the best objectives treatments for plantar heel pain · treatments for plantar heel pain objectives...

Its essential toreview the latest

outcomes studies.

The BestTreatments for

Plantar Heel Pain

Objectives

1) Understand the pathwayto wound healing through thethree phases of inflammatory,proliferative, and remodeling.

2) Introduce the reader tothe concerns of bacterial bur-den, hydration, and nutritionin wound healing.

3) Better comprehend theinter-related biology of woundsand bacterial contamination.

4) Comprehend the relation-ship between wound physiolo-gy and healing potential.

5) Further the reader’s un-derstanding of comprehen-sive wound management.

The BestTreatments for

Plantar Heel Pain

Its essential toreview the latest

outcomes studies.

AUGUST 2002 • PODIATRY MANAGEMENTwww.podiatrym.com 135

es which have fueled considerabledebate and critical analysis aboutthe validity and success of all inter-ventions for treatment of plantarheel pain—both operative and non-operative.(15,18)

Among all disciplines is near-universal agreement that the vastmajority of patients with plantarheel pain will be successfully treated

with non-operative strategies. How-ever, there is no uniform agreement,either within or between these disci-plines, as to which conservative in-terventions are most appropriate inachieving a successful outcome intreating plantar heel pain.

As managed care economics af-fected the medical profession during

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IntroductionFew conditions affecting the

human foot have stimulated moreinterest and controversy amonghealth care professionals than plan-tar heel pain syndrome. Over thepast decade, new surgical approach-es have been popularized, approach-

Douglas H. Richie Jr. D.P.M.

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the 1990’s, health care providers were pressured to de-velop evidence-based outcomes research to justify thecosts and benefits of prevailing clinical treatment strate-gies. Standards for quality outcomes research haveevolved for most health care disciplines, including podia-tric medicine.(17) However, scrutiny of published researchreporting outcomes of treatment of plantar heel pain inthe podiatric and orthopedic literature reveals numerousshortcomings in terms of valid design, methodology, andinterpretation of results.

The purpose of this article is to 1) Evaluate prevailingtheories about the pathomechanics of plantar heel pain,2) Present controversies that currently exist regarding eti-ology and treatment and, 3) Review outcomes reports ofnon-operative interventions used to treat large groups ofpatients with plantar heel pain syndrome.

PathomechanicsIn 1972 Snook and Chrisman, in reviewing the pre-

vailing literature relevant to plantar heel pain, stated “Itis reasonably certain that a condition which has so manytheories about etiology and treatment does not havevalid proof of any one cause.”(23) Sadly, thirty years later,this statement is still true.

Patients presenting with pain in and around theplantar tubercules of the calcaneus have been theorizedto have a wide array of possible injuries to various struc-tures in and around the plantar heel area (Table 1). Theseconditions include plantar fasciitis, calcaneal periostitis,enthesopathy, calcaneal stress fracture, calcaneal spur,nerve entrapment, fat pad atrophy and subcalcaneal bur-sitis. Systemic inflammatory conditions are known tocause plantar heel pain, most notably the seronegativespondyloarthropaties. This article will focus on all non-systemic etiologies. A summary of prevailing causes ofplantar heel pain is presented in Table 2.

The four most popular theories of the pathomechan-ics of plantar heel pain include plantar fascial strain, heelimpact shock, and nerve entrapment. The most com-pelling evidence supporting any of these theories isfound in the category of plantar fascial overload andstrain. Before discussing this area, the other two pro-posed mechanisms will be reviewed.

Nerve Entrapment TheoriesThe nerve entrapment theory of plantar heel pain has

been popularized by Don Baxter M.D., who has co-au-thored several papers dealing with the anatomy, diagnosisand treatment of heel pain attributed to an entrapment ofthe first branch of the lateral plantar nerve.(1,27) This nervehas been thus named “Baxter’s Nerve” even though it wasfirst described as a cause of plantar heel pain by Tanz in1963,(6) and later by Przylucki and Jones in 1981—tenyears before Baxter’s first paper on the subject.(2)

The first branch of the lateral plantar nerve (nerve tothe abductor digiti quinti brevis) is thought to lie in thedirect vicinity of the area where most patients complain ofplantar heel pain. Contrary to original anatomic descrip-tions, Baxter showed in a cadaver series that the first

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Table 1

Table 2

Figure 1

Figure 2

Figures 1 and 2 were adapted from

illustrations that appeared originally in Clinical Orthopaedics. Baxter D

E, Pfeffer GB: Treat-

ment of C

hronic Heel Pain by Surgical Release of the First Branch of the Lateral Plantar N

erve: Clin O

rthop. 279:229-235, 1992.

branch of the lateral plantar nerve is more proximal,and penetrates a tight myofascial septum separating theabductor hallucis muscle from the quadratus plantaemuscle, then courses plantarly, just anterior to the medi-al calcaneal turbercle (Figures 1 & 2). An entrapment isthought to occur at this fascial septum, or just under thecalcaneal margin. How such an entrapment occurs, how-ever, has not been proposed by any author. Surgical re-lease of the entrapment along with neurolysis of the firstbranch of the lateral plantar nerve has shown success in89% of patients with recalcitrant plantar heel pain.(27)

Other nerve entrapment theories of plantar heelpain include involvement of the medial calcanealnerve(3) as well a tarsal tunnel nerve entrapment.(14) Hen-drix et al demonstrated a 95% success rate with surgicaldecompression of the tarsal tunnel in his series of 51patients with chronic heel pain.(14) The pathomechanicsof this entrapment was speculated to be an invertedgait pattern, which was a compensation for a pre-exist-ing painful heel.

