Heel pain is common and often a source of pathology. Proper diagnostic history-taking and physical examination will contribute to accurate diagnosis. Plantar heel pain is seen in about 15% of adults. Plantar fasciitis is a common cause of heel pain, particularly in individuals who are active in sports. Symptoms manifest based on the presence or absence of a spur, hence the term "plantar fasciitis" has been used for a long time. However, due to the radiographic presence of calcaneal spur, the term "heel spur syndrome" has also been used. Regardless of the terminology debate, heel pain along the calcaneal plantar fascia is well-known, and diagnosis is straightforward.
Definition: Heel pain is common and often a source of pathology. Proper diagnostic history-taking and physical examination will contribute to accurate diagnosis. Plantar heel pain is seen in about 15% of adults. Plantar fasciitis is a common cause of heel pain, particularly in individuals who are active in sports. Symptoms manifest based on the presence or absence of a spur, hence the term "plantar fasciitis" has been used for a long time. However, due to the radiographic presence of calcaneal spur, the term "heel spur syndrome" has also been used. Regardless of the terminology debate, heel pain along the calcaneal plantar fascia is well-known, and diagnosis is straightforward.
Plantar fasciitis represents about 1% of all orthopedic clinic cases. It is estimated that over a million patients in the US seek treatment annually. The disorder is seen in about 15% of adults over their lifetime. It is relatively common among military personnel and active sports individuals. Heel pain can arise due to arthritic, neurological, traumatic, or other systemic conditions. The most common cause of heel pain is mechanical stress and microtrauma to the plantar fascia. Biomechanical etiology is often explained by a windlass mechanism and stretching of the plantar fascia. Compression of the medial plantar nerve and lateral plantar nerve branches can be significant factors. Reported risk factors for plantar fasciitis include working on foot all day and a high body mass index (>30 kg/m2). Excessive foot pronation, excessive running, high arch, discrepancy in leg length, sedentary lifestyle, and tightness of the Achilles tendon are also risk factors for plantar fasciitis.
Diagnosis of plantar fasciitis is based on patient's pain history, known risk factors, and physical examination. Most patients usually experience plantar heel pain when weight-bearing, whether getting up in the morning or after prolonged rest. Palpation of the medial plantar calcaneal region triggers sharp heel pain. Passive dorsiflexion of the ankle and toe dorsiflexion also cause discomfort or pain in the medial heel region. When the pain occurs, the location of tenderness, character of pain, current footwear, level of activity in work and sports, and history of trauma should be identified.
Treatments: Pain in about 75–95% of patients alleviates with conservative treatments such as rest, stretching, orthotic inserts, stretching, anti-inflammatory medication, injection, and night splint. However, pain relief may take as long as 6 months to several years. Therefore, for long-standing plantar fasciitis, extracorporeal shock wave therapy (ESWT) may be recommended. Recently, platelet-rich plasma (PRP) and stem cell therapies have been tried for plantar fasciitis treatment. Surgical release of the total or partial plantar fascia may be an option when all treatments fail.
Various therapies can be applied for heel pain syndrome (HPS). Although there is inadequate high-quality evidence evaluating the effectiveness of conservative treatment, controlled studies are being introduced lately. Initiating conservative treatment within the first 6 weeks of symptoms onset is generally accepted to expedite recovery from heel pain syndrome. Conservative treatment yields successful results in 6 to 10 months. Thus, most studies recommend conservative treatment as the initial treatment option for heel pain syndrome.
Several studies have recommended incorporating plantar fascia stretching exercises into heel pain syndrome treatment. Porter and colleagues conducted a prospective study to analyze the effect of Achilles tendon stretching exercise. Ninety-four patients were randomly divided into two groups (continuous Achilles tendon stretching with intermittent stretching). Data from this study suggested that both continuous (three times a day, three minutes) and intermittent (twice a day, five sets lasting 20 seconds each) Achilles tendon stretching exercises were effective in treating heel pain syndrome.
However, some conflicting views were presented. The difference in effects between Achilles tendon stretching and plantar fascia stretching was examined by DiGiovanni and colleagues. In their initial studies, patients were divided into Group A (plantar fascia stretching program) and Group B (Achilles tendon stretching program). Group A performed plantar fascia stretching by holding for 10 seconds, 10 times, three times a day. Group B, on the other hand, did Achilles stretching by holding for 1 second, 10 times, three times a day. After an 8-week follow-up, Group A showed significant improvement in morning pain. Group A had a higher percentage of positive responses in pain, activity limitation, and patient satisfaction compared to Group B. At the 2-year follow-up, there was no significant difference between the two groups; however, the value of plantar fascia stretching was superior to Achilles tendon stretching. Radford and colleagues studied 92 participants with heel pain syndrome. Participants were given Treatment A (five minutes of Achilles stretching every day and ultrasound on two nights a week for two weeks) and Treatment B (ultrasound on two nights a week for two weeks). There was no difference between Treatments A and B. Since the follow-up was only for 2 weeks, it is uncertain whether longer-term treatment would improve pain and outcomes.
