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How to differentiate plantar fasciopathy from other causes of plantar heel pain, advice for pharmacists on counselling patients and when to refer.
A 2017 survey conducted by The Pharmaceutical Journal found that 30% of pharmacists encounter a foot condition more than once per week. Pain on the under (plantar) surface of the heel is common in the adult and paediatric population; however, there could be up to 50 causes for this.
This article outlines the most common cause of plantar heel pain (PHP) in adults, plantar fasciopathy (PF), how to differentiate PF from other causes of PHP, the advice that pharmacists and healthcare professionals can give to patients and when to refer.
Around 10% of the adult population will experience PHP and in 80% of these cases, the cause is PF. People aged 40–60 years are most commonly affected, with some evidence suggesting that women experience pain for longer when the condition becomes chronic (i.e. continues beyond three months). PF is more commonly known as plantar fasciitis, but fasciopathy reflects the degenerative rather than inflammatory nature of the condition.
The pain experienced by people with PF is associated with a thickening of the plantar fascia where it originates from the calcaneum ([heel bone]; see Figure 1).
Figure 1: Plantar fasciopathy
Source: Andreas Ehrhard / Alamy Stock Photo. Blower N. Innovations in the management of heel pain. 2018
This area is a fibrocartilagenous enthesis. Although the reason for the thickening is debated, risk factors include mechanical tissue stress, load being transferred from the achilles tendon via fascial ‘tightness’, obesity (as opposed to increased body mass index [BMI], e.g. in the athletic population), ageing and occupational standing. The relationship between PF and the mechanics of the arches of the feet is, however, equivocal. Therefore, the use of foot orthoses, such as arch supports, is debated in this condition,.
There are signs and symptoms that can be established during basic history taking that will help to differentiate between PF and the other causes of PHP (see Table 1 and Table 2). Careful questioning by pharmacists alongside examination of a patient presenting with foot pain can help to elucidate the cause.
In the community pharmacy setting, the person undertaking this assessment should be confident in their knowledge of how to palpate the foot (see Figure 2) to establish the area of pain and how to take a patient history. Local policies and training will need to determine who undertakes this assessment.
When a patient presents with PHP (see Box 1), pharmacists should ensure an appropriate history is taken and relevant observations and examinations are made. Pertinent questions include:
It is important to be sure about the location of the pain. Not all pain under the foot is caused by the plantar fascia and not all PHP is caused by PF. The pain in PF is located at the point shown in Figure 2 or slightly further back (more proximal) on the plantar surface of the heel.
Figure 2: Palpating the area of pain caused by plantar fasciopathy
To be precise about the location of pain, pharmacy professionals should follow these steps:
Physical examination should only be undertaken by trained pharmacists who should be appropriately insured to do so. If it is not possible for a pharmacist to palpate the foot, the patient should be asked to press the foot to identify the area of pain instead.
If the pain is not in the area of the heel shown in Figure 2 and the patient does not fit the profile (see Box 1), they may have another cause of PHP. Table 1 describes the signs or symptoms that can help determine the cause of the patient’s heel pain. As an example, PF is never traumatic and is not usually seen in children. ×, ×
|Sign or symptom||Plantar fasciopathy||Other causes of plantar heel pain|
|Pain at rest, nocturnal||×||✔|
|Pain on initiation of activity (start-up pain)||✔||×|
|Obvious inflammation, bruising||×||✔|
|Sharp, achy pain||✔||✔|
|Numbness, tingling, burning pain||✔||✔|
However, there are numerous other potential causes of heel pain (see Table 2).
|*Please note that this table is not exhaustive|
|Skeletal||Calcaneal fracture, calcaneal apophysitis (Sever’s disease) — this is the main cause of heel pain in children|
|Soft tissue||Heel pad bruising, plantar fascial rupture (traumatic or post-steroid injection), pain in the arch from tendons (e.g. tibialis posterior tendinopathy)|
|Infection/foreign bodies||Calcaneal, soft tissue, foreign body|
|Systemic disease||Rheumatoid arthritis, tuberculosis, ankylosing spondylitis, inflammatory bowel disease, gout, psoriatic arthritis|
|Metabolic||Osteoporosis (also in high level athletes), Paget’s disease, hyperparathyroidism|
|Benign neoplasms||Lipoma, bone cysts, osteoid osteoma, giant cell tumour|
|Malignant neoplasms||Metastases, sarcoma (e.g. Ewing’s sarcoma in paediatrics)|
|Neurological||Local nerve affectation (e.g. first branch of lateral plantar nerve), tarsal tunnel syndrome, spinal referral (lumbo-sacral), chronic regional pain syndrome|
If, after taking a history, the pharmacist is confident the patient has PF, staged treatment is recommended. Table 3 outlines these stages, as well as the related advice and responsible clinician.
