PODIATRY

Plantar Heel Pain: The Science

Many of the let’s call them more glamorous, headline, marketable treatment options on offer to you. Were likely presented to your clinician at a medical conference under a pseudo educational soft marketing, “must have clinical tool” presentation.

image showing suggested inflammation of the planter heel area

First, we should set out the hard cold facts.

  • despite the extreme commonness of plantar heel pain, there is great confusion in general medicine over what the condition actually is.
  • of course, Plantar Heel Pain is not a diagnosis, it is a catch all label, and without a diagnosis.
  • 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 effective for all!.

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

Additionally, individuals with PHP generally present with impairments in foot posture/mobility, ankle or big toe dorsiflexion, weight-bearing duration, lower leg/foot muscle performance, and neuro-dynamic function, as well as co-morbidities including stress, depression, obesity, and low back pain. Footwear, activities, environment and occupation all play crucial roles in exacerbating or improving the condition.

“Great things are not accomplished by those who yield to trends and fads and popular opinion” – Jack Kerouac

This Blog is part one, and explores what almost certainly does not work, and if you are considering using these therapies, probably should NOT!.

Part 2 will explore the therapies with stronger evidence of efficacy, therefore those you might consider using.

Part 3 will look at those therapies that almost certainly do work and are backed up by strong evidence base. These you most certainly should be considering.

Mesenchymal Stem Cell Therapy (MSC)

The Australasian College of Sports Physicians position statement 2017 states unequivocally that:

  1. That MSCs are experimental and are not proven safe or effective for clinical use.
  2. The long-term harms from the use of MSCs have not been determined.
  3. That the patient is being offered a therapy that has not been validated through reliable research methods.

So, if you are considering delving into the very murky world of MSC Therapy, DONT or at least wait for valid research to be completed.

What is it?

  • LLLT is the application of red and near infra-red light within the band width of 600-1000 nanometers.
  • LLLT is purported to improve wound and soft tissue healing, reduce inflammation and relieve both acute and chronic pain.

The actual therapy may be either Laser Diode or  LED

So, does it work? Well, there have been 2 quite strong studies on the therapy, one showing reduced migration of inflammatory cells and improved quality of repair while reducing the functional limitations. (Casalechi et al Lasers in Medical Science; November 2013) and LLLT decreased Achilles tendon’s inflammatory process. De Jesus et al, Lasers in Medical Science; July 2014

 Unfortunately both these studies were performed on rats, and there is no convincing study at all showing any reliable efficacy for LLLT in the treatment of PHP.

A randomized and placebo-controlled study provided evidence for using low-level laser therapy for pain reduction. Pain measurements demonstrated statistically significant but clinically small effects favouring low-level laser therapy for night rest pain.

Conversely, data from one of the very few other randomized studies failed to support the clinical effectiveness of low-level laser therapy to address symptoms in individuals with plantar fasciitis.

Thus there is insufficient evidence in the published, peer-reviewed scientific literature to demonstrate that LLLT is effective. 

Why would you bother? Because, after years of evidence showing it does not work it is still being used. Many years ago, renowned Adelaide Physio Dave Butler labeled ultrasound as “ultrabullshit”, at a time when every physio practice in Australia had an ultrasound machine!

A recent review by Shanks et al concluded that:

There is currently no high-quality evidence available to support therapeutic ultrasound in the treatment of musculoskeletal conditions of the lower limb.

This review included a study by Crawford and Snaith, who found ultrasound (0.5 W/cm2 power, 3-MHz frequency, 1:4 pulsed duty cycle) delivered for eight 8-minute sessions at a frequency of twice weekly for 4 weeks no more effective than a sham treatment in treating those with heel pain.

The use of PRP / AB for the treatment of PHP can possibly be best summed up by a very recent paper which compared PRP infiltration to corticosteroid infiltration. The paper concluded:

“the treatment of plantar fasciitis with steroid or PRP injection was equally effective”

In other words, PRP is equally as effective as Corticosteroid, which, is not AT ALL effective in the management of PHP. The evidence is fairly clear that PRP / AB is not effective in the management of PHP.

photo of an injection to the plantar fascia

The results of 2 systematic reviews failed to yield evidence favouring any substantive clinical benefit of intracortical steroid injection (ICSI) for patients with heel pain / plantar fasciitis. (here and here)

Potential harms associated with ICSI may include injection-site pain, infection, subcutaneous fat atrophy, skin pigmentation changes, plantar fascia rupture, peripheral nerve injury, and muscle damage.

An important note before moving on is that used as an adjunct therapy ICSI there may be an indication, but we’re jumping ahead

image of dry needling being applied to a plantar heel area

This is what the evidence tells us, that the literature on the topic is frankly a shambles. Non-randomized studies, case reviews, opinion pieces and totally inappropriate study designs.

Based on this, there is currently insufficient evidence to recommend the use of dry needling, trigger point therapy or acupuncture in the treatment of PHP.

Most of the hard work in researching these treatments was done by the very entertaining Simon Bartold an Australian podiatrist with a scathing sense of humour and an acute eye for detail in clinical research. His delightful paper on this subject was intended to challenge clinicians to analyze why they treat heel pain the way they do. As a practitioner and past clinical educator I believe it’s important that we educate our patients properly about their condition and treatments available so they can make informed decisions on the course of their treatment. Be that in our offices or on the underside of the planet.

Next time we’ll review what “might work” in treating Planter Heel Pain.

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