This clinical practice guideline (CPG) is based upon consensus of current clinical practice and review of the clinical literature. The guideline was developed by the Clinical Practice Guideline Heel Pain Panel of the American College of Foot and Ankle Surgeons. The guideline and references annotate each node of the corresponding pathways.
Mechanical factors are the most common etiology of heel pain. Other causes include traumatic, neurologic, arthritic, infectious, neoplastic, autoimmune, and other systemic conditions. Diagnostic testing and treatment must be directed at the correct causative factors.
Mechanical Plantar Heel Pain (Pathway 2)
Mechanical heel pain is one of the most frequent conditions presented to foot and ankle specialists. Plantar heel pain is responsible for the majority of mechanical heel pain cases. Plantar heel pain is defined as insertional heel pain of the plantar fascia with or without a heel spur (Fig. 1).
The most common cause cited for plantar heel pain is biomechanical abnormalities that lead to pathologic stress to the plantar soft tissues (1–7). Localized nerve entrapment of the medial calcaneal or muscular branch off the lateral plantar nerve may be a contributing factor (8–11).
Patients usually present with isolated plantar heel pain upon initiation of weightbearing, either in the morning upon arising or after sitting for a period of rest. The pain tends to decrease after a few minutes, then returns as the day proceeds and time on the feet increases. Associated significant findings may include high body mass index, tightness of the Achilles tendon, pain upon palpation of the inferior heel, and inappropriate shoe wear (12–14).
Many patients will have attempted self-remedies before seeking medical advice. A careful history is important, including time(s) of day when pain occurs, current shoe wear, activity level both at work and at leisure, and history of trauma. An appropriate physical examination of the lower extremity includes range of motion of the ankle with special attention to decreased range of motion of dorsiflexion of the ankle, palpation of the inferior medial aspect of the heel, palpation of the medial aspect of the heel, the occurrence of bilateral symptoms, and angle and base of gait evaluation.
Following physical evaluation, appropriate radiographs may be considered. Radiographic identification of a plantar heel spur indicates that the condition has been present for at least 6–12 months, whether having been symptomatic or not (Fig. 2). As a rule, the longer the duration of heel pain symptoms, the longer the period to final resolution of the condition.
Initial treatment options may include nonsteroidal antiinflammatory drugs (NSAIDs), padding and strapping of the foot, and corticosteroid injections for appropriate patients. Patient-directed treatments seem to be as important in resolving symptoms. They include regular stretching of the calf muscles, avoidance of flat shoes and barefoot walking, use of cryotherapy directly to the affected part, over-the-counter arch supports and heel cushions, and limitation of extended physical activities.
Patients usually have a clinical response within 6 weeks of initiation of treatment. If improvement is noted, the initial therapy program is continued until symptoms are resolved. If no improvement is noted, the patient should be referred to a podiatric foot and ankle surgeon.
The second phase of treatment for the referred patient includes continuation of the initial treatment options with considerations for additional therapy: the use of custom orthotic devices, especially in the biomechanically malaligned patient, the use of night splints to maintain an extended length of the plantar fascia during sleep (15–22), a limited number of corticosteroid injections (23, 24), and cast immobilization for 4–6 weeks or the use of a fixed ankle walker-type device to immobilize the foot during activity (25). In patients with a high body mass index, a consultation and referral for an appropriate weight-loss program should be considered. Clinical response to this second phase of treatment will usually occur within 2–3 months in 85–90% of patients (26–30). For those who have shown improvement, phase 1 and phase 2 therapy should be continued until resolution of symptoms. When no improvement is noted, other systemic diseases should be considered (31–37).
The third phase of treatment continues phase 1 and/or 2 programs with the addition of cast immobilization in patients who may not have undergone that treatment in phase 1 or 2. Treatments that may be considered at this time include surgical plantar fasciotomy using a recognized technique (38–53) and extracorporeal shock wave therapy (ESWT) has shown promise (54–58). In the majority of cases, removal of the plantar heel spur does not seem to add to the success of the outcome in the surgical treatment of plantar heel pain (48, 59–61).
Following a therapeutic regimen as outlined in the pathways, 90–95% of patients will experience resolution of symptoms within 1 year. A subset of patients will have continued problems; additional research is needed to allow these patients to achieve symptom resolution.
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