The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010

doi:10.1053/j.jfas.2010.01.001

The Journal of Foot and Ankle Surgery

Volume 49, Issue 3, Supplement, May–June 2010, Pages S1-S19

https://doi.org/10.1053/j.jfas.2010.01.001 Get rights and content

Abstract

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

Section snippets

Heel Pain (Pathway 1)

The heel is a frequent area of pathology. Pain in the heel may be the result of arthritic, neurologic, traumatic, or other systemic conditions, although the overwhelming cause is mechanical in origin. Careful history and examination are generally indicative of etiology and appropriate diagnostic testing will lead to accurate diagnosis. Treatment is directed toward causative factors.

Plantar Heel Pain [Plantar Fasciitis, Plantar Fasciosis, Heel Spur Syndrome] (Pathway 2)

Plantar heel pain is the most prevalent complaint presenting to foot and ankle specialists and may be seen in upwards of 11% to 15% of adults (1). Plantar heel pain has been referred to in the published literature by many names including heel spur syndrome, which lends some importance to the radiographic presence of an inferior calcaneal spur to the clinical symptoms. The term plantar fasciitis has been used for years, likely in an attempt to recognize the actual symptoms occurring along the

Posterior Heel Pain (Pathway 3)

The posterior heel is the second most common location of mechanically induced heel pain. Pathology in this area is categorized as (1) Achilles insertional tendinopathy or enthesopathy, and (2) Haglund's deformity with or without retrocalcaneal bursitis (Figure 6).

Achilles enthesopathy most commonly presents with an insidious onset and frequently leads to chronic posterior heel pain and swelling 219, 220, 221. Pain is aggravated by increased activity (eg, walking, running) and increased pressure

Neurologic Heel Pain (Pathway 4)

Neurologic heel pain is defined as pain in the heel as a result of an entrapment or irritation of one or more of the nerves that innervate this region. Symptoms may arise in patients initially diagnosed with plantar fasciitis, and careful assessment may yield neurologically mediated pathology 32, 297, 298. Patients with a history of previous heel surgery or trauma should be highly suspect for neurologic heel pain 299, 300. The nerves or nerve branches (Figure 8) specifically considered are as

