Article Text

Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values
  1. Dylan Morrissey1,2,
  2. Matthew Cotchett3,
  3. Ahmed Said J'Bari1,
  4. Trevor Prior1,
  5. Ian B Griffiths1,
  6. Michael Skovdal Rathleff4,
  7. Halime Gulle1,
  8. Bill Vicenzino5,
  9. Christian J Barton3,6
  1. 1 Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, London, UK
  2. 2 Physiotherapy Department, Barts Health NHS Trust, London, UK
  3. 3 Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, La Trobe University, Melbourne, Victoria, Australia
  4. 4 Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
  5. 5 University of Queensland, School of Health and Rehabilitation Sciences: Physiotherapy, St Lucia, Queensland, Australia
  6. 6 Department of Surgery, St Vincent’s Hospital, University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Dr Dylan Morrissey, Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, London E1 4DG, UK; d.morrissey{at}qmul.ac.uk

Abstract

Objective To develop a best practice guide for managing people with plantar heel pain (PHP).

Methods Mixed-methods design including systematic review, expert interviews and patient survey.

Data sources Medline, Embase, CINAHL, SPORTDiscus, Cochrane Central Register of Controlled Trials, trial registries, reference lists and citation tracking. Semi-structured interviews with world experts and a patient survey.

Eligibility criteria Randomised controlled trials (RCTs) evaluating any intervention for people with PHP in any language were included subject to strict quality criteria. Trials with a sample size greater than n=38 were considered for proof of efficacy. International experts were interviewed using a semi-structured approach and people with PHP were surveyed online.

Results Fifty-one eligible trials enrolled 4351 participants, with 9 RCTs suitable to determine proof of efficacy for 10 interventions. Forty people with PHP completed the online survey and 14 experts were interviewed resulting in 7 themes and 38 subthemes. There was good agreement between the systematic review findings and interview data about taping (SMD: 0.47, 95% CI 0.05 to 0.88) and plantar fascia stretching (SMD: 1.21, 95% CI 0.78 to 1.63) for first step pain in the short term. Clinical reasoning advocated combining these interventions with education and footwear advice as the core self-management approach. There was good expert agreement with systematic review findings recommending stepped care management with focused shockwave for first step pain in the short-term (OR: 1.89, 95% CI 1.18 to 3.04), medium-term (SMD 1.31, 95% CI 0.61 to 2.01) and long-term (SMD 1.67, 95% CI 0.88 to 2.45) and radial shockwave for first step pain in the short term (OR: 1.66, 95% CI 1.00 to 2.76) and long term (OR: 1.78, 95% CI 1.07 to 2.96). We found good agreement to ‘step care’ using custom foot orthoses for general pain in the short term (SMD: 0.41, 95% CI 0.07 to 0.74) and medium term (SMD: 0.55, 95% CI 0.09 to 1.02).

Conclusion Best practice from a mixed-methods study synthesising systematic review with expert opinion and patient feedback suggests core treatment for people with PHP should include taping, stretching and individualised education. Patients who do not optimally improve may be offered shockwave therapy, followed by custom orthoses.

  • qualitative
  • rehabilitation
  • effectiveness
  • foot
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Footnotes

  • Twitter @DrDylanM, @Sports_Pod, @Bill_Vicenzino, @DrChrisBarton

  • Correction notice This article has been corrected since it published Online First. Figures 2 and 3 have been transposed.

  • Contributors The lead authors (DM and MC) had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. DM obtained funding, is guarantor, designed the study, selected eligible studies, performed the quality analysis, interviewed experts, constructed the patient survey and analysed and interpreted qualitative data, analysed and interpreted quantitative data, prepared the manuscript. MC conducted the search; selected eligible studies, performed the quality analysis and statistical analysis of quantitative data; interpreted the statistical analysis; prepared the manuscript. CJB: designed the study, selected eligible studies, performed the quality analysis; interpreted the statistical analysis of quantitative and qualitative data; reviewed and approved the manuscript. ASJB: selected eligible studies, performed the quality analysis, interviewed experts, reviewed and approved the manuscript. TP: selected eligible studies, performed the quality analysis, reviewed and approved the manuscript. IBG: selected eligible studies, performed the quality analysis, reviewed and approved the manuscript. HG: prepared the patient survey and analysed and interpreted qualitative data, reviewed and approved the manuscript. MSR: selected eligible studies, performed the quality analysis, reviewed and approved the manuscript. BV: performed the quality analysis, reviewed and approved the manuscript.

  • Funding DM was a recipient of funding from the PPEF for this study, and was part-funded by the NIHR/HEE Senior Clinical Lecturer scheme. This article presents independent research part-funded by the National Institute for Health Research (NIHR) CAT SCL-2013-04-003. CJB is supported by an MRFF TRIP Fellowship (APP1150439)

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests Three authors (MC, BV, MSR) each conducted a randomised controlled trial that was evaluated in this review.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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