In this section, we have included a plan to help guide the treatment of your heel pain. The plan that we have designed is based on the best available evidence, the experience of experts that treat plantar heel pain and also the experience and needs of people that have experienced this condition. It is important to consider that some treatment options might not be appropriate for you based on your ability to access the treatment; cost of the treatment but also your belief in certain treatments.
Included below is a figure which highlights a stepped approach to the treatment of your heel pain. We have recommended a series of treatments at each step. If there is minimal to no improvement at a particular step, then you can try the treatments at the next step.
A traffic light system has been used to highlight the strength, or how believable, the research is into that treatment option.
Plantar heel pain treatment steps
Understand your pain
Start by having a good understanding of your heel pain. Having knowledge of why you first developed pain and an understanding of the underlying condition can in fact reduce your pain! Remember that your thoughts, feelings, beliefs, mood and various events in your day can increase or decrease your pain. We would recommend that you review the section on ‘Why does it hurt’ and also complete the short quiz to test your knowledge of the condition.
In most cases, treatment of plantar heel pain will require persistence and patience. We would encourage you to stay positive as the best available evidence tells us that you will improve with time. Go to the section on ‘Patient stories‘ which includes real accounts of the experiences and challenges faced by people with plantar heel pain and how they treated their condition.
The core approach to treating plantar heel pain
Our research into plantar heel pain, which involved reviewing the evidence and interviewing experts and people with the condition, is that a plan that includes education, stretching, foot taping, and footwear changes is considered to be the ‘core’ approach to treatment of plantar heel pain. We would recommend that you review the section ‘What is the best treatment for plantar heel pain’, which reviews the importance of education, how to stretch your calf muscle and plantar fascia, tape your foot, change your footwear and modify your activity.
Do not look for a quick fix
There are numerous treatments for plantar heel pain and online sites claiming that plantar heel pain can be cured in 7 days. Do not look for a quick fix or a magic injection to cure your heel pain. High quality research evidence suggests that, on average, patients with plantar heel pain tend to have a 50-60% improvement in symptoms after 6 months of treatment. A quick fix may occasionally provide short term relief but often doesn’t address the key issues that are associated with the condition. Stick to the core approach to plantar heel pain and allow your body to heal your heel!
Can I still exercise?
A common question to a health professional is “Can I still exercise” and “How much can I exercise”? Our advice is to keep exercising providing it is not aggravating your symptoms. You may need to modify the amount of time on your feet and impact activities such as running and jumping. If needed, a health professional can provide guidance about the amount and intensity of your exercise, and how to monitor signs that you might be pushing it too much.
For people with persistent plantar heel pain (i.e. >3 months) it is important that activity is not avoided as avoiding activity can actually increase your pain! If you have been advised to modify your level of activity, find another form of activity that you enjoy and doesn’t worsen your heel pain (e.g. swimming, cycling, rowing). Alternative forms of exercise are great for your physical and mental health and will help reduce your pain!
If your symptoms have not improved over a period of three months, despite trying the core approach and having a good understanding of your heel pain you can consider treatment options in Step 2. However, it is important to consider that if you have strong beliefs or preferences for a certain treatment, or can access treatments on other ‘Steps’, then you are encouraged to explore those options with your health professional. Always remember the core approach to plantar heel pain needs to be maintained throughout each step. For example, don’t trial foot orthoses at Step 2 without still undertaking your exercises, modifying activity and wearing supportive footwear.
Step 2 treatment options
There is strong evidence to support the use of shockwave therapy in the short, medium and long term. It is typically used for people whose symptoms are persisting and not resolving with the core approach. Shockwave therapy is a safe treatment and can be implemented by health professionals who have access to a shockwave device.
There is strong evidence that custom made foot orthoses are effective for reducing pain in people with plantar heel pain, although orthoses have their best effect at 3 months and beyond. So, you will need to be patient and mindful that a reduction in pain may take some time to be noticed. Over the counter, or generic foot orthoses, might also be of benefit. However, your Podiatrist is best placed to determine what type of generic orthosis is best for your foot and footwear as there is not just one type of generic orthosis that is good for plantar heel pain.