Heel impact shock is commonly quoted as a causativefactor in the development of plantar heel pain syn-drome.(23) Further scrutiny of these reports shows no validobjective data to justify such a conclusion. Certainly, agroup of patients have been identified with plantar fatpad atrophy that is subject to periostitis and bursitis dueto lack of intrinsic cushioning.(12) However, this anatomiccharacteristic is not found amongst the majority of pa-tients treated for plantar heel pain in this country.

The calcaneal stress fracture theory is primarilybased upon a traction force applied to the calcaneus bythe plantar fascia, rather than an impact shock mecha-

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Figure 3

Figure 4

nism.(23) Calcaneal stress fractures have been reported inhigh-mileage runners who are subject to repetitive im-pact, heel cord and plantar fascial loads. These patientsmake up a small percentage of patients treated for plan-tar heel pain syndrome in this country.

Later, the use of cushioning modalities will be dis-cussed in the treatment of heel pain syndrome. The resultsof cushioning strategies are, for the most part, onlymarginally effective, which indirectly invalidates impactshock as a primary etiology of plantar heel pain syndrome.

Plantar Fascial StrainThe most widely-accepted theory of the etiology of

plantar heel pain syndrome is plantar fascial strain.Biopsies of plantar fascia samples taken from patientswith chronic heel pain have consistently demonstratedhistologic findings compatible with mechanical tearand inflammatory response.(8,12) The location of this me-chanical injury is most often at the plantar-medial mar-gin of the calcaneus.(7)

A widely-accepted consequence of chronic plantarfascial strain is the development of a plantar-calcanealspur.(13,23) In fact, many clinicians commonly label allpatients with plantar heel pain as having “heel spursyndrome.”(26)

Myths About Heel SpursIn a series of elegant anatomic studies using cryomi-

crotomy, McCarthy and Gorecki clearly showed thatthe common plantar calcaneal spur is not invested bythe plantar fascia.(19) Rather, the spur is invested by theabductor hallucis, quadratus plantae and flexor digito-rum brevis muscle origins and is clearly found superiorto the origin of the plantar aponeurosis. In light ofthese findings, the direct link between plantar fascialoverload and the formation of calcaneal spurs must bequestioned.

In 1963, Rubin showed that only 10% of patientswith radiographic evidence of heel spurs were actuallysymptomatic.(5) Since then, many authors have demon-strated that the majority of plantar heel spurs found onfoot x-rays are asymptomatic.(4,10)

Thus the role of a heel spur in the pathomechanicsof plantar heel pain syndrome is still poorly under-stood. Yet, clinicians commonly use the term heel–spursyndrome and many treatment strategies employ meth-ods to theoretically off-load a plantar calcaneal spur.

Theories of Plantar Fascia OverloadPlantar fascia strain has been speculated to result

from every imaginable foot type and biomechanical eti-ology. Both the podiatric and orthopaedic literature arereplete with unsubstantiated explanations of plantarfascial strain resulting from cavus foot types, flat foottypes, pronated feet and supinated feet.(13,21,23) In almostevery case, these pathologies have been speculated tocause a lowering of the medial arch of the foot, result-ing in fascial strain.

A valid and well-substantiated arch-lowering forceon the human foot is a tight heel cord.(12) Tightening ofthe heel cord in cadaver models not only lowers the

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arch, it causes significant rotationalmovements of the forefoot upon therearfoot, including midtarsal jointpronation and dorsiflexion and in-version of the first ray segment.(29)

Interestingly, the presence of atight heel cord has not been consis-tently found in groups of patientswith plantar heel pain syndrome. Inher study of 91 patients with heelpain, Barbara Warren found that theheel cord was actually tighter in acontrol group than in a group of pa-tients with plantar heel pain.(20) Con-versely, Kibler found that the heelcord was tighter on the symptomaticside of patients with heel pain, butcould not rule out a cause vs. effectrelationship.(11) Amis found that 75%of his patients with heel pain had atight heel cord.(10) However, there isno universal agreement as to the“normal” range of ankle joint dorsi-flexion necessary for humans, sostudies of tight heel cords are opento considerable subjective interpreta-

Heel Pain... bility than the posterior tibialtendon.(24) In his series on therole of the plantar fascia and archsupport, Sharkey found a significantelongation and deformation of thearch with complete fasciotomy.(29,30)

The arch of the human foot hasbeen described as both a beam and atruss.(34) Recent experimental evi-dence has validated the truss mech-anism as the primary explanation ofstability. A beam relies on the inter-locking relationship of the buildingblocks (bones) and the soft tissueconnections on the concave surface(ligaments)(Figure 3). The truss isdescribed as two struts connected bya tie rod (plantar fascia)(Figure 4).

