Accepted Manuscript

Plantar heel pain

Warrick McNeill, Dip.Phyty. (NZ) MCSP, Mark Silvester, Dip. Phty., Dip Manip. Ther.,
Adv Dip. Phty. (NZ)

PII: S1360-8592(16)30257-1
DOI: 10.1016/j.jbmt.2016.11.001
Reference: YJBMT 1440

To appear in: Journal of Bodywork & Movement Therapies

Please cite this article as: McNeill, W., Silvester, M., Plantar heel pain, Journal of Bodywork & Movement
Therapies (2016), doi: 10.1016/j.jbmt.2016.11.001.

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 ACCEPTED MANUSCRIPT
PREVENTION & REHABILITATION: EDITORIAL
Plantar heel pain

First Steps

A patients description of rising in the morning, placing their feet upon the floor, and taking their first step
with the associated report of the pain elicited under the foot (see fig. 1), usually alerts the health
professional to the likely possibility that the diagnosis will be related to the plantar fascia. The pain may

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subside and return later in the day particularly if the patient has been on their feet, but improves with rest.
Heel pain can also present following an increase in weight bearing activity. (McPoil et al 2008, Martin et al
2014, Berbrayer and Fredericson 2014). The diagnosis of Plantar fasciopathies is made by assessing the

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clinical picture as there is not a gold standard test for the condition (Beeson 2014).

Insert fig. 1 about here

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Heel pain affects millions of people worldwide and is divided into two broad categories, posterior heel
pain, and inferior (plantar) pain. Posterior heel pain most commonly is related to the Achilles tendon and
its increasing prevalence can be associated with the continuation of exercise into older age (Dinneen et al

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2016). This editorial focuses on inferior heel pain, of which Rosenbaum et al (2014) suggests that plantar
fasciitis is the most common culprit, accounting for 80% of patients with inferior heel pain, and is
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predicted to affect 1 in 10 people in their lifetime. They suggest that mechanical, rheumatologic or
neurologic conditions can all present with plantar heel pain. Hossain and Makwana (2011) suggest that
pain in the plantar heel area be initially named Heel pain syndrome (HPS) until clarification of the
symptoms can establish a firm diagnosis.
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Plantar Fasciitis, Fasciosis or Fasciopathy?

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Berbayer and Fredericson (2014) differentiate acute plantar heel pain symptoms produced by
inflammation, and, chronic pain in the same region, from degenerative causes. As the clinical course of
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plantar fasciopathy follows a predictable path they identify the acute phase as lasting 4 weeks, a sub-acute
phase which persists from 4 weeks to 3 months and a chronic phase that goes beyond 3 months. Despite
inflammation being cited as a primary cause there is little evidence to support the use of NSAIDs (non-
steroidal anti-inflammatory drugs) in the papers they quote. NSAIDs are typically prescribed in
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conjunction with other interventions as part of a trial of conservative measures, and 76% of patients report
improvement with their use, (Wolgin et al 1994). Lemont et als (2003) view that Plantar Fasciitis is a
condition without signs of classic inflammation, swelling, erythema or macrophage infiltration and is
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characterised, on histological examination, by chronic degenerative tissue changes, and therefore should
be renamed plantar fasciosis, is continuing to gain traction (Hossain and Makwana 2011) and reflects the
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sea-change reappraisal of the clinical nature of tendinopathies (Maffulli et al 2003, McNeill 2015). The use
of the term plantar fasciopathy blends the inflammatory and degenerative elements to the condition.

Insert fig.2 about here

Rosenbaum et al (2014) still state that NSAIDs are an appropriate treatment for HPS, which may reflect
the view that there is an inflammatory pathway to plantar fasciopathy (see fig. 2) as well as a degenerative
one. Rose and Singh (2016) appear to agree, they describe; acute events with a sudden onset of pain
during sporting activities as possibly being plantar fascia tears and best treated by ice, NSAIDs and
immobilisation till symptoms reduce, and a stiff soled boot for 6 weeks, or, peri-fascial oedema again best
treated with oral NSAIDs or even an ultrasound guided steroid injection above the plantar fascia (see
steroid injection discussion later).

