International Perspectives On Heel Pain

Darren Woodruff, DPM, DAPBM, DABMSP, CWSP (Canada), Benn Boshell, BSc (Hons), MSc (United Kingdom), Sanjay Sharma, MS, DPM, FDFM (India), Koji Kawamata, BSc Podiatry (Japan), and Steven R. Edwards, MSc(Oxon), MSc(Edinb), BSc Pod (Australia)

Feature

International Perspectives On Heel Pain

Darren Woodruff, DPM, DAPBM, DABMSP, CWSP (Canada), Benn Boshell, BSc (Hons), MSc (United Kingdom), Sanjay Sharma, MS, DPM, FDFM (India), Koji Kawamata, BSc Podiatry (Japan), and Steven R. Edwards, MSc(Oxon), MSc(Edinb), BSc Pod (Australia)

October 2021

Podiatry Today invited foot and ankle practitioners from around the globe to share their experiences with heel pain in their respective countries, whether changes due to the COVID-19 pandemic, challenges due to a lack of understanding of the training and abilities of podiatrists, or cultural trends that impact practice. In this compilation, the authors’ conveyed experiences aim to inspire readers to examine their own treatment algorithms, and think about how one can learn from, and collaborate upon, these successes and struggles abroad.

Addressing Heel Pain In Canada During A Global Pandemic

By Darren Woodruff, DPM, DAPBM, DABMSP, CWSP

The last 18 months have been very different for all of us. In March of 2020, when Canada closed its borders to everything but essential traffic, a lot of the country started to close as well. In many provinces, podiatry offices closed, while in others they remained open with restrictions on what types of patients they could see. This slowed my practice down quite drastically and we were only open for a few hours each day until the restriction lifted after about six weeks. As health care and public health are a provincial jurisdiction in such a large country, the lockdowns varied from region to region. Each province treats podiatry differently; some offer coverage for podiatry in their provincial health care while others do not. Some patients also have third-party insurance that covers podiatry services. Many patients see family doctors prior to seeing podiatrists, which is like an HMO insurance plan in the US. Patients do not usually need to wait very long to see a podiatrist in Canada. This has changed a little during the COVID-19 pandemic, as due to fear of the virus, people wait for weeks to months prior to coming to a clinic.

In my observation, Canadians have increasingly looked at their health during the pandemic, bringing more patients into clinics or to health care workers via technology. Telehealth appointments have become more popular with patients and physicians. The challenge with these appointments is finding the proper software or methodology to ensure security and privacy. They seek treatment for their ailments and are willing to pay the cost for treatments that will help. In my experience, podiatrists offer treatments for plantar fasciitis to patients according to evidence and insurance companies have little influence on, or burden towards, practice.

Heel pain is a common problem that brings patients to podiatry clinics, with the most common diagnosis being plantar fasciitis.¹ Risk factors for plantar fasciitis are varied and include weight gain, occupation-related activity, anatomical variations, poor biomechanics, overexertion, and inadequate footwear.² These factors emerged as even more important as of late due to the changes that associated with COVID-19. Throughout the lockdown in Canada, and very possibly in several other countries, people have gained weight during the recent quarantines. A survey of Canadians by Dalhousie University showed that 42 percent of Canadians gained weight during the pandemic.³ This weight gain puts more stress on the plantar fascia can lead to pain in the feet, especially in the heels.

The pandemic also necessitated many people working from home, utilizing technology. This allowed us to stay distanced and safe. However, working from home may lead to more time out of supportive shoe gear or orthotics. Another factor that can cause heel pain in the home is hard surfaces.⁴ Current home trends in our country involve replacing carpet with hardwood, tile, or linoleum. Hard flooring surfaces such as these can increase the stress on the feet and the plantar fascia. Increased time while working from home on these surfaces equals increased stress on the feet.

The pandemic has placed a lot of stress on the feet of health care workers and patients alike in Canada. Enhancing both podiatrists’ and patients’ understanding of the factors involved in addressing heel pain and plantar fasciitis will help prevent further cases and result in healthier feet in Canada.

The Impact Of COVID-19 On Primary Care Services In The United Kingdom

By Benn Boshell, BSc (Hons), MSc

Primary care services provide the first point of contact in the health care system, acting as the ‘front door’ of the National Health Service (NHS), a free service provided within the UK. Like most health care services around the world, the COVID-19 pandemic has had a significant impact on the day-to-day function of primary care services within the NHS. Initially, we saw a temporary discontinuation of several services provided by general practitioners (GPs), such as non-urgent musculoskeletal pain. This was the case until the development of adaptive triage processes to help general practitioners manage their caseload demand and ensure appropriate prioritization of the most serious conditions. The temporary discontinuation of course led to an inevitable backlog for conditions considered less serious, such as heel pain, where wait times are now longer than usual to have a consultation with a general practitioner.