Cadaveric studies have shownthat, without intact ligaments, thebone architecture of the human footis incapable of maintaining an archconfiguration when axial load is ap-plied.(22,24) When the entire centralband of the plantar fascia is severed,the human arch integrity is severelycompromised, with documented

tion. The essential factor in evaluat-ing this possible link between a tightheel cord and plantar heel pain isthe role of calf and Achilles stretch-ing in non-operative treatment pro-grams. Indeed, although stretchingis integral in most recommendedtreatments, the success of such inter-

vention is questionable. This will bediscussed later in this article.

The plantar fascia is the mostimportant arch-supporting mecha-nism of the human foot. In hisstudy of cadaver models subjectedto axial load, Thornardsen foundthat the plantar fascia had a twofold greater contribution to arch sta-

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Artificially supporting the arch does not

necessarily reduce strainin the fascia.

shift of alignment of the tarsal bones in allthree cardinal body planes. In addition,Sharkey showed, in cadaver models void of anintact central plantar fascia, that greater loadswere transmitted to the central metatarsals,due to loss of plantar stabilization of the proxi-mal phalanx on the metatarsal head.(30) Bend-ing and strain of the metatarsals can possiblylead to stress fractures in patients who haveundergone complete plantar fasciotomy.

In static, resting stance, the muscles of theleg and foot are inactive. Maintenance of archintegrity is entirely dependent on the osseouslocking of the tarsus and the truss mechanism ofthe plantar fascia. Without the aid of the extrin-sics to maintain the arch, static stance may bethe most stressful situation for the plantar fascia.

Anecdotally, clinicians have reported themost difficult challenges in managing plantarfasciitis in patients engaged in prolonged stand-ing activities.(15,36) Comparisons between the dy-namic foot condition and the resting, static footposition offer interesting challenges for treat-ment options for off-loading the plantar fascia.

Recent insights into the effects of off-load-ing the plantar fascia in a static foot modelwere offered in a series of studies conducted byKogler et. al. In nine cadaver specimens, axiallyloaded, six degree medial wedges placed underthe forefoot caused an increased strain in theplantar fascia while six degree lateral wedgescaused a significant decreased strain. Rearfootwedges, both medial and lateral, had no signif-icant effect on plantar fascial strain.(32)

In another study published by Kogler, theeffect of heel elevation on plantar fascia strainwas determined.(33) Simple blocks of 2,4 and 6cm thickness were placed under the heel of 12cadaver specimens and plantar fascia strain wasmeasured and compared to the heel flat condi-tion. Surprisingly, there was no evidence ofany reduced fascial strain with heel elevation.However, when the heel was elevated withshank contour platforms (simulating the effectof footwear with elevated heels) there was asignificant decrease in strain of the plantar fas-cia with increased elevation of the platform.

The results of Kogler’s research validatesthe experience of many patients who obtainrelief of plantar heel pain syndrome by wear-ing shoes with elevated heels. The mechanicaloff-loading of the plantar fascia cannot, how-ever, be explained by heel elevation alone. Infact, with a true truss mechanism, elevatingthe proximal strut (calcaneus) can be expectedto actually increase strain in the tie rod (plan-tar fascia)(figure 5). The reduction in plantarfascia strain occurring with contoured shankplatforms, according to Kogler, may be the re-

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Figure 5

Figure 6

Figure 7

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sult of lateral arch elevation whichsecondarily raises the medial archand thus decreases strain on the me-dial fascial structures (Figure 6).

The problem with most of thecadaver studies on plantar fasciabiomechanics is the fact that the in-vestigators did not evaluate or re-port on the foot-type of the speci-mens. The presence of a forefootvarus or valgus could have signifi-cant effect on the response to medi-al and lateral wedging of the fore-foot, as well as the lateral arch-rais-ing effect of a shank contoured ele-vation platform.

Another issue to consider is thephase in the gait cycle that is simu-lated in cadaver studies of lower ex-tremity function. Kogler, Thornard-sen and Kitaoka all evaluated theircadaver specimens in a foot-flat,static stance position. Sharkey eval-uated plantar fascia mechanics interminal stance (propulsive phase)when maximal strain on the plantarfascia is thought to occur. This as-sumption is somewhat debatable.Although ground-reaction forcespeak at heel rise and extrinsic mus-cle activity also reaches maximaltension, the windlass mechanism al-lows transmission of tension into ki-netic movement of pedal and legskeletal segments. Therefore, energyor strain in the plantar fascia istransferred to other parts of the footduring terminal stance. Without afunctioning windlass, occurringwith hallux limitus or during staticstance, strain develops in the plan-tar fascia and cannot be dissipatedor transferred into joint movement.