Table 1.
Alternate diagnoses to Plantar fascia related causes of inferior heel pain

Bone
Calcaneal stress Fracture
Calcaneal bone marrow oedema
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As HPS involves many different diagnoses (see Table 1.) that require quite different treatment approaches
it is clear that an understanding of the structure of the inferior heel area, the biomechanics of the foot, the
risk factors associated with injury and an assessment process is imperative if the path to recovery is to be
maximised by the treating Clinician.

Anatomy Biomechanics and Risk Factors

The Plantar fascia is actually a broad fibrous triangular aponeurosis extending from the medial and
anterior undersurface of the calcaneum to the base of the five proximal phalanges, it travels in a constantly
present central band, though in some, the medial and/or lateral bands are missing (Hossain and Makwana
2011). The intrinsic muscles of the foot are compartmentalised by the Plantar fascia. Posteriorly it is

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contiguous with the Achilles tendon and when the calf musculature contracts, the plantar fascia is
tightened by this connection. The structure of the stress dissipating fibrocartilage attachment to the
medial calcaneal tubercle helps the aponeurosis to withstand significant loads.

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The inferior heel is protected by its fat pad, which acts as a shock absorber, the reinforced, fat globule
filled honeycomb fat pad is known to degenerate beyond 40 years of age, losing thickness and height,

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while softening and reducing its protection of the heel (Rosenbaum 2014) , not surprising when the heels
fat pad has to dissipate 250% of body weight while running (Rosenbaum 2014). Beeson (2014) describes an
increasing thickness of the heel pad, but with the same effect of a loss of heel pad elasticity. The fat pad of
symptomatic feet presents a significantly lower energy dissipation ratio when compared to asymptomatic

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feet (Wearing et al 2009). When a patient reports pain on prolonged standing, bilateral pain and night
pain, but without first step pain, heel pad atrophy may well be implicated (Martin et al 2014).
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The role of the plantar fascia is to help support the arch of the foot via the skeletal truss formed by the hind
foot and forefoot and held along the bottom by the aponeurotic structure. A pes planus foot is predicted
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to apply greater loads to the plantar fascia and this matches the risk factor of over-pronation in HPS.
Beeson (2014) quotes 8 papers linking over pronation as a key risk factor in plantar fasciopathies, at odds
with Hossain and Makwanas (2011) view that over-pronation has not been verified as a risk factor, see
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Table 2. As it is, the gait cycle adds tension to the plantar fascia from heel strike to just before mid stance
and the tightening fascia prevents excessive pronation, unless the foot is dysfunctional (Walden 2015A).
The windlass tightening effect (see fig. 3) is used for propulsion. The intrinsic muscles of the foot assist in
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the creation of the desirably timed supinated and stiffened foot, and their loss of function, atrophy or over
length reduces movement efficiencies.
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Insert fig. 3 about here

A high body mass index (BMI) is a significant risk factor in one major group of patients, the over 40, often
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female, non athletic individual, and this risk is amplified if there is an increase in weight bearing activity,
such as occupational tasks with unsuitable footwear.
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Rosenbaum et al (2014) suggest heel spurs are associated with HPS but do not necessarily cause pain, they
state that both heel spurs and pain may develop from a common underlying pathologic condition. It is
possible then that excess weight in mature individuals in modern man is an explanation for the increased
incidence of calcaneal spurs, however, in the prehistoric record, hunter-gatherers who, in a specific
population studied by Weiss (2012), died at significantly younger ages than modern humans, on average at
32.2 years if male and 37.2 years if female. Yet this prehistoric group still presented with 3x more calcaneal
spurs than modern populations. This indicates that the increased activity likely required for survival in
prehistory had an effect in generating the favourable conditions for the development of heel spurs in that
population, a proportion of them possibly developing heel pain as well. This increased activity could
represent the increased activity in the modern athlete who is the other major risk group for the
development of HPS. Further research is required to determine if heel spurs are actually causal (Beeson
2014).
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Hossain and Makwana (2011) identify middle aged obese women as high risk though Beeson (2014) reports
the gender literature inconsistent. An obese designation is a BMI of over 30. Rano et al (2001) suggest that
decreasing an obese plantar heel pain patients BMI to a score of 25 or below (the same target for those
with an identified cardiovascular risk) is a desirable goal. If the average height of a woman in England in
2012 was 164.5cm (Moody 2013), for her to have a BMI of over 30 she would need to weigh approximately
82kgs. To drop to the target of a BMI of 25, she would need to lose approximately 15kg, which would need
to be done primarily with diet control as weight bearing, shock loaded, cardiovascular exercise could easily
aggravate the plantar heel pain. This weight loss goal without weight bearing exercise may well be very
difficult to achieve but not reducing the BMI probably increases the risk of chronicity.

