Plantar heel pain (PHP) or plantar fasciitis is a common and disabling musculoskeletal condition characterised by pain localised to the plantar aspect of the heel. It is aggravated by weight-bearing activities, is often most severe during the first steps after rest and can impair mobility, participation in physical activity, ability to work and health-related quality of life. Symptoms often persist for months to years. It is prevalent in about 10 per cent of the population, with the highest rates in women over 65 years and men aged 50 to 65, and is frequently associated with a higher body mass index. It is also commonly reported among factory workers, suggesting that long hours of standing or walking can play a role. In runners, it is the most common foot-related injury. While symptoms may improve over the long term, full recovery only occurs in about half of all cases.

Diagnosis is based on clinical assessment, including a subjective history as well as physical examination, and imaging confirmation is only necessary in resistant cases to rule out other causes. Differential diagnoses should be carefully considered. People with PHP typically report a gradual onset of pain localised to the plantar and inferior aspects of the heel, with pain spreading from the anteromedial calcaneus across the heel and into the proximal arch. Discomfort is often worse with initial weight-bearing after rest, improving after early activity, while prolonged standing or walking will often exacerbate the symptoms later in the day. Bilateral involvement occurs in about 40 per cent of cases. Factors including changes in training load, footwear and individual biomechanics need to be considered in addition to other physical factors.

In their Journal of Physiotherapy Invited Topical Review, Dr Matthew Cotchett and Prof Dylan Morrissey evaluate best practice evidence-based approaches to the management of PHP, highlighting a ‘core approach’. Evidence-based interventions they recommend include low-Dye taping, plantar fascia stretching exercises and education about PHP and its management. Education should include discussions about activity modification and load, pain beliefs, prognosis, metabolic health and comorbidities and choosing appropriate footwear. Addressing lifestyle factors such as sleep, nutrition and physical activity is also suggested as part of the core approach.

A stepped approach is recommended for patients whose PHP had not improved after four to six weeks. This includes the use of shock wave therapy and custom orthoses as an adjunct to the core approach. The use of corticosteroid injections is not supported by current evidence. The researchers also noted the lack of evidence supporting strengthening exercises and suggested that these be used as an adjunct to stretching exercises to improve and maintain general physical function in the lower limbs.

Matthew and Dylan suggest that future research focus on the evidence gaps in education and in better evaluation of clinical interventions – in particular, evaluation of individualised educational strategies and programs co-designed with people with lived experience of PHP. They also recommend that more research looks at lifestyle and psychosocial factors.

For more information, read the entire Invited Topical Review.

Dr Matthew Cotchett is a senior lecturer in podiatry and an early career researcher at La Trobe University. Matthew also works as a podiatrist in the Orthopaedic Outpatients Department of the Northern Hospital, Melbourne. He has a particular interest in the management of pain beneath the heel and completed a PhD that evaluated the effectiveness of trigger point dry needling for plantar heel pain.

Professor Dylan Morrissey is a consultant physiotherapist and professor of sports and musculoskeletal physiotherapy at Barts Health NHS Trust/Barts and the London Faculty of Medicine and Dentistry, Queen Mary University of London, where he is the academic lead for sports and exercise medicine. Dylan is interested in combining the best of educational, clinical and research practice in order to develop and deliver high-quality evidence-based physiotherapy for patients with musculoskeletal disorders.