Utilizing Off-loading PrinciplesPodiatric physicians have long

employed biomechanical principlesin the treatment of patients withplantar heel pain. However, there isno consensus in the podiatric litera-ture in terms of a uniform treat-ment approach utilizing functionalfoot orthoses and proper footwearprescription.

Many practitioners seek to con-trol pronation of the subtalar jointthrough the use of medially-postedfoot orthoses, both in the rearfootand forefoot. As Kogler’s work hasshown, and from a simple under-

Heel Pain... painful heels, 115 had a struc-tural deformity that would resultin a compensation with supinationof the forefoot on the rearfoot, pre-sumably through a longitudinal axisof rotation. Of these, 63 had a fore-foot valgus, 20 had a plantarflexedfirst ray, and 32 had an everted heelin stance. All three groups, therefore,would have a compensation mecha-nism which would invert (supinate)the forefoot on the rearfoot. Schererand co-workers theorized that thismovement would increase strain onthe medial portion of the centralband of the plantar fascia. Indeed,the later work of Kogler, using lateralwedges to reduce forefoot inversion,validated Scherer’s theory of foot me-chanics and plantar fascia strain.(32) Aproposed mechanism of plantar fas-cia overload appears in Figure 7.

Many practitioners simply relyon over-the-counter arch supports oron custom foot orthoses designedprimarily for arch support as a reme-dy for plantar heel pain syndrome.(21)

standing of the truss mechanism ofthe plantar fascia, the application ofa medial post under the forefoot willactually increase strain in the plan-tar fascia for most foot types. Onepossible exception is the true fore-foot varus, which is uncommon,and in the author’s experience, is

rarely associated with plantar heelpain syndrome.

Insight into the prevalence ofplantar heel pain in certain foottypes was provided by Scherer andthe Biomechanics Graduate ResearchGroup at the California College ofPodiatric Medicine.(26) In a prospec-tive study of 88 patients with 133

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Many patients have formed opinions

that their pain will never be totally cured.

The notion that support of the medial longitudinalarch will decrease strain on the medial portion of thecentral band of the plantar fascia has not yet been sub-stantiated. Although it has been well-proven that theplantar fascia is the most important soft tissue supportmechanism of the human arch, artificially supportingthe arch does not necessarily reduce strain in the fascia.

In his series of cadaver studies of plantar fascial strain,Kogler used five different types of custom and non-custom

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Figure 11

Figure 12

Figure 13

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foot orthoses to determine effects onplantar fascial strain in seven cadavericlower limbs.(31) These test orthoses in-cluded: a prefabricated stock arch in-sole, a custom “soft” accommodativedesign orthosis composed of viscoelas-tic material, a “semi-rigid” accom-modative design orthosis composed ofco-polymer, a “rigid” custom orthosiswith a Root Functional design, and aUCBL design rigid orthosis. The pre-fabricated device and the Root rigiddevice actually increased strain in theplantar fascia while the other threecustom devices decreased strain com-pared to the barefoot condition.

The devices that most effectively re-duced strain were those with higher api-cal arch height and increased slope ofarch shape in the central region of themedial arch. Although all five devicescould be considered arch supports, theshape of the device and the conformityto certain key areas of the medial archappeared critical in determining effec-tiveness to offload the plantar fascia.Thus, non-conforming arch supportshave the potential to actually increasestrain in the plantar fascia.

Evaluating Treatment Outcome Reports

A total of 10 published papers re-porting outcomes of various treat-

ments of plantarheel pain will be re-viewed. These pa-pers have all beenpublished withinthe past decadeand combine simi-lar modalities com-monly employedin this country fortreatment of plan-tar heel pain. Al-though the treat-ment strategies aresimilar, the resultsand conclusionsvary significantlyamongst the inves-tigators (Figure 8).

Wolgin sur-veyed 100 patientswho were treatedwith a variety ofcommon non-oper-ative interventionsfor plantar heelpain syndrome.(16)

Average time forfollow up surveywas 47 months.Good results wereobtained in 82 outof 100 patients, 14achieved fair resultsand 3 had poor re-sults (Figures 9 &10). The patientsrated Achillesstretching as themost effective treat-ment followed byrest and NSAID’s,both of which were

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Figure 16

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higher rated than “custom inserts.”Patients who did poorly were over-weight, had bilateral symptomsand had symptoms for a pro-longed period of time (more than10 months) before seeking medicalattention.

Tisdel and Harper utilized ashort-leg walking cast on 32 pa-tients who had failed 12 monthsof non-operative treatment forplantar heel pain. (39) After s ixweeks of cast immobilization, the

Heel Pain... years of treatment, with 59%of the patients resolved, the au-thors concluded that “Themethod is effective for treatmentof plantar fasciitis.”