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Increasing age has a degenerative effect on the histopathology of the plantar fascia, and has led to the
opinion that repetitive micro-trauma of the over strained plantar tissues are causative, and negatively
affect the healing process increasing oedema and collagen degeneration (Beeson 2014).

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The lack of ankle dorsiflexion in plantar fasciopathies has stimulated debate as to whether it is an effect
caused by the condition or indeed causal itself. Plantar equinus, a plantar flexed foot, is a position of rest

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when sleeping. Riddle et als (2003) view, after looking at single side plantar facsciopathies, is that the non
involved side also exhibits a lack of dorsiflexion - not expected if the restriction was effect only. Relative
flexibility as explained by Sahrmann (2002) indicates that tightened posterior lower leg musculature will be
compensated for with overpronation at the foot. Riddle et al believe this to be the most important risk

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factor.
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Areas of interest for future research looking at risk in plantar heel pain include hamstring tightness, leg
length discrepancy with the heel pain reported in the longer limb and decreased intrinsic muscle strength
(Martin et al 2014).
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Insert Table 2. about here

Table 2.
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Risk Factors based on moderate evidence Other reported risk factors that have not yet been
verified include:
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limited ankle dorsiflexion range of movement increased age

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high body mass index in non athletic reduced metatarsophalangeal joint extension
individuals
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running supinated feet

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work related weight bearing (associated with over pronated feet

poor shock absorption)
From Martin et al 2014 From Hossain and Makwana 2011

Examination

Physical examination should include palpation of the proximal insertion of the plantar fascia and the
windlass test - reproduction of the pain in the plantar fascia with passive MTP dorsiflexion which. The
presence of both findings suggest a plantar fasciopathy (Martin et al 2014). A gap at the proximal end of
the plantar fascia following a traumatic injury may indicate a rupture of the plantar fascia.
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Silfverskiolds test is one recommended method to assess resistance to dorsiflexion at the ankle (Hossain
and Makwana 2011), but limited dorsiflexion on its own does not only imply a plantar fasciopathy, it can
indicate achilles, posterior heel, or calf muscle problems as well. The identification of exactly where the
relevant pain is helps create the clinical picture to be interpreted.

Eliciting Nerve symptoms using tinels test on the medial side of the foot below the medial maleolus for
Tarsal tunnel syndrome, or a compression test of the medial calcaneal nerve posterior and inferior to the
tarsal tunnel, or indeed a compression of the first branch of the lateral planter nerve (Baxters nerve)
inferior to the tarsal tunnel is a useful exclusion from plantar fasciopathy (Hossain and Makwana 2011).

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Resisting great toe plantar flexion can indicate Flexor Hallucis Longus tendinopathy (Hossain and
Makwana 2011). Assessing the foot for pronation or supination can be quantified by using the Foot Posture
Index (Redmond et al 2006) but this might be relatively a non-specific test in plantar heel pain.

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Imaging

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Radiographic imaging in plantar fasciopathy is helpful to rule out other causes such as calcaneal bony
injury, but the presence or absence of heel spurs is not clinically relevant. Diagnostic ultrasound looking at
the thickness of the plantar fascia appears helpful, as a decreasing thickness of the plantar fascia occurs as
plantar fascia pain resolves (Martin et al 2014). MRI (magnetic resonance imaging) is often recommended

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if conservative measures appear to be failing or the presentation is atypical (Hossain and Makwana 2011).
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How well are Plantar fasciopathies treated by physical therapists?

