How does our psychological health play into pain, especially heel pain

The image shows a graph which illustrates the associations between pain catastrophizing, body mass index (BMI), and depressive symptoms with pain severity in tertiary referral orthopedic foot and ankle patients. The graph shows that as the level of pain catastrophizing, BMI, and depressive symptoms increases, the severity of pain also increases. This suggests that these factors play a significant role in the experience of pain in these patients and highlights the importance of considering psychological and emotional factors in the management of foot and ankle pain

­­Pain catastrophising, body mass index and depressive symptoms are associated with pain severity in tertiary referral orthopaedic foot/ankle patients


Matthew Holt1,2, Caitlin L. Swalwell1,3, Gayle H. Silveira4, Vivienne Tippett3, Tom P. Walsh1,3* and Simon R. Platt1,2


These studies are important. It is recognised in other fields and professions that there are psychosocial influences for pain development and management. It is most notable in research of back pain.


Patients with chronic foot and ankle pain are often referred for orthopaedic assessment. Psychological vulnerabilities influence pain states (including foot and ankle), therefore this study aimed to establish the prevalence and relative importance of compromised psychological health to perceived foot and ankle pain severity in people referred to an orthopaedic foot and ankle clinic with non-urgent presentations.


People with persistent pain often show symptoms unrelated to physical mechanical pathology. Foot and ankle pain has been associated with fat and body mass index, increased age, female gender and a range of psychosocial factors including depression and anxiety as well as reduced health-related quality of life (HRQoL).


The challenge for health professionals is addressing these.

Do we have the scope?

Can we really change them?

How do we make it patient centred?

How do you know if what we are saying and talking about is helpful?


Based on my interactions with other healthcare professionals, it appears that managing pain can be a significant obstacle that is hard to overcome. Though not everyone shares this sentiment, there seems to be a lack of education and implementation in the field. Despite the challenges, I believe that addressing pain with patients is crucial as it can improve treatment outcomes when combined with other therapies.

As for my own education, I was taught in a very mechanical way and was not aware of the other factors that contribute to pain. I used to think that BMI only affected the load on the heel, not the level of low-grade inflammation that can affect the pain experience and recovery. However, I have come to realize that the psychosocial elements of a patient's pain presentation can be a significant predictor of the pain experience and can negatively impact the likelihood of functional recovery. One recent study suggested that pre-operative depressive symptoms are associated with worse post-operative pain following total ankle arthroplasty and patients with end-stage ankle arthrosis demonstrate significantly worse mental component


Methods & Study population

Patients referred to a tertiary referral hospitals’ Department of Orthopaedics at Gold Coast University Hospital from May 2019 through April 2020 were invited to participate in this cross-sectional study. Upon receipt of referral, the foot and ankle orthopaedic consultants triage patients as Category 1 (urgent), Category 2 (semi-urgent) and Category 3 (non-urgent) which is the standard of practice for specialist hospital referrals in the Australian public health system. Category 1 and 2 is applied to patients triaged as having a condition which may deteriorate if not reviewed in an urgent (i.e. next available or within 30 days) or semi urgent (i.e. within 90 days) manner, respectively. Category 3 is applied to referrals for conditions considered not life or limb threatening and unlikely to deteriorate or have increased morbidity for which review in a specialist clinic/service is recommended within 365 days of being added to the waiting- list.

Psychological health


Depressive symptoms were present in 83 (48.3%) of the participants completing the CES-D questionnaire and 66 (38.4%) participants returned scores ≥40 on the CSI, classifying them as having CSS. Foot and ankle symptoms had been present for a median of over two-years (28.5 months, IQR 46.3 months) prior to referral and bilateral foot pain was reported by 37.2% participants. Multi-site pain was present in 88 (51.2%) participants and 31 (18.8%) participants had no other joint pain throughout their body.

An interesting finding:

In the study group, the found high rates of pain catastrophizing, CSS, and depressive symptoms. The analysis showed that 40% of the variance in patients' foot and ankle pain can be explained before specialist evaluation and without a formal orthopedic diagnosis. Among the factors they studied, pain catastrophizing had the strongest association with foot and ankle pain severity. Catastrophizing is a set of negative thoughts and beliefs that exaggerate the threat of pain and the helplessness to cope with it.


So, what does this mean? It suggests that while orthomechanical treatments such as taping, orthotics, and footwear can be effective, there are many other factors that can influence the success of these treatments. Could this be a reason why we don’t see great and significant improvements consistently when we research these treatments? E-g, orthotics for heel pain.


We need to consider and address these factors to help our patients achieve better outcomes.