Part 1 was all about what you definitely should not do to treat Plantar Heel Pain (PHP), this is all about what might be a reasonable option.

First up, let’s take a look at Extracorporeal Shock Wave Therapy (ESWT)

It has long been documented “well obviously ESWT works”, and for the most this is true. However, there is quite a gap in the literature in relation to when it works for PHP, and at what dosage, and with what type of beam. In short, there are quite a few variables.

ESWT may be either focused or radial, with radial being far and away the preferred method of application for PHP. However, many of the studies vary the energy densities at 2.5 bar or less (about 50% the capacity of most machines), often in an attempt to make the treatment comfort more tolerable.

A study by Chow and Cheing demonstrated that performing radial ESWT with a maximum tolerable energy density is a more effective treatment protocol than a fixed energy density in terms of relieving pain and restoring the functional activity of those with chronic heel pain. So, a lot of the studies are not comparing apples with apples.

Moving on from this, does it work?

There is now little doubt that ESWT is effective for chronic cases of PHP. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest pressure that can be applied. 

In relation for the use of ESWT for acute cases of PHP, the jury is still well and truly out. However, I expect this to change, especially on the back of this study, which claims:

“Early treatment is more likely to allow for maintenance of patients’ activity level. Also, waiting 6 months to treat plantar fasciitis with RSWT results in delays and inferior results. Early treatment is better for active and athletic patients.”

It should be noted that this is a pilot study with a relatively low level of evidence, with no larger randomized follow up study published to date.

Right now, there is no good evidence to recommend the use of ESWT in the management of acutePHP and up until recently that has guided most clinical use.

Manual therapies

There is minimal evidence to support the use of manual therapy and nerve mobilization procedures in the short term (1 to 3 months) for pain and function improvement. 

A very recent paper concluded:

“Current evidence on myofascial release therapy is not sufficient to warrant this treatment in chronic musculoskeletal pain”

Now this paper was not specific to PHP, and it should be balanced by this 2018 paper which concluded:

“manual therapy is clearly associated with improved function and may be associated with pain reduction in PF patients. It is recommended that clinicians consider use of both joint and soft tissue mobilization techniques in conjunction with stretching and strengthening when treating patients with PHP”

Based on the evidence then, best guess recommendation is that manual therapy may be effective, but mostly when associated with stretching, strengthening or the inclusion of other proven therapies. 

Stretching

The big question here is what structure are we stretching, CAN it be stretched, and does it work?

This RCT prospectively randomized fifty participants aged 40 to 60 years with a history of plantar fasciitis greater than 1 month into 2 groups. Group 1 was instructed to stretch the Achilles tendon while group 2 simultaneously stretched the Achilles tendon and plantar fascia. The study concluded:

“The simultaneous stretching of the Achilles tendon and plantar fascia for 4 weeks was a more effective intervention for plantar fasciitis. Patients who reported complete relief from symptoms at the end of the 4-week intervention in the simultaneous stretching group (n = 14; 56%) were double that of the stretching of the Achilles tendon–only group (n = 7; 28%)”

One can only be suspicious of the stretching methods employed in the study (especially given the authors declare a conflict of interest relating to a “pending patent”, presumably of the stretching platform), I think these results probably reflect the mainstream findings in the literature, that stretching of both the plantar fascia and the AT are better than stretching of either structure in isolation.

Whatever, stretching alone is unlikely to offer long term relief from PHP.

Night Splints

I’ve got to be honest at this point i`ve never used or prescribed night splints. I just never believed they would make a difference to the length of the plantar fascia! However, this is about the evidence for the therapy, not my opinion, so here it is.

Lee et al randomized patients with plantar fasciitis into 2 groups: foot orthoses and night splint versus foot orthoses alone. At 8 weeks following intervention, the group with the combination of night splint and orthoses had greater reduction in mean pain and greater improvement in self-reported function, than the group with foot orthoses alone.

Attard and Singh compared posterior versus anterior night splints in 15 patients with heel pain. Both devices reduced pain, but the posterior night splint was tolerated less, with more complaints of sleep disruption.

On the basis of the available evidence, the use of Night Splints might be helpful in reducing first step pain associated with PHP. However, factored into the decision must be the overwhelming view that compliance may be poor due to the discomfort of wearing such a bulky device in bed. If you can sleep great! because you won’t be doing anything else with one of these on your leg.

Strengthening

The concept that strengthening of the intrinsic foot muscles might have a role to play in the management of PHP, whilst around for some time, has only quite recently been investigated in the scientific literature.

A recent a systematic review found that there is a significant association between intrinsic foot muscle weakness and painful foot pathologies such as plantar fasciitis.

One of main problems is that we clearly don’t full understand the relationship between the weakening of the muscle and the origin of the pain. If both are symptoms of functional instability, then strengthening will prove to be of short-term benefit at best. Latey et al documented a link between intrinsic foot muscle weakness and painful foot pathologies such as plantar fasciitis. 

A very recent systematic review concluded:

“Based on the studies reviewed it was not possible to identify the extent to which strengthening interventions that improve intrinsic foot musculature may benefit symptomatic or at risk populations to plantar fasciitis / heel pain”

So in summary strengthening the intrinsic muscles of the foot most likely does play a role in the long-term management of PHP but as a lead actor or supporting role remains unclear.

Up next, what definitely, absolutely, positively works for Plantar Heel Pain!

Once again most of the hard work in researching/reviewing these treatments was done by Simon Bartold a world-renowned Australian podiatrist with impeccable credentials, a scathing sense of humour and an acute eye for detail in clinical research. His delightful paper on this subject was originally intended to challenge clinicians to analyze why they treat heel pain the way they do and make future choices more outcome-based.

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