A survey was undertaken of 285 UK based Physiotherapists questioning their management of plantar
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fasciopathies (Grieve and Palmer 2015), and reported to the World Confederation for Physical Therapy.
The most common approach was reportedly a hands off management approach consisting of advice
(92%), plantar fasciopathy pathology education (81%), general stretching exercises (74%), more specific
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stretches to the calf muscles (69%) and plantar fascia (66%). Only 7% prescribed orthotics (custom or
prefabricated) and only 1% of physiotherapists used night splints. Hands on therapies including massage,
myofascial release and trigger point therapy and were all used by less than a quarter of the respondents.
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The paper did not report on taping modalities. The authors suggested that that despite research evidence,
best practice was not always fully adopted by physiotherapists for the treatment of plantar fasciopathies
in the UK.
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CONSERVATIVE TREATMENT GUIDELINES

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As Plantar fasciopathies are tissue overload related (increased BMI in the non athletic population and
overuse in the athletic population) and probably combined with poor biomechanical alignment,
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inflexibility, and training errors (Beeson 2014), it is therefore thought that managing the over load is the
mainstay of the conservative treatment approaches.

Support tape

Taping to support the longitudinal arch can have positive effects on acute pain in the short term and, when
combined with orthotics, can produce longer term improvement. Berbreyer and Fredericson (2014) cite a
study by Lynch et al where 103 plantar fasciopathy patients were randomised into 3 groups including a
mechanical treatment group who were treated with the low dye taping method that supports the
longitudinal arch. (see Fig. 4.) The protocol was to low dye tape for 1 month followed by 2 months use of a
rigid customised orthotic. This group rated their functional outcome significantly better than the other two
groups treated with anti-inflammatory medication or with a visco-elastic heel cup.
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insert fig 4. A-C about here

Berbreyer and Fredericson (2014) also cite a short term study by Hyland et al which compared calcaneal
taping, sham taping, plantar fascia stretching and a control group who received no intervention.
Significant improvements in pain levels were found in the calcaneal taping group compared with sham
taping and calcaneal taping compared with a control group.

Collectively this indicates that taping to support the longitudinal arch along with other therapies plays a

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role in plantar fasciosis management but is probably mainly useful in the early stages of the condition and
useful for pain control. A drawback with rigid sports taping is that it is temporary, and with each strapping
occasion it is advisable that the strapping should be removed before 24 hours have elapsed (McNeill and

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Pedersen 2016). There can be skin breakdown issues (Berbrayer and Fredericson 2014) although in the
authors opinion these may possibly be less common in the foot than in other areas.

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Dynamic tape, an elastic tape with biomechanical effects, has the advantage of being able to be worn for
up to 5 days, according to Kendrick, its developer, and in uses associated with the plantar fascia the tape

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can assist in decelerating the navicular drop while the elastic recoil can help actively supinate the foot at
the appropriate time. Kendrick suggests using a double layer, a powerband, of the original dynamic tape or
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the newer black Eco tape which hits a higher resistance sooner in its stretch phase, making its use
applicable at the arch of the foot where there is less motion and a need to maintain the longitudinal arch
(Kendrick 2016). For an example of the use of dynamic tape in pronation control, see Web source 1. The
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evidence for dynamic tape is primarily anecdotal at this point of its validation phase, but may prove its
worth in the treatment of plantar fasciopathies.
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Orthotic support
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Analysis of biomechanics has shown that individuals with plantar fasciopathies have a greater range of
available eversion compared with healthy controls, there is also some suggestion that they have a greater
eversion velocity (Chang et al 2014). It is likely then that controlling excessive calcaneal eversion could help
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reduce pain and dysfunction in plantar fasciopathies. It is the authors view that control of calcaneal
eversion is a clinical key and may account for the fact that plantar fasciosis can also occur in a supinated
foot. Chang goes on to suggest that an arch support can significantly reduce the strain in the plantar fascia
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by shortening the distance between the rear and forefoot, changing the arch angle.
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Research suggests that an orthotic has short, medium and long term effects on reducing plantar
fasciopathy pain and dysfunction, however different types of orthoses have also been shown to be
effective including silicon pads and heel cups (Lee et al 2009)

Berbrayer and Fredericson (2014) summarises opinion, Good evidence exists that foot orthotics may be
useful as a treatment for plantar fasciopathy. A prefabricated shoe insert is recommended for acute and
subacute phases of that condition and customised devices can be considered if prefabricated inserts do
not provide sufficient pain relief.

