoses versus night splints	4	–2	0	0	0	Low	Quality point deducted for sparse data and weak methods
1 (25)	Health-related quality of life	Customised foot orthoses versus night splints	4	–2	0	0	0	Low	Quality point deducted for sparse data and weak methods
1 (170)	Pain relief	Customised orthoses plus taping versus night splints	4	–3	0	–1	0	Very low	Quality points deducted for sparse data, weak methods, and lack of statistical assessment of between-group differences; directness point deducted for high attrition rate
2 (at least 20)	Pain relief	Stretching exercises versus placebo or no treatment	4	–2	0	–1	0	Very low	Quality points deducted for sparse data and incomplete reporting of results; directness point deducted for difference in stretching exercise (weight bearing v non-weight bearing)
2 (at least 20)	Functional improvement	Stretching exercises versus placebo or no treatment	4	–2	0	–1	0	Very low	Quality points deducted for sparse data and incomplete reporting of results; directness point deducted for difference in stretching exercise (weight bearing v non-weight bearing)
1 (21)	Pain relief	Stretching exercises versus taping	4	–2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
1 (21)	Functional improvement	Stretching exercises versus taping	4	–2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
2 (at least 31)	Pain relief	Taping versus placebo/sham or no treatment	4	–2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
2 (at least 31)	Functional improvement	Taping versus placebo/sham or no treatment	4	–2	0	0	0	Low	Quality point deducted for sparse data and incomplete reporting of results
What are the effects of non-conservative treatments for plantar heel pain?
2 (122)	Pain relief	Corticosteroid injections versus placebo or no treatment (short-term)	4	–3	0	–1	0	Very low	Quality points deducted for sparse data, weak methods, and incomplete reporting of results in one RCT; directness point deducted for inconsistency between interventions (different corticosteroid injections, and ultrasound-guided versus unguided injections)
1 (82)	Functional improvement	Corticosteroid injections versus placebo or no treatment (short-term)	4	–3	0	0	0	Very low	Quality points deducted for sparse data, weak methods, and incomplete reporting of results
2 (122)	Pain relief	Corticosteroid injections versus placebo or no treatment (longer term)	4	–3	0	–1	0	Very low	Quality points deducted for sparse data, weak methods, and incomplete reporting of results in one RCT; directness point deducted for inconsistency between interventions (different corticosteroid injections; and ultrasound-guided v unguided injections)
1 (82)	Functional improvement	Corticosteroid injections versus placebo or no treatment (longer term)	4	–3	0	0	0	Very low	Quality points deducted for sparse data, weak methods, and incomplete reporting of results
1 (unclear: <200)	Pain relief	Corticosteroid injection plus local anaesthetic injection versus local anaesthetic injection alone (short-term)	4	–3	0	–2	0	Very low	Quality points deducted for sparse data, lack of placebo controls, weak methods (no between-group statistical analysis), and poor follow-up; directness points deducted for uncertainty of clinical relevance and heterogeneity between interventions
1 (unclear; <200)	Pain relief	Corticosteroid injection plus local anaesthetic injection versus local anaesthetic injection alone (longer-term)	4	–3	0	–2	0	Very low	Quality points deducted for sparse data, lack of placebo controls, weak methods (no between-group statistical analysis), and poor follow-up; directness points deducted for uncertainty of clinical relevance and heterogeneity between interventions
13 (at least 1307)	Pain relief	Extracorporeal shock wave therapy versus placebo	4	–2	–1	0	0	Very low	Quality points deducted for incomplete reporting of results and unclear number of participants in analysis; consistency point deducted for statistical heterogeneity between RCTs
5 (790)	Functional improvement	Extracorporeal shock wave therapy versus placebo	4	0	0	–1	0	Moderate	Directness point deducted for different intensities of ESWT
2 (53)	Pain relief	Low dose versus high dose extracorporeal shock wave therapy	4	–3	0	–1	0	Very low	Quality points deducted for sparse data, weak methods, and incomplete reporting of results; directness point deducted for differences in interventions (different doses and devices used to generate ESWT)
2 (110)	Functional improvement	Low dose versus high dose extracorporeal shock wave therapy	4	–3	0	–1	0	Very low	Quality points deducted for sparse data, weak methods, and incomplete reporting; directness point deducted for differences in interventions (different doses and devices used to generate ESWT)
2 (53)	Health-related quality of life	Low dose versus high dose extracorporeal shock wave therapy	4	–3	0	0	0	Very low	Quality points deducted for sparse data, weak methods, and incomplete reporting
1 (62)	Pain relief	Extracorporeal shock wave therapy versus corticosteroid injection plus local anaesthetic injection	4	–3	0	0	0	Very low	Quality point deducted for sparse data, incomplete reporting of results, and weak methods
1 (60)	Pain relief	Extracorporeal shock wave therapy plus local anaesthetic injection versus corticosteroid injection plus local anaesthetic injection	4	–3	0	0	0	Very low	Quality points deducted for sparse data, incomplete reporting of results, and weak methods
1 (60)	Functional improvement	Extracorporeal shock wave therapy plus local anaesthetic injection versus corticosteroid injection plus local anaesthetic injection	4	–3	0	0	0	Very low	Quality points deducted for sparse data, incomplete reporting of results, and weak methods
1 (65)	Pain relief	Extracorporeal shock wave therapy versus surgery	4	–3	0	0	0	Very low	Quality points deducted for sparse data, incomplete reporting of results, and weak methods
1 (65)	Functional improvement	Extracorporeal shock wave therapy versus surgery	4	–3	0	0	0	Very low	Quality points deducted for sparse data, incomplete reporting of results, and weak methods

We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.

Glossary

Achilles tendon stretching

A stretch achieved by either hanging the heel from a step while keeping the knee straight, or by leaning into the wall from a standing position with the affected leg placed behind the other leg.

Customised foot orthoses

Orthoses fabricated by moulding a thermoplastic or thermomouldable material over an impression (or negative cast) of a person’s foot with individual tailoring specific for each individual.

Extracorporeal shock wave therapy (ESWT)

Shock waves are pulsed acoustic waves that dissipate mechanical energy at the interface of two substances with different acoustic impedance.

Heel cups

Prefabricated rubber or silicone heel pads that contour the heel, thus surrounding and supporting the fibro fatty heel pad.

Heel pads

Padding underneath the heel that may be constructed from semi-compressed felt, sponge foam, rubber, or silicone.

Low-quality evidence

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Moderate-quality evidence

Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Plantar fascia stretching

A stretch achieved by crossing the affected leg over the other leg from a seated position, placing the fingers of the affected side across the base of the toes (distal to the metatarsal phalangeal joints), and pulling the toes back until a stretch in the arch of the foot can be felt.

Prefabricated orthoses

Orthoses which are already made to a pre-determined size and shape, and which can be used immediately as there is no lengthy fabrication process.

Very low-quality evidence

Any estimate of effect is very uncertain.

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.