02/17/2025
Psychological Effects of Plantar Heel Pain
The most frequent patient complaint currently seen in my clinic is plantar heel pain (PHP). Many podiatrists that I communicate with regularly also state that PHP is the most common diagnosis seen in their clinics. When treating patients with PHP, or for that matter, any pathology of the foot and lower extremity, we are trained as podiatrists to take a good history of the patient’s complaint. We might ask when the pain began, where the pain is located, if the pain has gotten better or worse over time, what has been the treatment for the condition in the past, and what current treatments are still being given. It is also important to ask how the pain is affecting their daily lives, including their work and their recreational activities.
We are also trained as podiatrists to pay attention to objective details in the treatment of PHP, and other foot and lower extremity pathologies. We examine the foot and lower extremity, palpate the tissues to find the points of maximum tenderness, do range of motion and muscle strength testing, watch patients function during gait, examine their shoes and review any diagnostic and imaging tests that may be available. In most of the conditions that we treat on a daily basis, there are generally some objective findings that explain the complaints that a patient reports. Unfortunately, for the very common condition of PHP, there may be very few, if any, objective findings as to the cause or severity of the PHP other than the patient’s subjective complaints of the pain and our palpation of the plantar heel eliciting a subjective complaint of pain.
Most podiatrists and other health-care providers rank the objective examination of the patient as being of more importance than the subjective part of the clinical examination. Obviously, when I can see something with my own eyes by looking at the patient’s foot and lower extremity, can feel an abnormality in the patient’s foot with my hands during manual examination, or can view the results from some clinical test or imaging study of a patient which demonstrates an abnormality in the location of the patient’s pain, I feel much more comfortable with my diagnosis than just listening to a patient’s subjective complaints, with no objective findings that explain the patient’s pain. However, in many cases of PHP, the subjective complaints are far more significant than the objective findings. As a result of this relative lack of objective findings in many patients with PHP, the podiatrist may tend to discount the subjective complaints of the patient as being less significant than the objective findings seen on examination and/or imaging of the patient’s foot.
Thankfully, possibly due to the relative high incidence of PHP and the commonly-noted disparity between subjective complaints and objective findings in patients with PHP, a number of researchers have recently started to focus on the psychological effects of PHP. Using psychological research techniques that have been validated for decades, researchers have now been able to better appreciate the significant toll that PHP can have on the lives of our patients, even though we may be hard-pressed to find any objective etiology for their PHP. These research studies are an important first step to allow us to better understand not only the physical limitations caused by PHP, but also the psychological effects that PHP may have on our patients.
In 2015, Matthew Cotchett and colleagues from LaTrobe University in Melbourne Australia were the first researchers to study the psychological effects of PHP. In their research, 84 subjects that had PHP for at least one month and had significant first-step pain in the morning were studied. The researchers found that, after accounting for age, s*x and BMI, symptoms of stress and depression were significantly associated with self-reported foot function, but not significantly associated with foot pain, in PHP subjects. Female subjects with PHP were also noted to have a higher correlation between foot pain and function and depression and stress than their male counterparts (Cotchett MP, Whittaker G, Erbas B. Psychological variables associated with foot function and foot pain in patients with PHP. Clinical Rheumatology. 2015 May;34(5):957-964).
In 2016, Cotchett and coworkers again studied the psychological effects of PHP. In this study, 45 subjects with PHP were matched by s*x and age to 45 subjects without PHP. Researchers measured the levels of depression, anxiety, and stress using the Depression, Anxiety and Stress Scale. Analysis of the two groups showed that subjects with PHP had greater levels of depression, anxiety, and stress than those subjects without PHP. After controlling for age, s*x, BMI, and years of education, symptoms of depression, anxiety, and stress were significantly higher in the subjects with PHP when compared to the subjects without PHP (Cotchett M, Munteanu SE, Landorf KB. Depression, anxiety, and stress in people with and without PHP. Foot & ankle international, 37(8):816-821, 2016).
In another study by Cotchett and colleagues, the psychological factors of “pain catastrophizing” and “kinesiophobia” were studied in 36 subjects with PHP. Pain catastrophizing is the tendency to describe a pain experience in more exaggerated terms than the average person, while kinesiophobia is the fear of pain due to movement. After controlling for age, s*x and BMI, it was found that kinesiophobia and pain catastrophizing were associated with foot function, and pain catastrophizing was associated with first step pain in people with PHP. These results led the researchers to recommend increased clinical awareness of these psychological factors (Cotchett M, Lennecke A, Medica VG, Whittaker GA, Bonanno DR. The association between pain catastrophizing and kinesiophobia with pain and function in people with PHP. The Foot, 1;32:8-14, 2018).
Finally, in a recently published mixed methods systematic review article by Cotchett and coworkers, 18 studies were analyzed regarding the psychosocial effects of foot and ankle pain. A synthesis of the data revealed that negative emotional and cognitive factors were more common in people with foot/ankle pain compared to those without foot/ankle pain. A significant association was also found between emotional distress with foot pain and foot function in people with PHP. In addition, kinesiophobia and pain catastrophizing were significantly associated with impaired foot function, and pain catastrophizing was significantly associated with first step pain in people with PHP. The data revealed emotional impacts, physical challenges, and a loss of self which seemed to be dependent on the individual and was not predictable (Cotchett M, Frescos N, Whittaker GA, Bonanno DR. Psychological factors associated with foot and ankle pain: a mixed methods systematic review. Journal of foot and ankle research. 2022 Dec;15(1):1-24).
Overall, these studies emphasize the fact that our patients with PHP, and foot and ankle pain in general, may have significant psychological distress due to their inability to perform their daily activities, and work activities, without pain and disability. Even though there may be few specific objective factors explaining why our patients have PHP, this should not decrease our respect for the subjective complaints and negative psychological effects that many of these patients have as a result of their painful plantar heels. Showing genuine concern not only about the physical needs of your patients, but also about the emotional health of your patients, are important factors which will improve your patients’ perception that you are a caring and empathetic podiatrist who is truly concerned about their well-being.
[Reprinted with permission from: Kirby KA: Precision Intricast Newsletter, Precision Intricast, Inc., Payson, AZ, November 2022.]
