Rationales and treatment approaches underpinning the use of acupuncture and related techniques for plantar heel pain: a critical interpretive synthesis

Heel pain (also known as plantar fasciitis or heel spur) is a very common problem that affects people around the world. This condition causes intense pain in the underside of the foot, especially in the morning or after periods of rest, and can become chronic, generating substantial impact on quality of life and significant costs to the health care system. Although several conventional treatments are available — such as stretching, orthotic insoles, anti-inflammatory medications, and corticosteroid injections — results are often limited, treatment adherence is low, and some procedures carry important risks for patients.

In this context, acupuncture has emerged as a promising alternative for the treatment of heel pain. However, an important challenge for researchers and clinicians is that acupuncture is not a single, standardized treatment but rather a diverse field of practices encompassing different theoretical approaches, application techniques, and treatment philosophies. Some acupuncturists base their practice on Traditional Chinese Medicine, others on modern neurophysiology, and many combine different explanatory models in their clinical work.

The primary aim of this study was to explore and understand the diversity of approaches and theoretical rationales used by acupuncturists when treating heel pain. Researchers from the University of Birmingham conducted a comprehensive analysis of the available scientific literature using a methodology called "critical interpretive synthesis." Unlike a traditional systematic review, which focuses on treatment efficacy, this approach allowed the authors to examine a broader range of scientific sources, including controlled studies, case series, and individual case reports, in order to identify patterns and develop a deeper understanding of how practitioners apply acupuncture in real-world practice.

The investigators analyzed 25 scientific publications reporting clinical experiences with acupuncture for heel pain, spanning three decades and four continents. The analysis revealed striking diversity in nearly every aspect of treatment. The prior duration of symptoms in patients ranged from 10 days to 30 years, and the studies included both acute and chronic cases. Practitioners conceptualized the problem in distinct ways: some diagnosed it as plantar fasciitis based on Western medical criteria, others applied Traditional Chinese Medicine diagnoses such as "Bi syndrome" or "kidney Qi deficiency," and some simply treated the pain without applying specific diagnostic labels.

As for treatment techniques, the findings showed that there is no dominant or universally accepted approach. Some practitioners used standardized protocols, applying the same acupuncture points to all patients, while others adopted fully individualized strategies based on case-specific assessment. Techniques ranged from traditional manual acupuncture to electroacupuncture, laser acupuncture, and other modalities. Interestingly, the researchers identified some apparent contradictions: while some practitioners applied heat (moxibustion) because they considered the problem to be "cold" according to Chinese medicine, others recommended ice because they interpreted the condition as inflammatory according to biomedical concepts.

The theoretical rationales used by practitioners also showed great variety. The authors identified four main categories of justification: traditional East Asian medicine (including meridian theory and specific point functions), modern pathophysiological explanations (such as myofascial trigger point theory and neurophysiology), empirical approaches based on the prior experience of other practitioners, and pragmatic considerations such as patient safety and comfort. Most practitioners did not follow a single model but combined different types of reasoning in their practice, demonstrating a more eclectic and flexible approach than traditionally imagined.

For patients, these results offer encouraging and important perspectives. First, the diversity of approaches suggests that there is flexibility to personalize treatment according to the specific characteristics of each case, including duration of symptoms, presence of specific tender points, and other individual particularities. Second, the finding that prior duration of symptoms may significantly influence treatment outcomes provides valuable information for setting realistic expectations: more recent cases tend to respond better to treatment. For practitioners, the study highlights the importance of considering multiple factors in clinical decision-making and suggests that there may be subgroups of patients who would benefit from specific treatment strategies.

The study also identified several important limitations to consider when interpreting the results. The analysis was based exclusively on written publications, which represents only a small portion of the existing knowledge in the acupuncture field, since much of practitioners' clinical wisdom is not formally documented. In addition, some relevant Chinese publications could not be obtained, and the focus on one specific clinical problem (heel pain) may limit the generalization of the findings to other conditions. The authors themselves acknowledge that their interpretations were influenced by their professional identities and experiences, and that a different team might have arrived at distinct insights.

The main conceptual contribution of this work was the development of what the authors called the "patchwork" model to understand how knowledge is constructed and applied in acupuncture practice. This metaphor suggests that practitioners create their clinical knowledge by combining different "pieces" or aspects — including theory, experience, patient context, practical considerations, and cultural influences — in a creative and iterative manner, similar to the process of creating a patchwork quilt. This model offers a new perspective for understanding the complexity inherent in acupuncture practice and may serve as a basis for future research and the development of more effective and individualized clinical protocols.