Pelvic Prime's Anatomy Academy Series
Heel Pain / Plantar Fasciitis
Risk Factors for Heel Pain
Knowing the risk factors for heel pain is crucial for prevention, early intervention, and tailored treatment. By understanding these factors, such as obesity or poor footwear, people can take preventive steps and seek timely treatment, preventing the condition from worsening. It also helps doctors create personalized treatment plans and allows patients to make informed health choices. Additionally, addressing these risk factors improves overall health.
Limited ankle dorsiflexion motion
High body mass index in nonathletic people
Running
Work-related activities that involve a lot of standing or walking, especially on hard surfaces
History and physical exam findings:
Knowing the history and physical exam findings for heel pain is crucial for accurate diagnosis and effective treatment. Understanding the patient's symptoms, onset, and previous injuries helps identify the cause and tailor treatment plans. It also reveals underlying issues like biomechanical problems or poor footwear choices. This information allows healthcare providers to track treatment progress and educate patients on preventing future heel pain through proper stretching, footwear, and activity modifications.
Plantar medial heel pain that is most noticeable with the first steps after inactivity and gets worse with prolonged standing or walking.
Heel pain that started after a recent increase in weight-bearing activities.
Pain when pressing on the inside part of the heel where the plantar fascia attaches.
Positive windlass test (pain when bending the big toe upward).
Negative tarsal tunnel tests (no nerve compression symptoms).
Limited active and passive movement when pointing the foot upward (dorsiflexion).
Abnormal Foot Posture-6 (FPI-6) score.
High body mass index in nonathletic individuals.
Differential Diagnosis:
Spondyloarthritis
Fat-pad atrophy
Proximal plantar fibroma
Outcome Measures:
Foot and Ankle Ability Measure (FAAM)
Foot Health Status Questionnaire (FHSQ)
Foot Function Index (FFI)
Lower Extremity Functional Scale (LEFS)
Physical Impairment Measures:
When checking a patient with heel pain/plantar fasciitis, doctors should measure:
Pain with the first steps after resting
Pain when pressing on the inside part of the heel where the plantar fascia attaches
They can also check the range of motion when moving the ankle up and down and the patient's body mass index if they are not athletic.
Foot and Ankle Examination Outline:
To help gather information about foot and ankle problems, experts have created a specific exam outline. A full lower-body check can be done if needed based on the patient’s symptoms.
Supine Range of Motion:
Dorsiflexion with knee extended
Dorsiflexion with knee flexed
Plantar flexion
Supination/inversion
Pronation/eversion
Great toe extension
Joint mobility assessment
Manual Muscle Testing:
Anterior tibialis
Posterior tibialis
Fibularis longus and brevis
Flexor hallucis longus
Soleus/gastrocnemius
Standing heel raise (gastroc-soleus muscle strength)
Dorsiflexion lunge test/tibio-pedal dorsiflexion range of motion
Other Assessments:
Foot Posture Index-6
Single-leg squat
Gait
Leg length
Single-leg balance
Special Tests:
Windlass test in both weight-bearing and non-weight-bearing positions
Tinel’s test with dorsiflexion and eversion
Palpation:
Medial calcaneal tubercle
Trigger point assessment of the gastrocnemius and soleus
Body of the calcaneus to check for stress fracture
Plantar surface of the calcaneus to check for fat pad atrophy
Posterior aspect of the calcaneus to check for insertional Achilles tendinopathy
Midsection of the plantar fascia to check for plantar fibromatosis
Imaging:
Usually, imaging studies are not needed for patients diagnosed with plantar fasciitis until they do not get better with basic treatments. If imaging is needed:
Xrays are done 1st
Weight-bearing X-rays are the first choice for those with chronic foot pain.
MRI without contrast or Ultrasound (if Xrays are Negative)
No significant differences have been found between US and MRI when looking for increased plantar fascia thickness.
For US: signs of plantar fasciitis include fascial thickening (more than 4 mm) and a dark appearance on the US.
For possible Baxter’s neuropathy, US can be combined with injections around the inferior calcaneal nerve.