As mentioned, DiGiovanni's study recommended plantar fascia stretching exercises instead of Achilles tendon stretching for short-term improvement. However, controlled studies are necessary to plan for heel pain syndrome.
Various types of orthoses such as heel cups and arch supports have been used to treat heel pain syndrome. Both prefabricated and custom-made orthoses have been provided. They can affect correction of foot deformities and provide cushioning with arch supports. Many studies have reported on evaluating the effects of orthotics. Lynch and colleagues conducted a study to compare the individual effectiveness of three conservative treatments for plantar fasciitis: NSAID and corticosteroid injection, viscoelastic heel cup followed by custom orthoses with initial low-Dye taping for mechanical treatment. This study reported that mechanical treatment provided more effective pain relief than other treatments. Pfeffer and colleagues conducted a multicenter study comparing conservative treatment for heel pain syndrome. They randomly assigned 236 patients to five treatment groups: stretching only, silicone heel pad, felt pad, rubber heel cup, or custom polypropylene orthopedic device. All groups also received Achilles and plantar fascia stretching. Following an 8-week follow-up, the group with prefabricated insoles combined with stretching showed the most improvement in symptoms. Landorf and colleagues conducted the longest and most comprehensive clinical trial evaluating foot orthoses. They divided 135 patients into receiving a sham orthosis (soft, thin foam), a prefabricated orthosis (rigid foam), or a custom orthosis (semi-rigid plastic). After a 3-month follow-up, pain and function improved in the prefabricated and custom orthosis group; however, only functional impact was significant. Following a 12-month follow-up, there was no significant difference between the groups. Foot orthoses were found to provide short-term benefits in pain and function, but no long-term pain or functional impact was reported. In summary of previous studies, short-term use of foot orthoses is a suitable treatment for heel pain syndrome, but prefabricated orthoses have no superior effect compared to custom-made orthoses.
Using night splints keeps the ankle in a dorsiflexed position during sleep to prevent contracture of the plantar fascia and Achilles tendon. Batt and colleagues conducted a study examining the use of night splints with 33 patients. The control group used a ViscoHeel soft heel cushion, took an anti-inflammatory medication, and did Achilles tendon stretching exercises, while the group using night splint followed the same method and wore a special ankle-foot orthosis during sleep. It was observed that the use of night splint was significantly more effective in reducing pain. When used in conjunction with a heel cushion, the combination of heel cushion, stretching, medication, and night splint was recommended as a preferred method. In a study by Roos and colleagues, it was reported that foot orthoses and night splints were effective in treating heel pain syndrome, but foot orthoses had higher compliance than night splints. Probe and colleagues reported on a prospective randomized study with 116 patients with heel pain syndrome. They divided them into two groups: Group 1 (anti-inflammatory medication for one month, Achilles stretching exercises, and footwear recommendations) and Group 2 (addition of dorsiflexion night splint for three months to the above treatment for one month). However, this study did not find a significant difference between the two groups. Therefore, night splint may be considered as a method in patients who do not improve despite several months of conservative treatment. While studies on walking cast immobilization have not been reported, a retrospective study has reported satisfactory results.
Although oral nonsteroidal anti-inflammatory drugs (NSAID) are commonly used in orthopedic clinics, including for plantar fasciitis treatment, there is insufficient reliable evidence on therapeutic efficacy. Donley and colleagues evaluated the advantage of the NSAID group when compared to the placebo group. Viscoelastic heel cups, night splints, or Achilles tendon stretching were added to both groups. However, there was no statistical difference between the two groups.
Based on this information, the use of night splints appears to be effective in the treatment of plantar fasciitis. Combining different treatment methods may help patients achieve better results in their treatment process. However, despite night splints and other conservative treatments, there is insufficient evidence regarding the efficacy of oral nonsteroidal anti-inflammatory drugs for heel pain syndrome.
To achieve more effective results in the treatment of heel pain syndrome, it is important for patients to make lifestyle changes and receive education on foot health. This will help patients adopt preventive measures such as selecting proper footwear, regular stretching exercises, and adequate foot care.
Conclusively, a combination of conservative treatment methods such as night splint, foot orthoses, Achilles stretching exercises, and appropriate footwear recommendations is recommended for the treatment of heel pain syndrome. However, treatment plans should be personalized based on each patient's individual needs and level of compliance. Moreover, further research and evidence-based approaches are important to increase the efficacy of these treatment methods and minimize the decreased quality of life caused by heel pain syndrome.
