Study on heel pain management: a prescription for debate

Plantar heel pain is no stranger to any medical profession dealing with foot complaints. The common and disabling problem affects between 4% and 7% of the population at any one time, accounting for up to 15% of foot complaints that receive medical care.

Given that the complaint can prevent people from engaging in sports and exercise, and the duration of recovery, it’s an area of great interest for researchers seeking more effective ways to treat the condition.

The British Journal of Sports Medicine recently published a study by researchers in the Netherlands that, perhaps controversially, looked not only at the type of treatment, but also who was providing it.

The study compared the treatment outcomes between one group that received routine care from a GP to two groups that were referred to a podiatrist. Of the latter groups, one received custom-made insoles while the other group were prescribed sham insoles. All three groups were given information about managing heel pain, including instructions for stretching and strengthening exercise.

After 12 weeks, the group receiving GP care reported slightly less pain during activity compared with the insole groups. The researchers concluded that podiatrist-prescribed custom insoles do not lead to better outcomes compared with usual GP care, and as such, healthcare providers should be “reserved” in prescribing custom insoles for the treatment of plantar heel pain.

A statement that certainly made podiatrists, and physiotherapists, who also treat heel pain, sit up and take note. Professor Hylton Menz, an NHMRC Senior Research Fellow at the La Trobe University Sport and Exercise Medicine Research Centre, said the study was generally well designed, but not without its limitations.

“There are a lot of studies that have looked at different interventions for heel pain, but this is one of the first that has compared outcomes between professions, and I think that’s why it’s been a little bit controversial.

“Some clinicians, particularly physiotherapists, may have doubts around the use of foot orthoses for heel pain because they would approach these conditions with exercise interventions. Some see a paper like this come out, and jump straight to the conclusion and think the study shows that orthotics are no good for heel pain, but the story is a little more complex than that.”

The critical issue with the study, as Professor Menz and colleagues penned in an editorial to the journal, was generalising the results beyond the context of the Dutch primary care system.

“The Netherlands has a universal health care system which the majority of patients access through the GP. From what is presented in the trial, it would appear that the care you can expect to receive for heel pain from a Dutch GP is far more extensive than what you would expect from a GP in Australia.”

The participants in the study also arguably received more extensive care than what is typical for even the Dutch system, with higher rates of heel cups prescribed, corticosteroid injections administered, and more consultations attended.

As far as the insoles are concerned, Professor Menz says the idea of a placebo in the form of a sham orthosis is an ongoing conundrum: the insole has to convince the wearer it’s having an effect, but in reality, providing minimal biomechanical support. Unfortunately, no biomechanical testing was undertaken in this study to assess how inert the sham devices were.

In addition, the key limitation with the custom orthoses arm of the trial was that the prescription was left to the discretion of the 50 podiatrists involved, and only limited detail was provided as to how this was done and what participants actually received.

Professor Menz says that far from feeling threatened, particularly as the study became fodder for social media, the results could actually be interpreted as a good news story for podiatrists.

“Essentially, what they found is that there’s not a lot of difference between the approaches. People’s heel pain improved across those three groups. In the podiatry group, all they provided was an orthosis, whereas podiatrists here in Australia typically use a combination of interventions.”

“If I didn’t look at the paper in detail and only saw the social media commentary, I’d think that was a bad for podiatry. In reality, for an Australian podiatrist, I think it has relatively little impact.”