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

Abstract

Objective: To develop a best practice guide for managing people with plantar heel pain (PHP).

Methods: Mixed-methods design including systematic review, expert interviews and patient survey.

Data sources: Medline, 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 criteria: Randomised 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.

Results: Fifty-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).

Conclusion: Best 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.

Keywords: effectiveness; foot; qualitative; rehabilitation.

Figure 1

Management approach for plantar heel pain when a person progressively fails to recover with addition of extracorporeal shockwave therapy (ESWT) at 4 weeks if the core approach is not working and then addition of orthoses at 12 weeks if there is still suboptimal improvement. PROM, patient-reported outcome measure.

Figure 2

Core approach to the management of plantar heel pain based on the best available evidence, expert opinion and the patient voice. The top layer (‘DO’) of taping, stretching and education are required initial interventions with each patient. The individual assessment (‘DECIDE’) is of which specific educational aspects are needed. BMI, body mass index; FF, forefoot; LTC, long-term condition; RF, rearfoot.

Figure 3

Flow diagram for study selection process. RCT, randomised controlled trial.