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Small needle-knife versus extracorporeal shock wave therapy for the treatment of plantar fasciitis: A systematic review and meta-analysis
2024, Heliyon
Plantar fasciitis (PF) is the most common cause of chronic heel pain among adults. Extracorporeal shock wave therapy (ESWT) is the recommended in the current guidelines, and the small needle-knife yields acceptable clinical effects for musculoskeletal pain.
To systematically compare the efficacy of the small needle-knife versus ESWT for the treatment of PF.
The present review was registered in the International Prospective Register of Systematic Reviews (i.e., “PROSPERO”, CRD42023448813). Two of the authors searched electronic databases for randomized controlled trials (RCTs) comparing the small needle-knife versus ESWT for the treatment of PF, and collected outcomes including curative effect, pain intensity, and function. Risk of bias was assessed using the Cochrane Handbook Risk of Bias tool and the quality of the RCTs was evaluated according to the Jadad Scale. The same authors independently performed data extraction from the included studies, which were imported into Review Manager version 5.4.1(Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2020) for meta-analysis.
The initial literature search retrieved 886 studies, of which 6 were eventually included in this study. Meta-analysis revealed no significant difference in curative effect (OR = 1.87; 95 % CI [0.80, 4.37], p = .15) nor short-term pain improvement (MD = 2.20; 95 % CI [-2.77, 7.16], p = .39) between the small needle-knife and ESWT. However, the small needle-knife may be more effective than ESWT for pain improvement in mid-term (MD = 9.11; 95 % CI [5.08, 13.15], p＜ .00001) and long-term follow-ups (MD = 10.71; 95 % CI [2.18, 19.25], p＜ .00001). Subgroup analysis revealed that the small needle-knife combined with a corticosteroid injection yielded a statistically significant difference in reduction of pain intensity at all follow-ups (MD = 4.84; 95 % CI [1.33, 8.36], p = .007; MD = 10.99; 95 % CI [8.30, 13.69], p＜ .00001; MD = 17.87; 95 % CI [15.26, 20.48], p＜ .00001). Meta-analysis revealed no statistical differences in short-term (MD = 1.34; 95 % CI [-3.19, 5.86], p = .56) and mid-term (MD = 2.75; 95 % CI [-1.21, 6.72], p = . 17) functional improvement between the needle-knife and ESWT groups. In a subgroup analysis of moderate-quality studies, the small needle-knife demonstrated a favorable effect on mid-term functional improvement (MD = 1.58; 95 % CI [0.52, 2.65], p = .004), with low heterogeneity (χ² = 0.77, p = .038, I² = 0 %). Conclusion: Pain reduction and functional improvement are essential for the treatment of PF. Therefore, treatment using the small needle-knife may be superior to ESWT. Results of this systematic review and meta-analysis may provide alternative treatment options for patients with PF as well as more reliable, evidence-based recommendations supporting use of the small needle-knife.
Comparing Myofascial Pain Syndrome Treatment with Dry Needling Versus Extracorporeal Shock Wave Therapy for Plantar Fasciitis on Pain and Function of the Heel
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The aim of this study was to compare the effects of dry needling (DN) and extracorporeal shock wave therapy (ESWT) in the treatment of plantar fasciitis (PF). The study included 55 patients with PF. The patients were randomly divided into 2 groups. The DN group applied 3 sessions of DN to the myofascial trigger points in the lower limb muscles. The ESWT group applied 3 sessions of ESWT to the plantar fascia. For clinical evaluation, we used a visual analog scale (VAS) (first step, rest, activity) and Foot Function Index (FFI) (pain, disability, activity). Assessments were done baseline, post-treatment first week, and fourth week. Maximum pain-free standing time (Max PfST) and maximum pain-free walking distance (Max PfWD) were recorded at baseline and post-treatment fourth week. In this study, we found significant improvement in VAS, FFI, Max PfST, and Max PfWD in both groups (p < .01). VAS-activity baseline-forth week change was significantly superior in the DN group compared to the ESWT group (p = .023). FFI-disability baseline-fourth week change was significantly superior in the DN group compared to the ESWT group (p = .048). There was no significant difference in other treatment-related changes between the groups (p > .05). However, VAS-rest baseline-fourth week change and FFI-pain baseline-fourth week change trended towards statistical significance between groups ((p = .056), (p = .052) respectively). This study showed that DN may be a good alternative treatment for patients with PF, with effects similar to or even superior to ESWT.
Platelet rich plasma therapy versus other modalities for treatment of plantar fasciitis: A systematic review and meta-analysis
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Plantar fasciitis (PF) is the most common cause of heel pain in adults. There are numerous non-operative treatments available including platelet rich plasma (PRP) injections. PPR has demonstrated effectiveness for a range of musculoskeletal conditions including plantar fasciitis.
To compare the effectiveness of PRP to other conservative treatment options for the management of PF.
A systematic search of PubMed and Google Scholar was performed for randomized control trials (RCT) comparing PRP to other treatment modalities. Studies met inclusion criteria if mean and standard deviations for visual analog scale (VAS) pain scores, plantar fascia thickness (PFT), Foot Function Index (FFI), or American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score were reported. Mean differences (MD) were used to compare VAS pain, PFT, FFI, and AOFAS between PRP and other treatments.
Twenty-one RCTs which altogether included 1356 patients were included in the meta-analysis. PRP demonstrated significantly greater improvements in VAS pain scores compared to extracorporeal shock wave therapy (ESWT) (SMD: 0.86; CI: [0.30, 1.41]; p = 0.002), corticosteroid injections (CSI) (SMD: 1.08; CI: [0.05, 2.11]; p = 0.04), and placebo (SMD: 3.42; CI: [2.53, 4.31]; p < 0.00001). In terms of FFI, no significant differences existed among PRP, ESWT, CSI, dextrose prolotherapy (DPT), and meridian trigger points (MTP) in enhancing foot functionality. However, PRP demonstrated a marked advantage over phonophoresis, showing a substantial improvement in FFI scores (SMD: 3.07, 95% CI: 2.34–3.81). PRP did not demonstrate superiority over ESWT, CSI, or MTP for improving PFT, but it was notably more effective than phonophoresis (SMD: 3.18, 95% CI: 2.43–3.94). PRP demonstrated significantly greater improvements in AOFAS scores over CSI (SMD: 3.31, CI: [1.35, 5.27], p = 0.0009) and placebo (SMD: 3.75; CI: [2.81, 4.70]; p < 0.00001).
PRP is more effective than CSI, ESWT, and placebo in reducing VAS and more effective than CSI and placebo in improving AOFAS. PRP did not demonstrate a consistent advantage across all outcome measures, such as PFT and FFI. These findings underscore the complexity of PF treatment and call for a more standardized approach to PRP preparation and outcome measurement.
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Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.
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Custom foot orthoses are used to treat a variety of foot pathologies. However, orthotic production requires significant hands-on fabrication time and expertise to produce orthoses that are both comfortable and effective. This paper introduces a novel 3D printed orthosis and fabrication method that utilizes custom architectures to produce variable-hardness regions. These novel orthoses are compared to traditionally fabricated orthoses during a 2-week user comfort study. Twenty (n = 20) male volunteers underwent orthotic fitting for both traditional and 3D-printed foot orthoses prior to engaging in treadmill walking trials and 2 weeks of wear. Each participant undertook a regional comfort, acceptance, and comparison analysis of the orthoses at three time points throughout the study (0, 1, and 2 weeks). Both the 3D-printed and the traditionally fabricated foot orthoses demonstrated statistically significant increases in comfort when compared to the factory fabricated shoe insert. Additionally, the two orthosis groups were not significantly different from each other in comfort rankings both regionally and overall at any time point. The similar comfort achieved by the 3D-printed orthosis to the traditionally fabricated orthosis after 7 days and 14 days emphasizes the potential of the future use of the more reproducible and adaptable 3D-printed orthosis manufacturing methodology.