There is moderate evidence that dry needling is effective for reducing pain in people with plantar heel pain, although like foot orthoses, dry needling has its best effect at 3 months and beyond. Experts recommend that dry needling is not to be used on its own but rather in combination with more important treatment options found in Step 1. Dry needling can be uncomfortable although pain is considered to be mild and brief and associated with the insertion of the needle.
If your symptoms have not improved, or your improvement has slowed, despite maintaining the core approach and attempting treatments at Step 2 (i.e. shockwave, orthoses and/or dry needling), it is recommended that options in Step 3 are considered. Before attempting options at Step 3, we believe that it is important to consider the following issues:
Have you continued to undertake the core approach in Step 1?
Reflect on your treatment plan from the previous 3-6 months. Have you modified your activity, addressed any footwear issues, correctly and consistently undertaken exercises, and tried taping your foot regularly? If not, we would recommend that you continue the core approach in Step 1 and add treatments from Step 2 and 3.
What has been your level of improvement to date?
Sometimes people with plantar heel pain can have false expectations of improvement. For most people, the improvement is slow. High quality research evidence suggests that patients tend to have a 50-60% improvement in pain after 6 months, irrespective of the treatment.
Do you have a good understanding of the condition?
It is important to reinforce your knowledge of the condition. The following points should be remembered:
- When pain beneath the heel is persistent (i.e. > 3 months), the pain that people feel is often influenced by your thoughts, beliefs, mood and day to day life events more than it was when your first had heel pain. Are you aware of anything in your life that might increase or decrease your pain? Focus on those things that help reduce your pain. Also, address those issues that might make your pain worse (e.g. walking barefoot, standing for long periods, too much exercise, negative thoughts, and a low mood).
- The best evidence suggests, that in most cases, plantar heel pain will resolve with time. You will need to be patient, persistent and courageous. Improvement won’t happen over night, but it will happen! If you are unsure about your diagnosis, seek the assistance of a health professional who can review your heel pain and your treatment plan.
- Exercise will not cause further injury or re-injury. Motion is lotion! The foot loves to be exercised but the key is to work out how much exercise you can undertake without making your symptoms worse during, immediately after and 24 hours after exercise. Refer back to the section on graded exercise to learn more about how much exercise you can do.
Step 3 treatment options
Corticosteroid injections are intended to reduce pain and inflammation. There is evidence to suggest that the pain relief from this injection may only be short term on average (i.e. 4 weeks), although some people will experience pain relief for a longer period of time. A short term pain reduction may be important for you and your goals, which can make this treatment option worthwhile. It is important that you continue to use the treatments that have been offered in steps 1 and 2.
Corticosteroid injections are very safe with only a few adverse effects. The most common adverse effect is short term pain related to the injection. Less frequent adverse effects include a plantar fascia tear, changes to skin colour, and thinning of the fat surrounding the injection site.
Walking boot (CAM walker)
A CAM walker is intended to reduce the forces that are placed on the heel when walking. The boot transfers these forces around the foot to the lower leg. This treatment option can be beneficial to reduce pain during activity, particularly if you have severe pain, or you need to stand for long periods.
A CAM walker should not be considered a long term solution. The use of a CAM walker can change the alignment of your legs and back, which may cause stress to be placed on other tissues. Also, you may experience some weakness after long term use as muscles that you normally use will not be active. It is important to use this treatment option after advice from a health professional.
If your symptoms have not improved, or your improvement has slowed, despite maintaining the core approach and attempting treatments at Step 2 (i.e. shockwave, orthoses and/or dry needling) and step 3 (i.e. corticosteroids and a walking boot), surgery can be considered.
A previous clinical practice guideline for plantar heel pain recommended a surgical approach be considered after 6 months of failed conservative care. However, the best available evidence suggests that people with plantar heel pain generally only experience a 50% to 60% improvement in symptoms after 6 months.
Importantly, the research evidence is uncertain about the effectiveness of surgery for plantar heel pain (i.e. there has been no high quality experiments that have evaluated the effectiveness of surgery for plantar heel pain).
Patients considering surgery for plantar heel pain are strongly advised to reflect on the following questions:
- Have you continued to undertake the core approach in Step 1?
- What has been your level of improvement to date? Sometimes people with plantar heel pain can have false expectations of improvement.
- Do you have a good understanding of the condition?
- Have you addressed any negative thoughts, incorrect beliefs, and/or issues with mood which might be affecting pain?