Heel Pain Study Colloquy

The Heel Pain Study undertaken by the American Orthopaedic Foot and Ankle Society has aroused much debate since it was launched more than two years ago. What many called the first-ever study of orthotic efficacy was first reported by BioMechanics in 1994 when the project was first being organized. Earlier this year, the study's conclusions were distributed in a press release and widely publicized by dozens of TV, radio, and newspaper outlets (the study had actually been promoted to the consumer press at various earlier points). While the media fell prone to sweeping generalities and overstatement, many in the biomechanics mainstream found themselves lining up against or in favor of both the study and/or the publicity surrounding the study. Ironically, while many are talking about the study, few have seen any hard data. The nine-page study, a draft of which was obtained by BioMechanics, will be published in a clinical journal sometime in the future.

Because the consumer media have presented the Heel Pain Study as a black and white matter, BioMechanics wanted to present the diversity of views on the topic. Many of the commenting practitioners were themselves involved in the study, or enjoy an acknowledged expertise in foot orthoses.

Glenn B. Pfeffer, MD
San Francisco, California

The American Orthopaedic Foot and Ankle Society's Heel Pain Study is the largest prospective randomized study on the treatment of plantar heel pain (plantar fasciitis) ever conducted. Fifteen orthopedic foot and ankle centers throughout the U.S. participated. All patients had isolated pain directly over the medial calcaneal tuberosity where the plantar fascia inserts onto the calcaneus. None of the patients had evidence of systemic disease or had undergone previous treatment. The results of the study speak for themselves, demonstrating that plantar heel pain is best treated initially with a program of Achilles tendon and plantar fascia stretching and the use of an inexpensive off-the-shelf shoe insert. A program of stretching only was equal in effectiveness to a program of stretching and the addition of an expensive custom-made orthotic device.

Because it is not possible to test every type of insert on the market, our Heel Pain Study Group chose those off-the-shelf inserts we considered the most commonly used in medical practice. We applied similar reasoning to the choice of the custom-made polypropylene orthotic device. To obtain the highest possible quality and constant standardization for the custom-made polypropylene insert, only one orthotic lab was used. We worked with ProLab in San Francisco, one of the premiere orthotic labs in the country, directed by Paul Scherer, DPM. Dr. Scherer is a professor of biomechanics at the California College of Podiatric Medicine, and one of the most respected podiatrists in the U.S. for his work on the use of orthotic devices.

Given the changes in healthcare delivery, it is especially important to provide high-quality and yet cost-effective medical care. Our study demonstrates that if we avoid the use of a costly custom orthotic device for the initial treatment of plantar heel pain, we can better serve our patients while saving more than $200 million annually.

Glenn B. Pfeffer, MD, is Chairman, Heel Pain Study Group, American Orthopaedic Foot and Ankle Society.

Carol Frey, MD
Los Angeles, California

The AOFAS heel pain study is a large prospective, randomized study which draws significant and clear conclusions that for the initial treatment of heel pain, the OTCs outperformed the custom-made device. Furthermore, I feel strongly that the biomechanical problems which can lead to heel pain are best addressed initially by a good stretching program-not an expensive custom-made orthotic device.

Carol Frey, MD, sits on the AOFAS Shoewear and Orthoses Committee.