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: Financial Disclosure: None reported.

: Conflict of Interest: Dr. Weil discloses consultant, advisory, and legal expert roles, as well as research funding, in association with ArthroCare Corporation, Orthometrix Inc., and Electro Medical Systems SA. Dr. Bouché discloses a proprietary interest in United Shockwave Therapies, LLC. Dr. Vanore discloses a consultant/advisory role with BME-TX and Ascension Orthopedics, stock ownership in BME-TX, and receipt of honoraria from BME-TX.

: Supplement to: The Journal of Foot & Ankle Surgery®

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Clinical Practice GuidelineThe Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010

Abstract

Section snippets

Heel Pain (Pathway 1)

Plantar Heel Pain [Plantar Fasciitis, Plantar Fasciosis, Heel Spur Syndrome] (Pathway 2)

Posterior Heel Pain (Pathway 3)

Neurologic Heel Pain (Pathway 4)

J Body Mov Ther

Clin Podiatr Med Surg

Clin Podiatr Med Surg

Clin Biomech (Bristol, Avon)

Foot Ankle

J Sci Med Sport

J Foot Ankle Surg

Clin Podiatr Med Surg

Clin Podiatr Med Surg

J Pain

Clin Podiatr Med Surg

Foot Ankle Clin

J Foot Ankle Surg

J Foot Ankle Surg

J Foot Ankle Surg

J Foot Ankle Surg

J Sci Med Sport

Clin Biomech (Bristol, Avon)

Phys Ther Sport

J Foot Ankle Surg

Shock wave therapy for chronic plantar fasciopathy

Br Med Bull

Plantar fasciitis: a degenerative process (fasciosis) without inflammation

J Am Podiatr Med Assoc

Surgical treatment of calcaneal spurs

J Am Podiatr Assoc

The anatomical basis of inferior calcaneal lesions

J Am Podiatr Assoc

Deep fascia of the foot. Anatomical and clinical considerations

J Am Podiatr Med Assoc

Normal and Abnormal Function of the Foot, vol. II

The windlass mechanism of the foot. A mechanical model to explain pathology

J Am Podiatr Med Assoc

Obesity and osteoarthritis: disease genesis and nonpharmacologic weight management

Rheum Dis Clin North Am

Plantar calcaneal spurs in older people: longitudinal traction or vertical compression?

J Foot Ankle Res

Plantar pressure differences between obese and non-obese adults: a biomechanical analysis

Int J Obes Relat Metab Disord

Plantar fasciitis: diagnosis and conservative management

J Am Acad Orthop Surg

Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study

BMC Musculoskelet Disord

Musculoskeletal disorders associated with obesity: a biomechanical perspective

Obes Rev

Risk factors for plantar fasciitis: a matched case-control study

J Bone Joint Surg Am

Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice

J Athl Train

Analysis of release of the first branch of the lateral plantar nerve

J Am Podiatr Med Assoc

The medial and inferior calcaneal nerves: an anatomic study

Surg Radiol Anat

Heel pain syndrome: electrodiagnostic support for nerve entrapment

Foot Ankle

Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve

Clin Orthop Relat Res

Medial calcaneal nerve: an anatomical study

J Am Podiatr Med Assoc

Chronic calcaneal pain in athletes: entrapment of the calcaneal nerve?

Am J Sports Med

Entrapment neuropathy of muscle branch of lateral plantar nerve: a cause of heel pain

J Am Podiatry Assoc

Technique for determining when plantar heel pain can be neural in origin

Microsurgery

Medial calcaneal nerve entrapment as a cause for chronic heel pain

Physiother Theory Pract

Nerve entrapment in painful heel syndrome

Foot Ankle Int

Plantar heel pain

Instr Course Lect

The painful heel syndrome: an entrapment neuropathy

Bull Hosp Joint Dis Orthop Inst

Clinical Practice Guideline
The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010