Davis, Severud and Baxter re-ported on the results of non opera-tive treatment of 105 patients withheel pain syndrome (38). A self-ad-ministered patient questionnairewas completed an average of 29months after initiating treatment.Treatment included Rest, NSAID,viscoelastic heel pad, Achil lesstretch, occasional steroid injec-tion, and custom foot orthosis“when warranted.” In rating theirlevel of pain resolution, 58% of thepatients reported good results, 31%fair, and 10% poor with an averagetime to resolution of 5.1 months(Figure 13). Somehow, the authorsconcluded that “The treatmentprotocol used in this study wassuccessful for 89.5% of the pa-tients.”

Powell and co-workers used aplantar fascia night splint (Figure14) on 37 patients who had 6months of heel pain symptoms.(37)

patients were then followed andinterviewed at an average of 15months post treatment (Figure 11).Despite the fact that good resultswere obtained in only 25% of thepatients, and over 40% of the pa-tients were dissatisfied, the au-thors concluded that “Casting ap-pears to be a reasonable option forpatients with recalcitrant heelpain and should be offered beforesurgical intervention.”

Mizel utilized a shoe modifica-tion with steel shank and anteriorrocker for patients who had failed

a 1 0 - m o n t hcourse of previ-ous treatment forplantar heel pains y n d r o m e . ( 4 1 )

After 16 monthsof this treatment,59% of the pa-tients reporteds y m p t o m s r e -solved, 18% wereimproved, 15%r e p o r t e d n ochange, and 7%were worse (Fig-ure 12). After two

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Figure 19 Continued on page 146

The splint was used for 30 days, and the patients fol-lowed up at six months with physician interview. A sur-vey revealed that 59% of the patients were satisfied,13% satisfied with reservation, and 10% dissatisfied(Figure 15). Despite the fact that 18% of the patientscould not tolerate the splint, and that only 59% of thepatients were satisfied, the authors conclusion was “Webelieve dorsiflexion splints provide relief from thesymptoms of recalcitrant plantar fasciitis in the majori-ty of patients.”

A more impressive result with night splinting was re-ported by Batt et. al., who used a custom-fabricated ten-sion plantar fascia night splint on 32 patients and used acontrolled, cross-over study design to compare splintingto NSAID, heel stretch and viscoelastic heel cushions.(40)

All 16 out of 16 patients using the night splint werehealed after 12 weeks, while only 6 of 17 patients werehealed in the control group. In the cross-over group, 8of 17 were healed once night splinting was utilized(Fig-ure 16).

Martin studied results of treatment of 157 patientswith an average of 12 months of heel pain prior to seek-ing care.(36) Treatment consisted of stretching, NSAID,night splint, and either a heel cup or a foot orthosis. Re-sults were good in only 51% of the patients, 88% ofwhom had had symptoms for 12 months or less. Fair re-sults were obtained in 38% of the patients, while 14% re-ported poor results. In evaluating patient compliancewith treatment, only 22% were compliant with stretch-ing, 57% with heel cup/orthosis, 58% with NSAID, and70% with night splint (Figures 17,18 & 19). The authorsconcluded that early, aggressive non-surgical treatmentwithin 12 months of onset of symptoms offers the bestchance of a favorable outcome.

Gill and Kiebzak reported less effective outcomes ofnon-operative interventions described in the previous re-ports.(35) In a large patient population (246 female and 165male) a treatment ratings survey showed that most inter-ventions showed disappointing results. In terms of effec-tiveness, cast immobilization led to improvement in 65%of patients, steroid injection improved 45%, NSAID 25%,and heel pad 27%(Figures 20 & 21). However, the overallimprovement with any treatment was rated poor or mild.The authors concluded that “The ineffectiveness of nonsurgical treatments noted in this study is at variance withmost published clinical studies.” Furthermore, these au-thors stated that “Physicians may be inappropriately at-tributing many of their success to their treatments, when,in fact, these treatments make very little difference in theactual outcome.”

An interesting classification of non-operative treat-ments for plantar heel pain is provided by Lynch and co-workers.(25) In their randomized, prospective study of 103subjects, three types of conservative therapy were utilized:Anti-inflammatory (dexamethasone injection), Accom-modative (viscoelastic heel cup), and Mechanical (low-dye strapping and custom foot orthosis). After 12 weeksof treatment, good to excellent results were obtained in70% of the patients in the mechanical group, 33% in the

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Figure 20

Figure 21

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beneficial cardiovascular ex-ercise program.

In the final analysis, the treat-ment strategy that yielded the bestresults in the shortest period of timewas the combination of low-dyestrapping(9) and prompt institutionof custom functional foot orthotictherapy. Both Scherer and Lynch,utilizing these strategies, achieved

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significant pain relief with non-op-erative care. Several authors con-cluded that certain treatments wereeffective, even though the time oftreatment needed to achieve mea-surable success exceeded two years.One has to question the overall ef-ficacy of such interventions if, dur-ing the two years of treatment, thepatient lost significant time fromwork or discontinued a potentially

Heel Pain...

anti-inflammatory group and 30%in the accommodative group (Fig-ures 22 & 23).