Calf length
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As the plantar fascia is directly contiguous with the fibres of the Achilles tendon the plantar fascia is placed
under tensile stress during different phases of the gait cycle. During early stance the foot pronates,
lowering the arch, and stretches the plantar fascia. As the heel starts to lift in late stance, the Achilles
tendon is tensioned on the calcaneus, and this pull is resisted by the plantar fascia creating tensile force
(Hossain and Makwana 2011). Excessive calf tension may increase this effect possibly contributing to the
overload of the fascia.

Multiple studies support the efficacy of stretching the calf muscles in plantar fasciopathies. (Berbrayer and
Fredericson 2014, Martin et al 2014, Kamonseki et al 2015). Some studies have included intermittent
stretch and sustained stretch but no particular method seems to be more beneficial (Berbrayer and

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Fredericson 2014, McPoil et al 2008). Some studies use the wall lean method to stretch gastrocnemius and
soleus and others use the heel lowering over a step method, both seem to work (McPoil et al 2008,
Kamonseki et al 2015). Recommendations from the orthopaedic section of the American Physical therapy

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association include stretching 2-3 times a day with either sustained (3 minutes) or intermittent (20 second)
holding time. The aim is to improve ankle dorsiflexion range (Martin et al 2014).

In the authors opinion failing to maintain correct alignment of the femur on the lower leg and at the ankle

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and mid foot while stretching is a common mistake made by a patient while practicing their home stretch
program. Therapists must ensure that as the calf is stretched the arch of the foot is maintained, initially
teaching the patient to watch for any inappropriate calcaneal movement into a valgus alignment that

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would allow the arch to flatten, effectively lengthening the arch not stretching the calf. For further
information see Calf stretching in correct alignment (Silvester 2016) later in this Prevention and
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Rehabilitation Section of this edition of the JBMT.
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Plantar fascia stretch

As the gait cycle progresses from stance towards toe off, the tension in the plantar fascia increases due to
the windlass mechanism extending the MTP joints creating tension in the fascia and raising the arch. A
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good quality trial with long term follow up shows that plantar fascia stretching is effective in relieving pain
and improving function in chronic plantar fasciopathy, with relief being maintained at a two-year follow-
up. Technique is deemed to be important with the stretch performed in a non-weight bearing position with
ankle dorsiflexed, the MTP joints passively extended and palpation of the fascia to feel it being stretched
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(DiGiovanni et al 2006) (see Fig. 5)

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insert fig 5. about here

A number of studies have used combined Achilles and plantar fascia stretching and found this to be
effective (McPoil et al 2008, Kamonseki et al 2015, Martin et al 2014). Hamstring stretches with combined
stretching were also found to be effective (Kamonseki et al 2015).

Manual Therapy

Since there is general agreement that lack of dorsiflexion is a risk factor in plantar fasciosis it is appropriate
to assess whether the reduced range is myofascial i.e. gastrocnemiussoleus in origin or if it is articular,
usually reduced dorsiflexion at the talocrural joint. If the ankle is stiff, there will be a hard end feel in
dorsiflexion and, when stretching, the patient may feel the restriction anteriorly in the joint rather than
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posteriorly in the muscle. This may be accompanied with a reduced posterior glide of the talus. If this is the
case the talocrural joint could be mobilised in an anterior-posterior direction to regain dorsiflexion
(Landrum et al 2008, Vicenzino et al 2006).

Self massage in the form of foam rolling or roller massage may be used if extrapolation on the findings
reported in Rios Monteiro et al (2016), published in this section of the JBMT, can be made.

There is some limited evidence that a manual therapy approach including ankle joint mobilisation and calf
soft tissue release with deep massage and myofascial trigger point release to increase calf flexibility is
helpful in improving function and reducing pain in plantar fasciosis patients, at least in the short term
(Martin et al, 2014, Santos et al 2016, Saban and Deutscher 2014). In practice, manual therapy to assist the

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effects of exercise would be commonplace and, in the authors opinion, appropriate.