Electrophysiologic studies can also help diagnose conditions like tarsal tunnel syndrome, entrapment of the medial calcaneal nerve, and S1 radiculopathy.
Manual Therapy Treatment
Manual therapy involves various techniques to help with joint and soft tissue issues. Clinicians use a combination of joint and soft tissue mobilization to treat lower extremity joint mobility and calf flexibility deficits, decrease pain, and improve function in patients with heel pain or plantar fasciitis.
Joint Mobilization: This includes both thrust and non-thrust techniques, which involve skilled passive movements at different speeds and amplitudes within or at the end of a joint’s range of motion (ROM). These techniques aim to improve joint mobility and reduce pain.
Several studies compared joint mobilization to other treatments like customized foot orthoses and conventional physiotherapy. Joint mobilization generally showed greater improvements in pain and function.
Soft Tissue Mobilization: This is skilled passive movement of soft tissues like fascia, muscles, and ligaments to reduce pain and improve ROM. Reviews of literature indicate that soft tissue mobilization, including deep massage and neural mobilization, can significantly improve pain and function in patients with heel pain. Techniques include:
Instrument-Assisted Soft-Tissue Mobilization (IASTM). Studies comparing IASTM to therapeutic US showed that IASTM, combined with a home exercise program, was more effective in reducing pain and improving function over both short and long terms.
Myofascial Release (MFR)
Myofascial Trigger Point (MTrP) Therapy. Studies found that adding MTrP therapy to ultrasound (US) and stretching significantly reduced pain and improved function over 2 weeks.
Muscle Energy Techniques. Adding muscle energy techniques to conventional therapy showed superior improvements in ROM, pain intensity, and foot function compared to conventional therapy alone.
Strain/Counterstrain Techniques
Massage: This uses the hands to promote muscle relaxation.
Dry Cupping: Heated cups are placed on the skin, creating suction as they cool. This helps mobilize tissues and increase blood flow. Studies found significant short-term pain reduction and improved ROM with dry cupping, but effects were not maintained after 2 days.
Overall, recent studies support the use of manual therapy for improving pain, function, and disability related to lower extremity issues, particularly heel pain and plantar fasciitis. Manual therapy, involving joint and soft tissue techniques, remains a recommended treatment for these conditions due to its effectiveness and low risk of adverse effects.
Muscle Stretching Treatment
Studies support the effectiveness of plantar fascia-specific and gastrocnemius/soleus stretching for improving pain, function, and disability. Treatment times ranged from 1 week to 12 months with no serious side effects reported. Future research should focus on long-term outcomes and the effects of stretching additional muscles like the hamstring and fibularis.
Gastrocnemius/Soleus Stretching: This involves stretching the back calf muscles, including the gastrocnemius and soleus muscles, Achilles tendon, and related structures.
Can be done with or without bearing weight.
Stretching the ankle upward (dorsiflexion) with a straight knee targets the gastrocnemius muscle
Stretching the ankle upwards (dorsiflexion) with a bent knee targets the soleus muscle and other short plantar flexors.
Stretching can also be done in a sitting position with legs straight to stretch the back of the knee and hip, which we call hamstring stretching.
Plantar Fascia Stretching: This targets the plantar fascia, a band of tissue on the bottom of the foot.
Can be done with or without bearing weight.
The stretch involves applying pressure to the base of the toes (metatarsal heads) and pulling the toes upward (dorsiflexion).
Pressure can also be applied to the plantar fascia itself.
The ankle should be neutral or dorsiflexed during the stretch.
Study findings comparing different treatment groups:
Effects on Balance: A study looked at the effect of stretching alone, foot exercises, and foot and hip exercises on balance. No significant differences in balance were found among the three groups after 8 weeks.
Foam Rolling vs. Self-Stretching: Comparing the gastrocnemius/soleus and plantar fascia. Immediately after the interventions, there was no significant difference between the groups in pain or range of motion. However, the self-stretching group had better outcomes for muscle pressure pain tolerance.
