Review
Factors associated with chronic plantar heel pain: a systematic review

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Summary

Chronic plantar heel pain (CPHP) is one of the most common soft tissue disorders of the foot, yet its aetiology is poorly understood. The purpose of this systematic review was to examine the association between CPHP and the various aetiological factors reported in the literature. Seven electronic databases and the reference lists of key articles were searched in August 2005. The resulting list of articles was assessed by two independent reviewers according to pre-determined selection criteria and a final list of articles for review was created. The methodological quality of the included articles was assessed and the evidence presented in each of the articles was descriptively analysed. From the 16 included articles, body mass index in a non-athletic population and the presence of calcaneal spur were the two factors found to have an association with CPHP. Increased weight in a non athletic population, increased age, decreased ankle dorsiflexion, decreased first metatarsophalangeal joint extension and prolonged standing all demonstrated some evidence of an association with CPHP. Evidence for static foot posture and dynamic foot motion was inconclusive and height, weight and BMI in an athletic population were not associated with CPHP. The findings of this review should be used to guide the focus of prospective cohort studies, the results of which would ultimately provide a list of risk factors for CPHP. Such a list is essential in the development of new and improved preventative and treatment strategies for CPHP.

Introduction

One of the most common foot disorders encountered by health professionals is chronic plantar heel pain (CPHP). It has been reported to account for 15% of all adult foot complaints requiring professional care and is prevalent in both athletic and non-athletic populations.1, 2 The condition occurs in approximately 2 million Americans per year, affecting as much as 10% of the population over the course of a lifetime.3 It is generally observed in those over 40 years of age, but has been reported in people from 7 to 85 years and does not seem to be gender-specific.2, 4 The typical complaint shared by most individuals is pain under the medial heel during weight-bearing, especially in the morning and at the beginning of weight-bearing activities such as walking.2, 5 The nature of the pain has been described as burning, aching and occasionally lancinating. Athletes may experience pain at the beginning of a run, which increases after the run.2 While not usually disabling, it can severely limit weight-bearing activities, leading to a reduction in both sporting and everyday activities.

In the literature CPHP has been described as painful heel syndrome, plantar fasciitis, subcalcaneal bursitis, neuritis, medial arch pain, subcalcaneal pain, stone bruise, calcaneal periostitis, subcalcaneal spur and calcaneodynia.1, 6 As with many conditions where the true aetiology is unclear, CPHP has become a generalised term encompassing a broad spectrum of pathologies affecting the heel. However, plantar fasciitis is considered to be the most common cause of pain and the terms are used interchangeably in the literature.2, 7

The aetiology of CPHP is poorly understood and is probably multifactorial.2, 8 Many risk factors for the development of the condition have been hypothesised in the literature and are commonly classified as intrinsic or extrinsic. Intrinsic risk factors are anatomical and biological characteristics of individuals that predispose them to injury.4 Biological factors suggested in the literature include increasing age, increasing body mass index (BMI), height and weight gain; anatomical factors include limited ankle dorsiflexion, leg length discrepancy, heel pad thickness, increased plantar fascia thickness, pes planus (excessive pronation of the foot), cavus (high arched) foot, muscle imbalance, limited first metatarsophalangeal joint (MPJ) range of motion (ROM) and calcaneal spur.2, 8, 9 Postulated extrinsic factors include prolonged weight bearing, improper shoe fit and wear, previous injury and running variables such as surface, speed, frequency and distance per week.2, 4, 8

The evidence for most of these factors is limited or absent.8 Risk factors suggested in the literature are generally based on theories or assumptions arising from associations found between CPHP and variables identified in case-control or case-series studies. These study designs cannot examine the temporal relationship between the factors identified and CPHP because cases are assessed only after the disorder has been diagnosed. For this reason causality cannot be established in case-series and case-control studies. Factors ‘associated with’ CPHP can be identified, but not ‘risk factors’ per se. The aim of this review was to examine the association between CPHP and the intrinsic and extrinsic factors reported in the literature.

Section snippets

Literature search

In August 2005 an electronic database search was conducted. A standard search term was entered into each database followed by a search using terms individual to the mapping tree of that particular database (Fig. 1). Electronic database searching was supplemented by searching the bibliographies of relevant articles.

From titles and abstracts, two reviewers (DBI and JLC) independently reviewed the literature searches according to predetermined selection criteria (Fig. 1) to identify potentially

Search strategy

The initial search strategy yielded 279 potentially relevant articles (267 from electronic databases and 12 via bibliography searching). From titles and abstracts, 34 articles were extracted for full-text review. This final review yielded 16 publications, comprising 13 case-control and 3 case-series studies.

Methodological quality

Table 1 presents the results of the methodological quality assessment of included studies. Quality assessment scores ranged from 38 to 90% (mean = 68%); 13 papers scored between 60 and 90%.

Six

Discussion

Despite the widespread prevalence of CPHP, only 16 papers were identified that attempted to identify aetiological factors associated with the condition. All papers examined in this review were either case-control or case-series in nature meaning that the available evidence could provide information regarding an ‘association’ between CPHP and the various aetiological factors, but no ‘risk factors’ for the condition could be identified. The findings of this review are summarised in Table 9.

The

Conclusion

The most recent systematic review of the interventions used to treat CPHP concluded that current treatment strategies used by clinicians provide only marginal gains over no treatment at all.6 This highlights the need to improve current treatment strategies as well as the need to prevent the onset of the disorder. Prevention strategies need to be based on a set of risk factors. However, current levels of evidence do not allow for the identification of risk factors. The findings of this review

Practical implications

  • Increased body mass index is strongly associated with chronic plantar heel pain in a non-athletic population.

  • Calcaneal spur is associated with chronic plantar heel pain but is likely to be part of the spectrum of pathology rather than a risk factor.

  • Identifying factors associated with chronic plantar heel pain will assist in identifying at risk individuals and the development new and improved preventative and treatment strategies.

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