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Alignment control and hip strength

As overpronation is a risk factor in fasciopathies (Beeson 2014) it follows that alignment correction at the

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foot is an appropriate intervention, hence the use of orthotics and the justification for their efficacy, but as
the foot does not work in isolation and is at the end of the kinetic chain, it is the authors view that foot
alignment should be considered as part of that hip down kinetic chain.

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The relationship between lower limb injury and leg alignment has been explored in a number of studies.
Barton et al (2012) looked at the positive relationship between increased rearfoot eversion, increased
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medial tibial rotation and increased hip adduction in a patellofemoral pain group. Similarly in his clinical
commentary Powers (2010) argues that some injuries in the lateral thigh and knee could benefit from
proximal stability rehabilitation at the hip and trunk and that the analysis of biomechanics should be
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incorporated into knee rehabilitation programs.

Kamonseki et al (2015) looked at the effect of stretching exercises with and without strengthening of the
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foot intrinsic muscles and the hip lateral rotators and abductors. All conditions improved with stretching
but no additional improvements from strengthening were reported. In the authors opinion while isolated
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strengthening of the hip lateral rotators and abductors may appear to be a rational strategy in a mal-
alignment based pathology, it is more important for that strengthening to come from integrative exercise
manifesting the strength as alignment improvements during gait and movement. The isolated hip muscle
strengthening strategy employed by Kamonseki et al, was therefore unlikely to produce a more positive
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response. A strategy of this type that relates directly to overpronation has been put forward by Wallden
(2015B).
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Overall there is no current direct evidence that links alignment improvements at the hip and knee to
improved alignment at the foot and therefore less pain and dysfunction in plantar heel related
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pathologies, however it remains fertile ground for thought. The authors contend that future research into
mal-alignment based pathology of the lower limb using an integrative hip strengthening strategy may
produce different results in the treatment of heel fasciopathies. Martin et al (2014) do recommend
therapeutic exercise and neuromuscular re-education, though grade the advice at the lowest strength of
evidence - expert opinion.

Intrinsic foot muscle training

Despite the Authors view that the foot should be incorporated in whole lower limb exercise strategies,
there are researchers addressing the importance of the intrinsic foot muscles. Huffer et al (2016) have
conducted a systematic review on strength training for plantar fasciitis and the intrinsic foot musculature,
they concluded that there was, limited external validity that foot exercises, toe flexion against resistance
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and minimalist running shoes may contribute to improved intrinsic foot musculature function. A 2014
systematic review found that there is a significant association between intrinsic foot muscle weakness and
painful foot pathologies such as plantar fasciitis (Latey et al 2014). Intrinsic foot muscle strengthening may
fall into Martin et als (2014) expert opinion category and still be a recommended treatment strategy.

Short foot exercises that aims to strengthen the foot intrinsics and maintain the longitudinal and
transverse arches have been studied. The exercise action is described as drawing the metatarsal heads
back to towards the heel without curling the toes with the long toe flexors. (Mulligan and Cook 2013) A
paper by Lee et al (2016), published in this section of this edition of the JBMT, looking at foot exercise and

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kinesio taping in patients with patellofemoral pain and a pronated foot, found the short foot exercise to be
significantly better at increasing the Abductor Hallucis muscle activity over kinesio taping applied to the
rear foot in a supinated position.

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Eccentric exercise
As eccentric exercise is useful in tendinopathies evidence is starting to be published that suggests that
eccentric loading of the calf musculature, along with conventional physical therapy treatment is useful in

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the treatment of plantar fasciopathies. (Rupareliya et al 2015).
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Night Splints

There is ample evidence that night splinting reduces the pain and disability associated with plantar
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fasciosis especially first step pain (McPoil et al 2008). One research team randomised the allocation of
orthotics against orthotics and night splints. At the 8 week follow up the night splint group reported less
pain and improved function (Martin et al 2014). Another group randomly assigned two groups. One group
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tested NSAIDs, corticosteriod injection and orthotics, the other group had the same but with the inclusion
of night splinting. There was a significant positive difference in the night splinting group (Martin et al
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2014).