Monophasic Pulsed Current (MPC) and Stretching: Comparing the effects of MPC alone versus MPC combined with plantar fascia stretching on heel pain and tenderness found no significant differences between the two groups after 4 weeks.
Achilles Tendon and Plantar Fascia Stretching: Compared stretching of the Achilles tendon alone versus stretching of both the Achilles tendon and plantar fascia found that the combined stretching group showed significantly better pressure pain tolerance.
Manual Therapy and Stretching: Found that adding stretching to manual therapy and ultrasound significantly improved pain and function over 6 weeks.
Home Stretching vs. Physical Therapy-Based Stretching: Comparing home-based plantar fascia stretching to physical therapy-based stretching (which included other treatments like dry needling and massage) found no significant differences between the groups in pain and function.
Clinicians should use plantar fascia-specific and gastrocnemius/soleus stretching to provide both short-term and long-term pain relief, as well as to improve function and reduce disability.
Therapeutic Taping
This includes using both rigid tape (like athletic tape or Leukotape®) and elastic tape (like Kinesiology or Dynamic Tape®) applied to the foot or ankle. Rigid tape provides mechanical support, while elastic tape allows movement while offering support. All types of tape can affect the body's response when applied to the skin.
Effectiveness of Taping
Two systematic reviews found taping effective for short-term treatment of plantar fasciitis.
A meta-analysis found low-dye taping significantly decreased pain compared to controls for 1 to 6 weeks.
Another study compared Dynamic Tape® to low-dye taping in 57 subjects. Dynamic Tape® significantly decreased pain more than low-dye taping, but low-dye taping reduced foot pronation more.
Comparisons with Other Treatments:
Kinesiology taping to extracorporeal shock wave therapy (ESWT). Both treatments significantly improved pain and function with no significant difference between them.
Conventional therapy with kinesiology taping led to significantly greater pain and disability improvement after 3 weeks compared to conventional therapy alone.
Kinesiology taping with other therapies: Found positive short-term effects of kinesiology taping on pain and function compared to other therapies.
Taping, both rigid and elastic, is supported for short-term pain relief and improved function. Elastic tape may offer better pain relief than rigid tape in the short term. Combining kinesiology taping with conventional therapy can further improve outcomes. Taping is generally safe, with mild skin irritation being the only reported side effect. Clinicians should use foot taping techniques, either rigid or elastic, along with other physical therapy treatments for short-term pain relief and improved function in individuals with plantar fasciitis.
Foot Orthoses
These are supports placed inside the shoe or around the ankle (ankle-foot orthotic) to support the arch of the foot and relieve pressure on the plantar fascia. They can be custom-made or prefabricated.
Effectiveness of Foot Orthoses:
Three systematic reviews with meta-analyses and one without found a more conservative view on the benefits of orthoses compared to previous guidelines.
Found no significant pain reduction when orthoses were compared with controls (including sham or flat orthoses) at 1 to 6 weeks and 7 to 12 weeks.
Another study compared custom orthoses to ESWT (shock wave therapy). At 24 weeks, the custom orthoses group had significantly better outcomes in evening pain, foot pain, foot function, general foot health, and physical activity.
A study found that custom orthoses combined with ESWT and stretching significantly reduced pain at 1 month and 6 months compared to placebo insoles.
Clinicians should not use orthoses, either prefabricated or custom-made, as the only treatment for short-term pain relief in people with plantar fasciitis.
Clinicians may use orthoses, either prefabricated or custom-made, combined with other treatments to reduce pain and improve function in people with heel pain or plantar fasciitis.
Four meta-analyses suggest a small to no effect of using custom or prefabricated orthoses alone for short-term management of plantar fasciitis. Combining orthoses with other treatments like stretching and ESWT shows positive outcomes. Long-term follow-up studies favor custom orthoses over ESWT for pain and function. There is limited evidence on the best type, material, and design of foot orthoses.
Night Splints
These are plastic devices worn while sleeping to keep the ankle from bending downwards.
Clinicians should prescribe night splints for 1 to 3 months for individuals with heel pain or plantar fasciitis who consistently have pain with the first step in the morning.
