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A Delphi consensus paper on strengthening exercises for plantar heel pain

This is a paper I wrote in conjunction with my supervisory team. You can access the paper at the Journal of Foot and Ankle Research here: https://10.1186/s13047-023-00668-2 . The following is a brief summary and re-cap of that paper.

- Purpose: Develop a foot and ankle strengthening program for plantar heel pain (PHP).

- Method: Engaged a diverse range of experts using a Delphi consensus method over three rounds.

- Outcome: Created progressive strengthening programs for three patient types—young athletic adults, overweight middle-aged adults, and older adults.

- Significance: Provides clinicians with a guideline for prescribing effective strengthening exercises for PHP.

- Caution: We do not know the effectiveness of these exercises in the management of PHP or any other condition. However, if you are new to prescribing exercise it may provide you with a reference point to begin understanding how to use strengthening as part of clinical practice.


Understanding Plantar Heel Pain and Its Challenges

Plantar heel pain (PHP) is a common issue affecting many individuals, resulting in pain, reduced function, and sometimes significant psychological distress [REF]. While various treatments have been explored, muscle strengthening is emerging as a promising approach. However, there has been a lack of clear guidelines on what specific exercises should be included in a strengthening program for PHP.

The Delphi Consensus Study: Method and Process

To address this gap, we conducted a study using the Delphi method, a structured communication technique often used to achieve consensus among experts. Here's a brief overview of our process:

1.     Selection of Experts: We invited 38 experts from diverse fields (podiatry, physiotherapy, orthopedics, etc.), out of which 24 agreed to participate.


2. Three Rounds of Surveys:

- Round 1: Experts provided initial input on exercises and training variables.

- Round 2: They reviewed and rated these exercises and variables.

- Round 3: Final adjustments were made based on previous feedback to reach consensus.


Key Findings: Exercises and Training Variables

Through this process, we developed three tailored progressive strengthening programs for three distinct patient profiles, younger athletic adult, overweight middle-aged adult and older adult. There was not a huge variation in exercise selection across the different profiles. And there was some commonality in general exercise selection as shown in the graph below.


1. Younger Athletic Adult:

- Focused on exercises like heel raises, short foot exercises, and digital plantarflexion.

- Emphasized daily exercise routines with progressive load increases.


2. Overweight Middle-aged Adult:

- Included seated short foot exercises and toe spread outs.

- Recommended every second day routines to manage load and avoid overtraining.


3. Older Adult:

- Highlighted digital plantarflexion with bands and single leg standing.

- Suggested moderate intensity with progression from seated to standing exercises.


Practical Applications for Clinicians

These programs offer a starting point for clinicians managing PHP, providing a structured approach to strengthening the foot and ankle muscles. By following these or any strengthening program, you have an opportunity to:


- Address Muscle Weakness: Target specific muscles such as the foot intrinsics, calf, and flexor muscles.

- Improve Function: Increase tissue load capacity, enhance impact absorption, and reduce strain on the plantar fascia.

- Tailor to Patient Needs: Adjust exercises based on patient age, physical activity level, and specific symptoms.


Importantly, though, it is unclear by what mechanism strengthening exercises may have the biggest effect on foot and ankle pathology and pain. We know strengthening exercises make muscles stronger, but we do not know how they benefit a patient overall. We also don’t know if the specific programs provided in this paper will make a patient stronger or get them better.


Clinical Insights and Future Directions

While these programs are a valuable step forward, it is important to consider individual patient responses and adjust accordingly. Further clinical trials will be essential to validate the effectiveness of these programs and refine them based on real-world outcomes.

If we want to consider the mechanisms by which the exercises are working, we can consider whether these exercises make a patient stronger and, in turn, improve load tolerance and capacity or if they improve kinesiophobia and reduce fear of movement. These questions cannot be answered in this paper but are worth considering when considering the application of strengthening exercises for your patient.

For those of you on the front lines treating PHP, integrating these evidence-based exercises into your practice can potentially enhance patient outcomes. However, always stay open to evolving evidence and be prepared to adapt your approach as more research becomes available.

Future studies should consider what these exercises do and, even further, how effective they are. Stay tuned to see our work in the future.



This Delphi consensus study marks a significant advancement in developing a structured, expert-driven strengthening program for PHP. By leveraging the collective wisdom of specialists, we have laid the groundwork for more effective and standardised treatments. I encourage clinicians to apply these programs in practice and consider how they do or don't work with your patients. Whlie we in the background work on providing the evidence for how and why they work as well as their effectiveness.

For free access to the whole paper: https://10.1186/s13047-023-00668-2


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