Do you have pain on the bottom of your heel? Orthotics may help . . .

I’m completing a PhD investigating interventions for heel pain, and my wife recently started experiencing pain in her plantar heel when getting out of the bed in the morning. I’m sure she felt lucky she was married to someone who could provide her the best advice on how to reduce her pain. However, it’s been three months now, and she still has pain in her heel in the mornings. . .

In the community, pain experienced in the plantar heel is commonly called “plantar fasciitis” or “heel spurs”. However, there may be a number of different causes of pain in the plantar heel, and recently, the term “plantar heel pain” has been suggested.[1) Regardless of the aetiology, most people respond to the same initial treatments—such as weight reduction, activity modification, stretches for the plantar fascia, and changes to footwear.

These were the initial treatments that I suggested to my wife. She tried them, however our two small children often disrupted her efforts, especially the plantar fascia stretches, which should be performed before getting out of bed in the morning.

For plantar heel pain, a variety of other treatments are available, with no clear evidence for which treatment provides the most benefit. Examples include dry-needling, night splints, extracorporeal shockwave therapy, and corticosteroid injections. Another treatment option is foot orthoses (orthotics), which are frequently used for plantar heel pain. It is unclear how they reduce plantar heel pain, but some evidence indicates that they reduce plantar pressures at the heel,[2,3] decrease the strain on the plantar fascia,[4] and may have an effect by altering joint motion, muscle activity, postural sway or sensory feedback.[5-9]

My wife is not concerned about how foot orthoses work, she is mainly concerned with reducing her pain. That is, her focus is on what is referred to as ‘patient outcomes’ (i.e. what is important to patients). Likewise, in my PhD research, I have focused on what is important to patients in an investigation of the effectiveness of foot orthoses for plantar heel pain.  I conducted a systematic review and meta-analysis on the benefits of foot orthoses for the pain and functional deficits that patients experience with plantar heel pain. I was also interested in ‘first step’ pain, as this is the most common complaint reported by people with plantar heel pain. The findings of our review titled ‘Foot orthoses for plantar heel pain: a systematic review and meta-analysis’ have been published in the British Journal of Sports Medicine.

In this systematic review, we identified 19 randomised trials (that included a total of 1660 participants) that met our inclusion criteria. We assessed the quality of these trials and found that 89% were at high risk of bias, while the strength of the evidence (assessed using the GRADE approach) was very low to moderate. This suggests that we have reduced confidence in the results, and that they may change when new trials are included in the meta-analysis.

One of the key findings was that foot orthoses demonstrated a small to moderate effect for reducing pain when compared to sham foot orthoses (sham foot orthoses are control devices that are designed to offer minimal support to the foot). This suggests that foot orthoses may be effective at reducing pain for patients with plantar heel pain. However, because researchers assess average effects from a sample of people, not everyone experiences a benefit from orthoses, so they may not be effective for everyone. Furthermore, we didn’t find that foot orthoses were effective immediately, and took greater than 6 weeks to provide an effective reduction in pain. We also didn’t find any evidence to indicate that foot orthoses were or were not effective at improving function or reducing ‘first step’ pain, however both of these outcomes were infrequently reported.

Another key finding was that prefabricated foot orthoses are as effective as customised foot orthoses. This finding was consistent across trials that investigated this comparison. The importance of this finding is financial, as prefabricated foot orthoses are less expensive than customised foot orthoses with an equivalent effectiveness, so there is a strong argument to use prefabricated orthoses first.

Overall, our review indicates that foot orthoses are an effective treatment option for plantar heel pain. However, the pain reductions may not be immediate, and patients may need to combine foot orthoses with other treatments. Furthermore, the strength of this evidence is poor, and these findings may change when new trials are included in a meta-analysis. So if we apply these findings to my wife, she may benefit from either prefabricated or customised foot orthoses, but it’s important to remember that noticeable pain reductions may not occur straight away, and she may need other treatments.

About Glen Whittaker

Glen is a podiatrist based in Melbourne. He is currently an Associate Lecturer and PhD Candidate at La Trobe University, and is a member of the La Trobe Sports and Exercise Medicine Research Centre. Glen’s PhD is comparing the effectiveness of foot orthoses and corticosteroid injections for plantar heel pain. In another life, Glen completed a psychology degree, which he has managed to put to some use by investigating psychological factors associated with plantar heel pain.

References

[1] Riel H, Cotchett M, Delahunt E, et al. Is “plantar heel pain” a more appropriate term than “plantar fasciitis”? Time to move on. Br J Sports Med. February 2017:bjsports-2017-097519. doi:10.1136/bjsports-2017-097519.

[2] Bonanno DR, Landorf KB, Menz HB. Pressure-relieving properties of various shoe inserts in older people with plantar heel pain. Gait Posture. 2011;33(3):385-389. doi:http://dx.doi.org/10.1016/j.gaitpost.2010.12.009.

[3] Chia JKK, Suresh S, Kuah A, Ong JLJ, Phua JMT, Seah AL. Comparative trial of the foot pressure patterns between corrective orthotics, formthotics, bone spur pads and flat insoles in patients with chronic plantar fasciitis. Ann Acad Med Singapore. 2009;38(10):869-875.

[4] Kogler GF, Solomonidis SE, Paul JP. Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain. Clin Biomech (Bristol, Avon). 1996;11(5):243-252. doi:http://dx.doi.org/10.1016/0268-0033(96)00019-8.

[5] Mills K, Blanch P, Chapman AR, McPoil TG, Vicenzino B. Foot orthoses and gait: a systematic review and meta-analysis of literature pertaining to potential mechanisms. Br J Sports Med. 2010;44(14):1035-1046. doi:10.1136/bjsm.2009.066977.

[6] McMillan A, Payne C. Effect of foot orthoses on lower extremity kinetics during running: a systematic literature review. J Foot Ankle Res. 2008;1(1):13. doi:10.1186/1757-1146-1-13.

[7] Murley GS, Landorf KB, Menz HB, Bird AR. Effect of foot posture, foot orthoses and footwear on lower limb muscle activity during walking and running: A systematic review. Gait Posture. 2009;29(2):172-187. doi:10.1016/j.gaitpost.2008.08.015.

[8] Ritchie C, Paterson K, Bryant AL, Bartold S, Clark RA. The effects of enhanced plantar sensory feedback and foot orthoses on midfoot kinematics and lower leg neuromuscular activation. Gait Posture. 2011;33(4):576-581. doi:10.1016/j.gaitpost.2011.01.012.

[9] Landorf KB. How do foot orthoses work. Pod Now. 2016;19(5):24-27.