Low-Level Laser Therapy (LLLT)
Low-Level Laser Therapy (LLLT) is a non-invasive treatment that uses low-intensity laser light to relieve pain and promote healing. LLLT works by delivering light energy to the affected area, penetrating the skin, and being absorbed by the cells. This reduces pain by decreasing inflammation and promoting endorphin release, aids healing by stimulating cell repair and increasing blood flow, and reduces swelling. This procedure takes about 10-20 minutes, with multiple sessions often needed.
Five studies reviewed found that LLLT helps reduce pain for people with plantar fasciitis.
A meta-analysis that included 14 studies with 817 people. showed that LLLT improved pain more than a control treatment in the short term (1 to 6 weeks).
LLLT compared to shock wave therapy (ESWT) and high-intensity laser therapy found no significant difference in pain reduction between these treatments in the short term.
LLLT combined with rehabilitation improved pain better than rehabilitation alone in the short term.
LLLT led to better pain scores three months after treatment compared to controls.
When looking at disability measures, no significant difference was found between LLLT and a placebo in the short term.
Clinicians should use LLLT as part of a rehabilitation program for people with acute or chronic plantar fasciitis to decrease pain in the short term.
A high-quality meta-analyses show that LLLT can provide a small improvement in pain in the short term for both acute and chronic plantar fasciitis. However, the evidence for LLLT improving disability is inconsistent. No harms were reported for LLLT treatment. More research is needed to determine the best LLLT settings, including wavelength, energy dosage, duration, and frequency.
Phonophoresis
Treats heel pain by using ultrasound waves to deliver anti-inflammatory medication like ketoprofen gel through the skin. The ultrasound increases skin permeability, allowing the medication to penetrate deeper and work more effectively. This non-invasive treatment reduces pain and inflammation without injections or surgery. During a session, a healthcare provider applies the medicated gel and uses an ultrasound device on the heel. The painless procedure lasts about 10-15 minutes, and multiple sessions may be needed for optimal results.
Clinicians may use phonophoresis with ketoprofen gel to reduce pain in individuals with heel pain or plantar fasciitis.
Electrotherapy
Treats heel pain by using electrical currents to reduce pain, decrease inflammation, and promote healing. This non-invasive method stimulates nerves and muscles, increases blood flow, and releases endorphins, the body’s natural painkillers. It can be used alone or with other treatments like stretching and physical therapy, offering a convenient, drug-free option for pain relief.
Found that noninvasive interactive neurostimulation was more effective than ESWT in reducing pain and medication use after 4 and 12 weeks.
Comparing dry cupping to electrical stimulation showed similar improvements in pain and function for both after 4 weeks.
Found that iontophoresis with conventional therapy was more effective than conventional therapy alone for pain and function over 2 weeks.
Found that interferential therapy with conventional therapy was superior to conventional therapy alone for pain and function over 15 days.
Mixed evidence exists for the use of electrotherapy. While some studies support its use, the overall effect sizes are small. Manual therapy, stretching, and foot orthoses remain the primary treatments. Clinicians may use manual therapy, stretching, and foot orthoses instead of electrotherapy for short-term and long-term improvements for individuals with heel pain or plantar fasciitis. Iontophoresis or premodulated interferential current electrical stimulation can be used as a second line of treatment.
Ultrasound (US)
Treats heel pain, such as plantar fasciitis, by using sound waves to reduce pain and promote healing. The sound waves penetrate deep tissues, increasing blood flow, reducing inflammation, and accelerating healing. It also helps relax tissues and break down scar tissue.
Comparing ultrasound and stretching to fake ultrasound and stretching found no significant differences in pain or function between the groups.
Two meta-analyses compared ultrasound to ESWT, and found that both treatments showed improvement, but ESWT was more effective for pain during activity.
There is no high-quality evidence supporting the use of ultrasound to improve the effects of stretching exercises for plantar fasciitis. ESWT is more effective for improving pain during activity. Clinicians should not use ultrasound to enhance the benefits of stretching treatment in individuals with plantar fasciitis.