Fast forward a year-and-a-half from March 2020, when the UK first went into a national lockdown. What we now see is that typically, patients with heel pain first receive a telephone consultation with either their general practitioner, practice nurse or first contact practitioner (FCP) to discuss their symptoms. It is well established that the most common cause of heel pain is plantar fasciitis.⁵ Therefore, the frequency of this diagnosis is no surprise. Subsequently these patients receive routine basic advice such as rest, ice, compression and elevation (RICE), stretching exercises, pain medication, and footwear advice. Unfortunately, this sometimes leads to misdiagnosis, as there are many other causes of heel pain that mimic the symptom pattern of plantar fasciitis, such as Baxter’s nerve entrapment, plantar fat pad syndrome and plantar fascia rupture, to name a few. Over the past year I have seen many examples of misdiagnosis due to the changes made within primary care services, where a key part of the consultation process, the physical examination, has been sacrificed to maintain social distancing as much as possible. In my observation, this has also led to inappropriate treatment recommendations, delays in recovery and poor patient outcomes.

With COVID-19 likely to be around for the foreseeable future, it is likely we will see a continuance of initial general practitioner telephone consultations offered to podiatry patients. Although this is far from gold standard service, the NHS has been severely stretched by the impact of COVID-19. On the other hand, this is a great opportunity for podiatrists in private practice to step up and let the public know about our expertise and how we can help. Podiatrists in private practice offer rapid access to a specialist where patients can receive a face-to-face consultation, and in my opinion are more likely to receive a correct diagnosis, appropriate treatment and achieve better outcomes.

Gaps And Opportunities In The Treatment Of Heel Pain In India

By Sanjay Sharma, MS, DPM, FDFM

A person with heel pain usually visits a primary physician or an orthopaedic surgeon in India and the Indian subcontinent due to the absence of a podiatry department and podiatrists in general in most hospitals. In my observation, across my 10 years of podiatry practice, heel pain is a common condition, rarely believed to be a symptom of severe disease, even though heel pain can relate to arthritis and other bone, joint and neurological conditions.

Before patients present to the clinic or hospital, they would have often tried various home remedies or over-the-counter medications, including, but not limited to, medicated oil application, massages, fomentation (applying hot, cold, moist substances) to relieve pain, and over-the-counter analgesics. Then, they start seeking medical care only when they have excruciating pain, or when nagging pain hampers routine activity. The most common diagnosis given to patients with heel pain by the primary physician, possibly after an X-ray, is Achilles tendinitis, calcaneal spur or plantar fasciitis. However, in my experience, other conditions causing heel pain, like bursitis, heel pad atrophy, Haglund’s deformity, tendinitis, tarsal tunnel syndrome, nerve entrapment, etc., are also present and rarely diagnosed. In my observation, these can be attributed to a lack of clinical knowledge amongst general physicians about various podiatric conditions and the traditional neglect of the foot and ankle conditions amongst the population.

A prospective study conducted in one of the leading medical institutes in India performed X-ray imaging for 200 subjects who came to the outpatient department with heel pain. Of these subjects, 118 (59 percent) had calcaneal spurs, with an increased preponderance towards females. The most affected age group was between 40 and 50 years.⁶

The most common approach that I see primary physicians take for a person with heel pain is the aforementioned X-Ray to rule out a spur. Depending on the clinical diagnosis, they may advise physical therapy and prescribe analgesics. Finally, surgical intervention (like spur excision or plantar fascial release) or corticosteroid injections, may become an option when the patient visits an orthopaedic surgeon. Unfortunately, plantar pressure scans are still a rarity in India. For a population of 1.3 billion, we may have about 200 plantar pressure scanners, limited to a few metropolitan cities, and the custom orthosis market is also in nascent stages. Moreover, most of the population favors sandals and flip-flops over a shoe, and walks barefooted indoors. Thus, in my observation, primary physicians or orthopedists rarely consider biomechanics and biokinetics as an etiology of heel pain.

The cost of non-surgical treatment for heel pain in India ranges from $3 to $68 per episode of pain, and the cost of surgical treatment ranges from $350 to$5500.⁷ At FootSecure, the first and the only podiatry clinical chain in India, of the 20 or so patients we see daily, at least five complain of chronic or acute heel pain. These people undergo a comprehensive foot and ankle clinical examination, plantar pressure scans, X-ray and whereever necessary, assessment of vascular status of the lower limbs and bone density, neuropathy screening, ultrasound and magnetic resonance imaging (MRI) to get an accurate diagnosis. Then, we offer conservative, pedorthic, surgical and rehabilitation treatment options as the case demands.

