Sports Medicine Research: In the Lab & In the Field: Don’t Wait Around: Authors Inject Rankings for Heel Pain Treatment Options (Sports Med Res)

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Monday, July 23, 2018

Don’t Wait Around: Authors Inject Rankings for Heel Pain Treatment Options

Comparative Effectiveness of Treatment Options for Plantar Heel Pain: A Systematic Review with Network Meta-Analysis       

Babatunde OO, Legha A, Littlewood C, Chesterton LS, Thomas MJ, Menz HB, van der Windt D, Roddy E. Br J Sports Med. 2018. [Epub ahead of print]

Take Home Message: No treatment is clearly best to decrease heel pain and increase function; however, a corticosteroid injection with or without exercise may be most beneficial.

https://www.flickr.com/photos/35080385@N08/30956691112
Plantar heel pain is common in the general and athletic population. It is likely caused by multiple factors, which can make its treatment lengthy and frustrating. There are many conservative treatment options (watchful waiting, injections, orthoses); however, we don’t know how to rank the effectiveness of these treatments. One solution to this problem is a network meta-analysis, which allows researchers to assess multiple treatments at once and rank the treatments. Therefore, the authors conducted a network meta-analysis of 31 clinical trials to evaluate the effectiveness of the treatments for relieving pain and increasing function in patients with plantar heel pain. The randomized clinical trials included in this review met the several criteria: participants were 18 years or older (2450 participants), had specific information on dosage and procedures, and had outcome measures collected at least 24 hours after treatment (ranged from 4 to 104 weeks). The studies included 10 different or combinations of exercise therapy, corticosteroid injections, non-steroidal anti-inflammatory drugs (NSAIDs), orthoses, extracorporeal shockwave therapy (ESWT), or usual care/placebo. The authors collapsed primary outcomes of pain and function into 3 categories: short term (1 to 6 weeks), medium term (6 to 12 weeks), or long term (> 12 weeks). The authors found no clear evidence that any treatment was best. However, ESWT or a corticosteroid injection with or without exercise therapy may offer the best results over all time frames. Exercise, which might not be helpful in the short- or medium-term may offer long-term benefits. 

This was an interesting study because though the authors failed to find one treatment option was best for improving pain or function, they were able to rank the commonly used treatments for heel pain. The ranking system revealed that corticosteroid injections with or without exercise therapy reduced pain and improved functional outcomes across all time frames. However, we should be cautious because of the wide variability in the possible benefits of these treatments. Placebo (watchful waiting) was not surprisingly the least effective; however, of note was that NSAIDs and orthoses ranked lower than one might expect. Given the limited information on the long-term effects of these treatment options and the doubts about what may be the ideal treatment option more robust randomized trials are needed to identify the best treatment for heel pain. At this time, exercise had the best outcomes over a long term. Medical professionals should be mindful of these findings when they suggest options such as watchful waiting, expensive orthosis, or NSAIDS that could have negative side effects that may not be helpful in treating patients with heel pain. It may also be worthwhile to discuss the benefits of an injection with a home exercise plan to relieve pain and offer long-term benefits.

Questions for Discussion: What do you currently use to treat heel pain? What exercises or treatments do you perform to help increase function in patients with heel pain?

Written by: Jane McDevitt
Reviewed by: Jeffrey Driban

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