Thermal Therapy (Heat Therapy)
Treats heel pain by using heat to reduce pain and promote healing. The heat increases blood flow, reducing inflammation and relaxing muscles. It also accelerates healing and improves flexibility. This non-invasive treatment, using heat packs or specialized devices, offers a convenient and effective way to manage heel pain without medications or surgery.
A study looked at the effects of local heat applied to trigger points compared to fake heat. The heating group had significant pain reduction and improved tenderness thresholds immediately after treatment.
One study supports using local heat to decrease pain and improve tenderness thresholds. This treatment may be more suitable for home use rather than in a clinic. More research is needed to study the effects of local heat combined with other treatments and to find treatment parameters that are practical for clinical use.
Dry Needling
Dry needling is a treatment where a thin needle is used to penetrate the skin and stimulate muscle trigger points and connective tissues to manage pain and movement issues. It provides short-term pain relief and long-term functional improvements. This treatment can be used alone or with other therapies like stretching and manual therapy.
A meta-analysis found that dry needling reduced pain and related disability.
Another meta-analysis confirmed that dry needling effectively decreased pain in the short term.
Comparing dry needling to no treatment found significant pain reduction in the dry needling group.
Combining dry needling with stretching exercises significantly improved pain and function compared to stretching alone.
Found that adding electrical dry needling to manual therapy, exercise, and ultrasound resulted in greater improvements in function and disability than the same treatments without dry needling.
Clinicians should use dry needling on muscle trigger points in the calf and foot muscles to reduce pain and improve function in both the short and long term.
Research supports dry needling as an effective treatment for both short- and long-term pain reduction and long-term improvements in function and disability. Typical treatment involves 1 to 6 sessions targeting trigger points in the calf and foot muscles. Although dry needling can be effective on its own, it is often combined with other treatments like stretching and manual therapy. Mild side effects, such as post-needling soreness and minor bleeding, are common but resolve on their own.
Education and Counseling for Weight Loss
Education and counseling for weight loss helps treat heel pain by reducing stress and pressure on the feet. Excess weight can worsen conditions like plantar fasciitis by increasing the load on the heels. By teaching effective exercise strategies and providing nutritional advice, clinicians help patients achieve a healthy weight, alleviating heel pain and improving foot health. This approach also enhances overall mobility and quality of life, making it a key part of heel pain treatment.
Clinicians can provide education and counseling on exercise strategies to help individuals with heel pain or plantar fasciitis gain or maintain optimal lean body mass. They can also refer individuals to a healthcare practitioner for nutrition advice.
Therapeutic Exercise and Neuromuscular Re-Education
Several high-quality studies have shown the effectiveness of strengthening and stretching exercises for treating heel pain.
One study compared strengthening exercises for toe flexors, ankle muscles, and the gastrocnemius to stretching exercises for the gastrocnemius, soleus, and plantar fascia. Both groups showed significant pain reduction and improved gait, with no significant differences between them.
Another study found that high-load strength training led to greater improvements in pain and foot function compared to stretching alone.
Research confirmed the benefits of heavy-slow resistance training and supervised exercise programs, which showed significant improvements in pain and function.
Clinicians should prescribe therapeutic exercises, including resistance training, for the foot and ankle muscles.
Multiple randomized controlled trials (RCTs) have provided strong evidence that combined interventions, including manual therapy, patient education, stretching, resistance training, and neuromuscular re-education, improve pain and function in both the short and long term. There is weaker evidence that isolated strengthening exercises provide significant pain reduction. There is no clear evidence to suggest one type of strength training is superior to another.
Reference: Thomas A. Koc Jr., PT, PhD, DPT, OCS, Christopher G. Bise, PT, DPT, PhD, OCS, Christopher Neville, PT, PhD, Dominic Carreira, MD, Robroy L. Martin, PT, PhD, Christine M. McDonough, PT, PhD. "Heel Pain – Plantar Fasciitis: Revision 2023. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health from the Academy of Orthopaedic Physical Therapy and American Academy of Sports Physical Therapy of the American Physical Therapy Association.