Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values

Abstract

ObjectiveTo develop a best practice guide for managing people with plantar heel pain (PHP).MethodsMixed-methods design including systematic review, expert interviews and patient survey.Data sourcesMedline, Embase, CINAHL, SPORTDiscus, Cochrane Central Register of Controlled Trials, trial registries, reference lists and citation tracking. Semi-structured interviews with world experts and a patient survey.Eligibility criteriaRandomised controlled trials (RCTs) evaluating any intervention for people with PHP in any language were included subject to strict quality criteria. Trials with a sample size greater than n=38 were considered for proof of efficacy. International experts were interviewed using a semi-structured approach and people with PHP were surveyed online.ResultsFifty-one eligible trials enrolled 4351 participants, with 9 RCTs suitable to determine proof of efficacy for 10 interventions. Forty people with PHP completed the online survey and 14 experts were interviewed resulting in 7 themes and 38 subthemes. There was good agreement between the systematic review findings and interview data about taping (SMD: 0.47, 95% CI 0.05 to 0.88) and plantar fascia stretching (SMD: 1.21, 95% CI 0.78 to 1.63) for first step pain in the short term. Clinical reasoning advocated combining these interventions with education and footwear advice as the core self-management approach. There was good expert agreement with systematic review findings recommending stepped care management with focused shockwave for first step pain in the short-term (OR: 1.89, 95% CI 1.18 to 3.04), medium-term (SMD 1.31, 95% CI 0.61 to 2.01) and long-term (SMD 1.67, 95% CI 0.88 to 2.45) and radial shockwave for first step pain in the short term (OR: 1.66, 95% CI 1.00 to 2.76) and long term (OR: 1.78, 95% CI 1.07 to 2.96). We found good agreement to ‘step care’ using custom foot orthoses for general pain in the short term (SMD: 0.41, 95% CI 0.07 to 0.74) and medium term (SMD: 0.55, 95% CI 0.09 to 1.02).ConclusionBest practice from a mixed-methods study synthesising systematic review with expert opinion and patient feedback suggests core treatment for people with PHP should include taping, stretching and individualised education. Patients who do not optimally improve may be offered shockwave therapy, followed by custom orthoses.

Custom-Made Foot Orthotics for People With Lower Limb Conditions

“…7 Other conservative interventions for foot conditions are available, such as magnetized insoles (cushioned insoles with magnetic foil embedded in the foam under the proximal arch), 8 prefabricated heel lifts, 9 and resting night splints (braces that hold the foot in place, with the toes pointed up). 1 Custom-made orthotics improve plantar pressure redistribution and gait mechanics 8,10,11 However, a 2020 CADTH report 12 found inconsistencies regarding the effectiveness of customized or prefabricated foot orthotics compared to control interventions (standard insole, placebo, or none) in alleviating pain and improving foot function in patients with chronic foot pain. Another CADTH 13 report from 2019 found no difference between custommade and prefabricated foot orthotics for pain reduction or functional improvement, based on a limited amount of evidence.…”

“…Six systematic reviews, 1,5,7,8,27,28 5 RCTs, 9,[29][30][31][32] 1 economic evaluation, 33 and 2 evidence-based guidelines 34,35 were included in this report.…”

“…The 6 systematic reviews 1,5,7,8,27,28 had broader inclusion criteria considered than the present review. Specifically, the systematic reviews investigated other types of mechanical or offloading devices (e.g., orthopedic footwear, shoes with heel lifts, taping, ankle-foot orthoses, fibreglass heel cast) 1,7,8,27,28 or other interventions (e.g., dermal infrared thermometry, education, extracorporeal shockwave therapy, physiotherapy, stretching). 5,7,8 Two systematic reviews also included non-randomized studies.…”

“…Specifically, the systematic reviews investigated other types of mechanical or offloading devices (e.g., orthopedic footwear, shoes with heel lifts, taping, ankle-foot orthoses, fibreglass heel cast) 1,7,8,27,28 or other interventions (e.g., dermal infrared thermometry, education, extracorporeal shockwave therapy, physiotherapy, stretching). 5,7,8 Two systematic reviews also included non-randomized studies. 1,7 Only the subset of primary RCTs meeting the inclusion criteria is presented in this report.…”

Corticosteroid injection or dry needling for musculoskeletal pain and disability? A systematic review and GRADE evidence synthesis

“…In addition, a previous study showed that steroid injection is the second most used therapy for managing shoulder pain by Australian general practitioners [16]. Despite the frequent use of these therapies, clinical practice guidelines for musculoskeletal conditions have not usually mentioned neither dry needling nor corticosteroid injections as first line treatment [17][18][19][20][21]. Some guidelines have recommended dry needling and corticosteroid injection as adjunct treatment for some musculoskeletal conditions such as plantar fasciitis and Achilles pain, but it is suggested to be used with caution [18,19,21].…”