The role of the pharmacy team focuses mainly on providing the initial advice outlined in Table 3. Any healthcare professional seeing a patient with PF who has not been advised or treated previously should start with these measures.
|Duration of pain||Treatment advice||Responsible clinician|
|Source: National Institute for Health and Care Excellence. Clinical knowledge summaries: plantar fasciitis.|
|0–6 weeks (or no previous advice or treatment)||Initial advice for all patients: stretching exercises (see Figure 3); rest from irritating activities such as long periods of standing; supportive, cushioned shoes (avoid barefoot); weight loss; cushioned/gel insoles (see Box 2); analgesia||Any|
|6 weeks–3 months (if above advice fails or symptoms severe)||Guided corticosteroid injection; podiatry treatment; physiotherapy treatment||GP, consultant, extended scope allied healthcare professional, Health and Care Professions Council (HCPC)-registered podiatrist or physiotherapist|
|3–6 months||Extra-corporeal shockwave therapy||Consultant or HCPC-registered podiatrist or physiotherapist|
|6–12 months||Platelet-rich plasma infiltration, surgery||Consultant|
The evidence base does not support the use of foot orthoses for the treatment of PF. However, it is recognised that anecdotally they can be of benefit and that this is not reflected in the research, possibly owing to inappropriate study design. As such, advising patients that arch supports will improve the condition may be misleading; however, general cushioning from shoes and insoles will help (see Box 2).
Analgesia should be advised on the basis of the severity of the pain being experienced by the patient, in accordance with National Institute for Health and Care Excellence guidance. Some symptoms may be helped by over-the-counter analgesics. However, analgesia alone will not be enough to treat the condition effectively and should not be considered without the additional advice in Table 3.
Rest alone will not be enough to alleviate all the pain in PF but avoiding deliberately aggravating activities (e.g. high-impact activities such as running, standing for long periods and walking barefoot) will help to reduce the aggravating factors. Wearing good footwear (see Box 3) is likely to improve PF symptoms but, again, there are no controlled trials to support this. However, as the pain from PF emanates from the thickening of the plantar fascia under the heel, cushioning and protecting this area can help relieve symptoms.
Shoes can be a cause of foot pain. They can be too high or too low at the heel, have little or no support (e.g. slip-ons such as ballet shoes) and can be the wrong length, width fitting or shape for the patient’s foot. The internal stitching or tacks may also rub against the foot.
In general, shoes should have an upper made from a natural material that will stretch and allow evaporation of moisture, have an adequate width, depth and shape to the toe box to prevent rubbing, and have a heel height of less than 4cm to prevent forefoot pressure and aid normal walking mechanics.
Patients should be advised to wear the right shoe for the activity they are doing. Women do not have to avoid wearing high heels or ballet shoes to prevent foot pain, but it is best not to wear these if walking for longer distances or standing for sustained periods. Some occupations, however, make this more difficult to achieve.
A good pair of shoes to walk longer distances in should have a synthetic sole to help support and cushion the foot (especially on harder surfaces) and a fastening so that the shoe moves with the foot, rather than the foot moving around in the shoe.
In plantar fasciopathy, one of the most important features of a shoe that will help relieve symptoms is cushioning inside the shoe and a thicker sole, ideally with a fastening so the foot can work more efficiently.
It is known that stretching is effective at relieving pain in PF but the method of stretching is poorly described. There is some consensus that stretching the plantar fascia is more effective than stretching the calves alone; therefore, the stretches described in Figure 3 are recommended.
Figure 3: Exercises to manage foot pain
Source: Courtesy of Versus Arthritis
Symptoms may be improved by weight loss, achieved through diet and low-impact physical activity. There is a specific correlation between increased BMI in the non-athletic population and PF. Patients should be advised of the link and signposted accordingly.
Patients seeking NHS treatment should be referred to their GP for onward referral. However, patients who are seeking private treatment should ensure the clinician recommended is appropriately qualified. Podiatrists working in private practice will usually take self-referrals from patients. However, a referral from a healthcare professional can be useful in identifying medical history and medicines (which patients sometimes forget and often do not realise are important in diagnosing their condition). Podiatrists/chiropodists and physiotherapists should be registered with the Health and Care Professions Council, which regulates 16 health and care professions.
Referrals to NHS podiatrists vary. Some NHS community trusts accept self-referral, while others have tight restrictions on who can be referred.
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The author was not paid to write this article and The Pharmaceutical Journal retained full editorial control at all times.
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2018.20205661