The need of the hour in our country is to create awareness about various foot and ankle conditions, including heel pain, and create the necessary infrastructure to provide preventive, curative and rehabilitative treatment.

A Closer Look At Heel Pain And Foot Care In Japan

By Koji Kawamata, BSc Podiatry

Heel pain is an important podiatric topic in Japan, as Japanese people have interest in heel pain and treatment due to the ineffectiveness of traditional and historical treatments. Heel pain in my practice can include or be due to plantar fasciitis, Achilles tendinopathy, abductor hallucis injury, posterior tibial tendon dysfunction, abductor digiti minimi injury, cuboid syndrome, a tight quadratus plantae, gastrocnemius or soleus, contusion of the calcaneus, thin fat pads, etc.

Japan is a very developed country with generally a high-level standard for medical care. However, regarding podiatric medicine, this same standard does not exist, as the lack of podiatry schools means a lack of foot specialists in our country. If people have heel pain, they go to the hospital or clinic to see an orthopedic specialist. Normally, in my observation, most of orthopedists take X-rays and give poultices (cold or hot patches) or non-steroidal anti-inflammatory drugs. Some use shockwave therapy. Some patients see a non-licensed practitioner or osteopath (not considered a medical doctor license in Japan) who may use taping or publicly available insoles on the market. In my experience, podiatrists are the experts in accurate diagnosis and of foot pain, biomechanical assessment, and the importance of proper shoes. This is especially challenging to communicate, however, when most Japanese doctors still do not know about the podiatry profession.

One Japanese medical issue is some doctors may claim to be a foot specialist, even if this is not so. They designate themselves as a foot clinic or hospital, and in my observation this happens even at some universities with no podiatrists or podiatry professors. This problem would not occur overseas. In Japan, the authority of doctors is very strong and in my experience, government offices do not hold that same level of authority. Since more Japanese patients are paying attention to heel pain, in my opinion, these self-proclaimed specialists use the field of podiatry and insoles as business tool. There appears to be no understanding of orthotics versus insoles and of biomechanical control. Thinking that flat arches cause all heel pain, they recommend a foot sole plate (insole) to the patient. This foot sole plate is made by a prosthetist in their clinic or hospital without a podiatrist’s prescription. Some doctors know that these insoles do not work, as the technique is outdated. Patients can use national health insurance for them, only paying 10 to 30 percent of the cost of the insole, even so, it is considered expensive.

These current techniques are not effective for patients with heel pain, and it is my hope that trained podiatrists will grow in numbers in Japan, sharing our expertise and knowledge with the entire medical community and patient population.

Analyzing The Heel Pain Treatment Habits Of Australian Podiatrists

By Steven R. Edwards, MSc(Oxon), MSc(Edinb), BSc Pod

In my experience, plantar heel pain is the most common foot and ankle condition presenting to Australian podiatric practice and it presumably affects our patients in a similar manner to those in the United States. This being said, the treatment habits of Australian and US podiatrists probably have subtle differences due to differences in training, access to medicines, and other multi-factorial elements. In the US, 10 percent of the population experiences plantar heel pain at any one time, resulting in 1,000,000 visits per year to podiatric and medical professionals for treatment.⁸ The annual cost of these visits is between 192 and 376 million US dollars.⁹ The statistics in Australia are similar, with plantar heel pain affecting four to seven percent of the community.^10-13

Plantar heel pain has associations with reduced quality of life, social isolation, reduced functional capacities and decreased perception of a person’s health status. It accounts for up to eight percent of all running injuries and usually affects sedentary, middle-aged or older adults. The classical presentation is post-static dyskinesia and pain during ambulatory tasks, particularly after periods of inactivity.¹⁴ The etiology of plantar heel pain is often multifactorial, and thought to be an overuse injury due to repetitive strain of the plantar fascia. Predisposing factors include pes planus and cavus foot postures, limited ankle joint dorsiflexion, and others. Among all cases, 85 percent do not have a known systemic risk factor.^14-17

I personally submitted a survey (not yet published) online to 2,672 Australian podiatrists with 25 options for their preferred treatments for plantar heel pain (see figure above). Respondents could select more than one option. One may notice a trend towards physical-therapy style treatments as the most preferred (259 and 250 votes for taping and stretching/strengthening, respectively). Traditional custom orthoses came in third, with 197 votes, followed by extra-corporeal shockwave therapy, which has gained popularity in Australian podiatric practices over the last 10 years.