While heel pain is often reduced with conservative treatments such as Achilles stretching or orthoses, about 20?n persist as chronic pain and may require additional treatment. ESWT is considered a potential method for treating patients with chronic heel pain. Despite numerous studies on the efficacy of ESWT, variations in ESWT application make comparisons of studies complex. Low energy ESWT (energy flow density <0> 0.28 mJ/mm2) reported a success rate of 90% and a success time point of 3 months. Although the mechanism of ESWT in the treatment of plantar fasciitis is not clear, the author recommends that moderate- to high-energy ESWT provides a safe and suitable treatment for patients resistant to other treatments.
Corticosteroid injection is not recommended due to the lack of evidence and the potential harm in medium- to long-term follow-up. Crawford and colleagues prospectively examined the effectiveness of corticosteroid injections. Prednisolone injection (25 mg) reduced heel pain significantly in one month. However, no significant differences were observed at 3 and 6 months. Other studies have shown that corticosteroid injections temporarily resolve symptoms but their long-term follow-up results are not superior to other treatments. Additionally, this treatment has caused plantar fascia tears in 2–10% of injected patients. Therefore, corticosteroid injection should only be used for patients resistant to other conservative treatments.
Platelet-rich plasma (PRP) injection is an attractive topic related to conservative methods for plantar fasciitis. Kumar and colleagues conducted the largest (50 plantar fasciitis cases) prospective cohort PRP treatment study; the AOFAS score increased from 60.6 to 81.9. However, this study did not include a control group.
A randomized single-blind controlled study by Monto showed that the outcomes of the PRP group were significantly superior to the control group (40 mg Depo Medrol). A study by Kim and colleagues showed significant improvements in disability and activity restriction scales in the PRP group at a 6-month follow-up. However, Akashin reported no significant difference between the PRP group and the control group (40 mg methylprednisolone). Vannini and colleagues reported that clear evidence for using PRP in the foot and ankle region did not emerge. In summary, PRP injection may be a recommended treatment for patients resistant to other treatments, but further research is needed.
Stem cells are undifferentiated cells found in bone marrow, fat tissue, and blood in adults. Mesenchymal stem cells have therapeutic potential. Therefore, mesenchymal stem cells have been used in the treatment of musculoskeletal disorders. Kiter and Kalaci reported that autologous blood injection was more effective for plantar fasciitis than corticosteroid injection. To our knowledge, there are no reports examining the effects of stem cell injection for heel pain syndrome. However, heel pain is related to mechanical repetitive trauma and associated with degenerative changes. Therefore, stem cell injection theoretically may improve heel pain syndrome. Currently, PRP injection is commercially used as a concentrated growth factor infusion. In the future, growth factors and mesenchymal stem cells may be used for treating heel pain syndrome.
Surgical treatment has been performed in about 5% of all patients with intractable heel pain syndrome. Surgery should be considered for patients with continuous and severe pain from plantar fasciitis despite conservative treatment for 6–12 months. Instead of fasciotomy to prevent the recurrence of fibrotic healing, partial fasciectomy is preferred. Patient selection should be stringent, and patients should be warned about possible recurrence of pain.
Operations include:
Open partial release (fasciotomy)
Open partial resection (fasciectomy)
Open partial plantar fascia release with release of the first lateral plantar nerve branch (Baxter’s nerve)
Open partial plantar fascia release with proximal and distal tarsal tunnel release
Endoscopic plantar fascia release
Gastrocnemius lengthening (Achilloplasty)
In short, surgical procedures involve open or endoscopic plantar fascia release, excision of abnormal tissues, and nerve decompression with or without resection of the calcaneal spur. Current reports support the use of minimally invasive surgical approaches rather than broad open surgical incisions. The removal of the plantar heel spur is not related to the success of surgical outcomes. If nerve compression is concerned, nerve release combined with fasciotomy is necessary. The most common complications of surgical treatment for plantar fasciitis are collapse of the medial longitudinal arch and persistent pain. If the patient has continuous pain, the surgeon should consider checking for other etiologies, especially neuritis or nerve compression (particularly Baxter nerve entrapment). The Baxter nerve can compress beneath the abductor hallucis muscle. Careful release is necessary if this occurs during surgery.
There are a variety of treatment options available for plantar fasciitis treatment, and they should be applied depending on the individual's condition and resistance to other treatments. Conservative treatments are generally the first step, and if unsuccessful, advanced treatments such as ESWT and PRP injections can be considered. Corticosteroid injections should be reserved for limited cases in patients resistant to other treatments. Stem cell therapy and surgical methods, although currently less common, may play important roles in the future for plantar fasciitis treatment. Further research is needed to determine the efficacy of these treatments.