This same significant favorableoutcome with a mechanical ap-proach to off-loading the plantarfascia was obtained by Scherer andco-workers.(26) In their prospectivestudy of 73 patients, a subgroup re-ceiving low-dye strapping and cus-tom functional foot orthoses onlyobtained good results in 81% of thepatients, fair results in 15%, andpoor results in 4%(Figure 24).

There are numerous difficultiesin evaluating all of these outcomestudies and drawing meaningfulconclusions. Clearly, there weredifferences in assessment of successdepending on whether the resultswere determined by confidentialpatient interview or obtained by in-terview from the treating practi-tioner. It is well known that pa-tients will report a more favorableoutcome to the treating doctor ver-sus a more realistic assessment in aconfidential survey, conducted by aneutral party.

Of interest is the disparity be-tween a patient assessment of suc-cessful treatment outcome (Good,Fair, Poor) versus overall pain relief.In many studies, a majority of pa-tients reported a good outcome, yetstill had significant pain. As Martinstates, in evaluating patients whohave been treated for long term heelpain, “Because of the chronic natureof the patient’s symptoms, their ex-pectations for complete relief mayhave been low.” Thus, many pa-tients who present for treatment ofplantar heel pain have already hadtheir pain for an extended periodand have formed opinions that theirpain will never be totally cured.

Among almost all of these stud-ies, there was near universal agree-ment that the longer the patienthad experienced pain prior to treat-ment, the less likely would a suc-cessful treatment outcome occur. Ingeneral, those patients having painfor more than 12 months prior totreatment were most resistant tonon-operative interventions.

In this regard, there appears adisparity among clinicians as to theamount of time necessary to expect



better results that the other groups in less than one-fourth the period of time (See Table 3).

ConclusionsPlantar heel pain syndrome continues to stimulate

controversy regarding pathomechanics and treatment.Patients developing heel pain can expect to be offered adivergent approach, depending on the specialty theyseek treatment from. Even within certain specialties,there is considerable variation of opinion regarding thepathomechanics and treatment of plantar heel painsyndrome.

Recent cadaveric studies have shed light on the roleof the plantar fascia in supporting the arch as well asthe effects of certain strategies to decrease strain in thisstructure. Some widely accepted notions about forefootwedging and heel elevation have now been disputed.Relating the results of laboratory research to a practicalclinical setting and to a variety of foot types remains achallenge to today’s podiatric physician.

Non-operative treatment strategies for plantar heelpain have been evaluated in outcomes studies by anumber of investigators. The results of these studies arecontradictory, and conclusions must be made cautious-ly. The reasons for such skepticism are the following:

1. True outcomes research has yet to be conducted inthis area, following accepted methodology and utilizing ap-

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Table 3

29 Sharkey NA, Ferris L, Donahue SW:Biomechanical Consequences of Plantar Fas-cial Release or Rupture During Gait: Part I—Disruptions in Longitudinal Arch Conforma-tion. Foot Ankle Int. 19:812-819, 1998.

30 Sharkey NA, Ferris L, Donahue SW:Biomechanical Consequences of Plantar Fas-cial Release or Rupture During Gait: Part II: Al-terations in Forefoot Loading. Foot Ankle Int.20:86-95, 1999.

31 Kogler GF, Solomonidis SE, Paul JP:Biomechanics of longitudinal arch supportmechanisms in foot orthoses and their effecton plantar aponeurosis strain. Clin Biomech.11:243-251, 1996.

32 Kogler GF, Veer FB, Solomonidis SE,Paul JP: The Influence of Medial and LateralPlacement of Orthotic Wedges on Loading ofthe Plantar Aponeurosis. J Bone and JointSurg. 81A:1403-1413, 1999.

33 Kogler GF, Veer FB, Verhulst SJ,Solomonidis SE, Paul JP: The Effect of Heel El-evation on Strain Within the Plantar Aponeu-rosis: In Vitro Study. Foot Ankle Int. 22:433-439, 2001.

34 Sarrafian SK: Functional Characteristicsof the Foot and Plantar Aponeurosis underTibiotalar Loading. Foot Ankle. 8:4-17, 1987.

35 Gill LH, Kiebzak GM: Outcome of Non-surgical Treatment for Plantar Fasciitis. FootAnkle Int. 17:527-531, 1996.

36 Martin RL, Irrgang JJ, Conti SF: Out-come Study of Subjects with Insertional Plan-tar Fasciitis. Foot Ankle Int. 19:803-810, 1998.

37 Powell M, Post WR, Keener J, WeardenS: Effective Treatment of Chronic PlantarFasciitis with Dorsiflexion Night Splints: ACrossover Prospective Randomized OutcomeStudy. Foot Ankle Int. 19:10-17, 1998.

38 Davis PF, Severud E, Baxter DE: PainfulHeel Syndrome: Results of NonoperativeTreatment. Foot Ankle Int. 15:531-534, 1994.