Pre-fabricated (non-prescription) orthoses came in fifth (72 votes). Hypothetically, if we stratified the data by clinician age and experience, I would estimate that these votes would mostly come from podiatrists within their first five years of practice, as in my observation, universities in Australia recommend them over custom devices. Betamethasone sodium acetate was the most popular injectable corticosteroid (seven votes). Podiatrists could also leave comments on treatments not included in the survey, with compression stockings and musculoskeletal trigger point therapy being other popular treatment choices. One should note the lack of votes for surgical options, likely due to the small number of podiatric surgeons who completed this survey.

Access to prescription medicines for Australian podiatrists is still in its infancy. In order to write prescriptions and administer drugs like corticosteroids, podiatrists must undertake a rigorous post-graduate internship. At the time of this publication, less than three percent of Australian podiatrists have completed this qualification.¹⁸ It is my hope that this will change considerably over the next decade.

It would be interesting to perform this survey every five years, as I am sure the results would change considerably, especially considering the increasing number of podiatrists gaining access to prescription medications. I await with interest the opportunity to learn more about the habits of other countries regarding their treatment of plantar heel pain.

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3. Cross B. Canadians put on pounds during the pandemic. Available at: https://www.producer. com/farmliving/canadians-put-on-pounds-during-pandemic . Published May 13, 2021. Accessed September 14, 2021.

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6. Lourdes RK, Ram GG. Incidence of calcaneal spur in Indian population with heel pain. Int J Res Orthop. 2016;2(3). Available at: http:// dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20163126. Accessed September 23, 2021. Accessed October 5, 2021.

7. Verma S. Heel pain: treatment, procedure, cost and side effects. Lybrate. Available at: https:// www.lybrate.com/topic/heel-pain. Accessed September 23, 2021.

8. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25(5):303-310.

9. Tong KB, Furia J. Economic burden of plantar fasciitis treatment in the United States. Am J Orthop (Belle Mead NJ). 2010;39(5):227-231.

10. Dunn JE, Link CL, Felson DT, et al. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol. 2004;159:491–498.

11. Hill CL, Gill TK, Menz HB, et al. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res. 2008;1(1):2.

12. Menz HB, Tiedemann A, Kwan MMS, et al. Foot pain in community-dwelling older people: an evaluation of the Manchester foot pain and disability index. Rheumatol. 2006;45:863– 867.

13. Thomas MJ, Whittle R, Menz HB, et al. Plantar heel pain in middle-aged and older adults: population prevalence, associations with health status and lifestyle factors, and frequency of healthcare use. BMC Musculoskelet Disord. 2019;20:337.

14. Morrissey D, Cotchett M, J’Bari AS, et al. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. Br J Sports Med. 2021;55(19):1106-1118.

15. Martin RL, Davenport TE, Reischl SF, et al. Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014;44:A1–33.

16. Finkenstaedt T, Siriwanarangsun P, Statum S, et al. The calcaneal crescent in patients with and without plantar fasciitis: an ankle MRI study. AJR Am J Roentgenol. 2018;211(5):1075-1082.

17. Arnold MJ, Moody AL. Common running injuries: evaluation and management. Am Fam Phys. 2018;97(8):510-516.

18. Statistics. Podiatry Board Ahpra Website. Available at: https://www.podiatryboard.gov.au/ About/

Dr. Woodruff is board-certified by the American Board of Podiatric Medicine, American Board of Wound Management and by the American Board of Multiple Specialties in Podiatry. He is currently in private practice in Red Deer, Alberta, Canada working at Central Alberta Podiatry.

Mr. Boshell works as a podiatrist in private practice. He has a specialist interest in heel pain and is clinical director of The Heel Pain Expert in the United Kingdom. He is also the author of The Plantar Fasciitis Bible and host of The Heel Pain Expert podcast.

Dr. Sharma is the Vice President of the Telemedicine Society of India, Karnataka Chapter, and Secretary of the Indian Podiatry Association, Karnataka Chapter. He is in practice with and Founder of FootSecure in Bangalore, India and Co-Founder of Yostra Labs.

Dr. Kawamata previously practiced in Australia as a primary and sports podiatrist before returning to Japan to introduce podiatry to the community there. He is in practice with and the owner of Tokyo Podiatry Clinic in Tokyo.

Dr. Edwards holds Master’s degrees in podiatric medicine and evidence-based health care and is an Adjunct Lecturer of podiatric medicine and pharmacology at the La Trobe University podiatry school in Bundoora, Australia. He is currently undergoing podiatric surgical training in Melbourne, Australia and primarily practices at Brighton Specialist Centre in Brighton, Australia.