The issue with night splinting for plantar fasciopathies appears to be the tolerance to the intervention. This
issue was addressed by Attard and Singh (2012) by testing an anterior and a posterior night splint. They
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found that both night splints were effective in reducing pain but the anterior night splint was more
effective. They postulate that this may be because it was more comfortable and therefore the patients
were more compliant to the treatment.
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Steroid injection

There is evidence of short term pain relief following steroid injection into the proximal plantar fascia
(Berbrayer and Fredericson 2014). A thickened fascia is associated with plantar fasciosis and imaging
studies have shown a decrease in the thickness of the fascia post injection. However, in vitro studies have
shown that tendon and fascia failing loads decrease by approximately 35%, showing an increased risk of
plantar fascia rupture. It is likely that the risk is higher in the foot than in other areas of the body because
of weight bearing stresses. Martin et al (2014) identifies that there is limited evidence for corticosteroid
injections for heel pain / plantar fasciitis as the potential harm is not offset by the benefits. If a patient is
prescribed a steroid injection they may be able to mitigate a percentage of risk if they are instructed to
reduce activity for 2-3 weeks. Other complications of steroid injections into this area include injection site
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pain, infection, plantar fat pad atrophy, lateral plantar nerve injury, calcaneal osteomyelitis, skin
pigmentation changes and muscle damage (Berbrayer and Fredericson 2014, Martin et al 2014).

Extracorporeal shock wave therapy

This is a form of sound wave therapy applied to the heel which produces micro trauma to the damaged
tissue and subsequent regeneration. Complications include pain in the calcaneal area and calcaneal
erythema. A number of trials have shown that it is effective and a meta-analysis of 11 high quality trials
concluded that it should be used to treat chronic plantar fasciopathy and should be strongly considered

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before surgery as a treatment option (Berbrayer and Fredericson 2014).

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When do conservative measures require reassessment?

Thomas et al (2010) advise that patients should have chronic symptoms and have been treated

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conservatively for six months before being referred for extracorporeal shockwave therapy or surgical
interventions such as fasciotomies or nerve releases.

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Summary
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The clinical treatment of plantar fasciopathies involves taping the arch of the foot usually producing
immediate pain relief. Providing the patient then with orthotics usually means they can then be weaned
off taping. Assessment of dorsiflexion restriction helps determine manual therapy intervention. Usually
calf stretching is begun early and this is done with any lower limb valgus corrected. Manual therapy should
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be targeted to the structure which is limiting dorsiflexion. If this is, say, soleus then trigger point therapy
and deep massage into soleus to assist stretching can be chosen. Contract/relax stretching by the
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therapist may be included. If the ankle is stiff it can be mobilised. Plantar fascia specific stretching should
also be commenced early in treatment. Assessing lower limb valgus alignment and strength in the hip
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lateral rotator abductors is important at this point. If the patient has a valgus alignment in the lower limb
and weakness in the ipsilateral hip then a strengthening and alignment strategy to correct this alignment
and integrate it into normal gait is recommended. Night splinting is recommended if progress is deemed
to be slow but as tolerance to wearing a night splint may prove difficult it might not be instituted early in
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the treatment process.

Authors
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Warrick McNeill, Dip.Phyty. (NZ) MCSP *

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Physioworks, 53 Wimpole Street, London W1G 8YH, UK

*Corresponding author. Tel.: +44 7973122996.
E-mail address: warrick@physioworks.co.uk (W. McNeill)

Mark Silvester, Dip. Phty., Dip Manip. Ther., Adv Dip. Phty. (NZ)

Back for the Future. 366G Huia Road, Titirangi, Auckland 0604, New Zealand

______________________________________________________________________________
References
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Web source 1:
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Figure 2. Nomenclature. (Note; the size of the circle does not represent incidence)

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Figure. 4A. 4B. 4C. Low dye taping

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Figure. 5. Plantar fascia stretch technique

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Hi Caroline

the editorial figures are attached below

see the word doc for legends after the reference list

Best

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Warrick
Warrick McNeill

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MCSP
Director Physioworks

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tough on the causes of pain

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Physioworks Chartered Physiotherapy and Pilates Clinic
53 Wimpole Street
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London
W1G 8YH
United Kingdom

E: warrick@physioworks.co.uk
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W: +44 (0) 845 331 6116

M: +44 (0) 7973 122 996
www.physioworks.co.uk
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