39 Tisdel CL, Harper MC: Chronic PlantarHeel Pain: Treatment with a Short Leg Walk-ing Cast. Foot Ankle Int. 17:41-42, 1996.

40 Batt ME, Tanji JL, Skattum N: PlantarFasciitis: A Prospective Randomized ClinicalTrial of the Tension Night Splint. Clin J SportMed. 6:158-162, 1996.

41 Mizel MS, Marymont JV, Trepman E:Treatment of Plantar Fasciitis with a NightSplint and Shoe Modification Consisting of aSteel Shank and Anterior Rocker Bottom. FootAnkle Int. 17:732-735, 1996.

Dr. Richie is inprivate practicein Seal Beach, CA.He is Section Edi-tor of the Journalof Foot and AnkleSurgery and is onthe Board of Di-rectors of theAmerican Acade-my of Podiatric

Sports Medicine. Dr. Richie is a consult-ing editor for this magazine.

treatment assessment. Foot Ankle 9:91-95,1988.

11 Kibler WB, Goldberg C, Chandler TJ:functional biomechanical deficits in runningathletes with plantar fascitis. Am J Sports Med19:66-71, 1991.

12 Kwong PK, Kay D, Voner RT, et al:Plantar fascitis: Mechanics and pathomechan-ics of treatment. Clin Sports Med 7:119-126,1988.

13 Schepsis AA, Leach RE, Gorzyca J: Plan-tar Fascitis. Etiology, treatment, surgical re-sults, and review of the literature. Clin orthop266:185-196, 1991.

14 Hendrix, CL, Jolly GP, Garbalosa Jc: En-trapment Neuropathy: The etiology of in-tractable chronic heel pain syndrome. JourFoot & Ankle Surg 37: 273-279,1998.

15 Pfeffer G, et al: Comparison of Customand Prefabricated Orthoses in the InitialTreatment of Proximal Plantar Fasciitis. FootAnkle Int. 20:214-221, 1999.

16 Wolgin M, Cook C, Graham C,Mauldin D: Conservative treatment of plantarheel pain: long-term follow-up. Foot Ankle.15:97-102, 1994.

17 Wrobel, James S: Outcomes Research inPodiatric Medicine. J Am Podiatr Assn 90:403-409, 2000.

18 O’Malley MJ, Page A, Cook R: Endo-scopic Plantar Fasciotomy for Chronic HeelPain. Foot Ankle Int 21:505-509, 2000.

19 McCarthy DJ, Gorecki GE: Theanatomical basis of inferior calcaneal lesions. JAm Podiatry Assoc 69:527, 1979

20 Warren BL, Jones CJ: Predicting plantarfasciitis in runners. Med Sci Sports Exerc19:71-73, 1986.

21 Warren BL: Plantar Fasciitis in Runners:Treatment and Prevention. Sports Med.10:338-345, 1990.

22 Murphy GA, Pneumaticos SG, KamaricE, Noble PC, Trevino SG, Baxter DE: Biome-chanical Consequences of Sequential PlantarFascia Release. Foot Ankle Int 19:149-152,1998.

23 Karr SD, Subcalcaneal Heel Pain: Or-thop Clin North Am 25:161-173, 1994.

24 Thordarson DB, Kumar PJ, Hedman TP,Ebramzadeh E: Effect of Partial Versus Com-plete Plantar Fasciotomy on the WindlassMechanism. Foot Ankle Int. 18:16-19, 1997.

25 Lynch DM, Goforth WP, Martin JE,Odom RD, Preece CK, Kotter MW: Conserva-tive Treatment of Plantar Fasciitis A Prospec-tive Study. J Am Pod Med Assoc. 88:375-379,1998.

26 Scherer PR: Heel Spur Syndrome. Path-omechanics and Nonsurgical Treatment. JAm Pod Med Assn. 81:68-72, 1991.

27 Baxter DE, Pfeffer GB: Treatment ofChronic Heel Pain by Surgical Release of theFirst Branch of the Lateral Plantar Nerve: ClinOrthop. 279:229-235, 1992.

28 Schon LC, Glennon TP, Baxter DE:Heel Pain Syndrome: Electrodiagnostic Sup-port for Nerve Entrapment. Foot Ankle14:129-133, 1993.

propriate measurement techniques.2. Assessment of a successful out-

come of treatment will vary significant-ly depending on whether the patientversus the clinician provides the finalanalysis.

3. Patients with plantar heel painhave poor expectations for total, perma-nent pain relief when they present fortreatment.

4. Clinicians can use treatmentsthat require up to 24 months to achievesuccess, yet conclude such treatmentsare effective.

5. The longer a patient has symp-toms prior to treatment, the less likelyany non-operative treatment is going tobe successful.

Although comparisons betweenstudies are difficult to make, somefindings appear worth noting.Specifically, those groups of patientswith plantar heel pain, treatedpromptly with low-dye taping andcustom functional foot orthosistherapy, had the most favorable out-come of treatment.

Until further insight into thepathomechanics of plantar heelpain is attained, there will continueto be controversy—and, unfortu-nately, continued significant num-bers of patients suffering from thisdisorder. �

References1 Baxter DE and Thigpen CM: Heel pain:

Operative results. Foot Ankle 5:16, 1984.2 Przylucki J, Jones CL: Entrapment neu-

ropathy of muscle branch of lateral plantarnerve. J Am Pod Assoc 7:119, 1981.

3 Savastano AA: Surgical neurectomy forthe treatment of resistant painful heel. RhodeIsland Med J 68:371, 1985.

4 Shama SS, Kominsky SJ, Lemour H:Prevalence of non-painful heel spur and its re-lation to postural foot position. J Am PodiatrAssn 11:215, 1983.

5 Rubin G, Witten M: Plantar calcanealspurs. Am J Orthop 5:38, 1963.

6 Tanz SS: Heel pain. Clin Orthop 28:169,1963.

7 D’Abrosia RD: Conservative manage-ment of metatarsal and heel pain in the adultfoot. Orthopedics 10:137, 1987.

8 Leach RE, Seavey MS, Salter DK: Resultsof surgery in athletes with plantar fascitis.Foot Ankle 7:156, 1986.

9 Dye L: Dye technique of foot correction.J Natl Assoc Chirop 29:1, 1939.

10 Amis J, Jennings L, Graham D, et al:Painful heel syndrome: Radiographic and

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6) The plantar fascia appearsstrained when the midtarsal jointis:

A) PronatedB) SupinatedC) WedgedD) Rotated

7) Treating painful heels is mostsuccessful when patients seektreatment within:

A) Two yearsB) Three yearsC) 12 monthsD) 14 months

8) Patients initially presenting fortreatment with plantar heel painusually have the following expec-tation level of achieving successwith treatment:

A) HighB) LowC) NoneD) Surgical

9) Outcomes research on patientswith plantar heel pain will havedifferent results, depending onwhether the results are deter-mined by:

A) The treating physicianB) The patientC) A neutral partyD) All of the above

10) The two most effective treat-ments reported in outcomes re-search in the treatment of plantarheel pain are:

A) NSAIDS and restB) Heel pad and stretching

1) Which of the followinganatomic structures is NOT com-monly implicated as a cause ofplantar heel pain?

A) Plantar fasciaB) First branch of lateral plan-tar nerveC) Calcaneal periosteumD) Extensor digitorum brevis

2) The nerve most commonly im-plicated in plantar heel pain syn-drome is:

A) Medial plantarB) Medial calcanealC) SuralD) First branch of lateralplantar

3) The primary structure(s) in-vesting a heel spur are:

A) plantar aponeurosisB) abductor hallucis and flexordigitorum brevisC) peroneal tendonD) posterior tibial tendon

4) The most important soft tissuesupport of the human arch is:

A) Plantar fasciaB) Posterior tibial tendonC) Short plantar ligamentD) Spring ligament

5) Wearing elevated heel shoesdecreases strain in the plantar fas-cia by:

A) Relieving the truss tie rodB) Shifting weight to the toesC) Providing a shank contourD) Activating the intrinsicmuscles

C) Night splint and steroidsD) Low-dye taping and func-tional foot orthoses

11) At least one study of plantarfascia night splints, with cross-overdesign, has shown the followinglevel of success:

A) LowB) HighC) NoneD) Variable

12) In static stance, the followingmuscles are active:

A) Posterior tibialB) Anterior tibialC) Abductor hallucisD) None

13) A forefoot valgus causes thefollowing compensation of themidtarsal joint:

A) PronationB) SupinationC) DorsiflexionD) Plantarflexion

14) In evaluating cadaver studiesof plantar fascia strain, which vari-able NOT discussed would bemost important:

A) Foot type of the specimenB) Weight of the limbC) DorsiflexionD) Pronation

15) Strain across the metatarsalshas been observed after plantarfasciotomy because the following

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structure is de-stabilized:A) Heel cordB) Tibial nerveC) Extensor tendonD) Metatarsophalangeal joint

16) The following treatments for plantar heel pain have been reviewed, EXCEPT:

A) NSAID’sB) Heel cushionC) AcupunctureD) Orthotic

17) The windlass mechanism is compromised whenthe following clinical situation is present:

A) Functional hallux limitusB) Nerve entrapmentC) Heel pad atrophyD) Periostitis

18) Plantar fasciotomy can be expected to lead tothe following change in the medial arch:

A) ShorteningB) LengtheningC) ElevationD) Adduction

19) Which of the following is NOT considered amechanical approach to relieving plantar heel pain:

A) Custom foot orthoticB) Low dye tapingC) Viscoelastic heel cupD) Stretching heel cord

20) Impingement of the First Branch of the LateralPlantar Nerve can involve the following structuresEXCEPT:

A) Abductor Hallucis muscleB) Quadratus Plantae muscleC) Posterior calcaneal tubercleD) Plantar medial edge of calcaneus

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EXAM #6/02Plantar Heel Pain

(Richie)

1. A B C D

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