Case Study 8th Feb – Arch Pain

A 67-year-old male presented with arch pain and heel pain in his left foot left. He reported that the pain came on suddenly and has been present for over 2 months. He is retired, however he is a physically active person who plays golf 3 times a week, and also enjoys running and going to the gym where he regularly does bench presses and squats. He informs the podiatrist that he thinks he has Plantar Fasciitis.

He had tried a few remedies at home to relieve his heel pain, these included a few stretches that were incorrect, and were further aggravating his arch pain. He also performed some gentle passive stretches in the mornings, which were of no harm, and were quite beneficial to his heel pain.

He had also performed an ultrasound, which confirmed he had Plantar Fasciitis of the left foot.

He had firm orthotics which he used previously for different reasons, however he found them to be too firm and uncomfortable to wear with his newly developed heel pain. Furthermore, upon examination of the orthotics, it became apparent that they did not have adequate cushioning on top of the orthotics, or a plantar fascial groove, which is a ridge designed inside the orthotic to accommodate for the plantar fascia and unload it, allowing recovery to take place.

However, it was explained that once the inflammation of the plantar fascia is taken down and there is no more heel pain, he may be able to tolerate his old orthotics. Hence new orthotics were not prescribed for him at this stage.
It was explained to him that extra cushioning on top of the orthotics along with a plantar fascial groove can greatly help in reducing his heel pain, as well as correcting any biomechanical misalignments, and relieving the Arch Pain.

His footwear was also assessed. He commonly wore 3 sneakers, one of which was the best suited for his foot type. He was asked to wear the desired sneakers which provided maximum support to his feet and will hence help to
reduce his arch pain.

Arch Pain Examination

Upon physical examination, the left heel was very sore on the squeeze test, where the origin of the plantar fascia from the base of the heel was firmly palpated along with the body of the Plantar Fascia to its insertion at the base of the toes. The area closest to the inside of the heel elicited the most pain on palpation. There was also arch pain on palpation, but no swelling, redness or warmth was noted.

The patient was asked to perform a single leg heel raise on his right foot which he achieved without a problem. However, when asked to perform the same test on his left foot he underperformed and was limited by pain. This test adds stress to the Plantar Fascia and is a good indicator of Plantar Fasciitis. Most patient’s with Plantar Fasciitis at the base of the heel can perform the test, if there are not tears and the condition is not acute, but patient’s with Plantar Fasciitis that involves irritation through the arch of the foot too will struggle, and will report Arch Pain during the lift.

The cause of the heel pain was explained to the patient. The plantar fascia was being overly stretched away from its insertion to the heel bone, causing it to become inflamed. The patient had Plantar Fasciitis of the medial slip. The strain was sufficient to cause inflammation and irritation through the mid fibres of the Plantar Fascia also. This is not as common as the inflammation at the base of the heel.

Biomechanical Assessment for Arch Pain

A thorough biomechanical assessment was conducted to understand the causes and/or contributing factors of his heel and arch pain.
On gait analysis, he reported pain every time his heel hit the ground, and mild pronation at the subtalar joints was noted. There was early heel lift with both feet affected, and this is usually due to shortening of the calf muscles.

He had very tight gastroc muscles, which further increases the pull going through the plantar fascia, contributing to the pain. The correct way to stretch the calf muscles, without stretching the plantar fascia was demonstrated to the patient.

Furthermore, his arches were measured in a relaxed stance position and it was noted that they were higher than average. It was explained to him how his high arches were also contributing to the arch pain he gets, and ways this can be accommodated for.

Heel and Arch Pain Treatment

An immobilisation boot was placed on the left foot. The patient was asked to walk a short distance, and reported no to very minimal pain inside the boot.

He kept the boot on for a period of 4 weeks, and his heel pain was re-examined. Upon palpation of plantar fascia, he reported mild pain, but this was much less painful than the initial heel pain examination. He was asked to remove the boot after 4 weeks and monitor his progress.

The heel was also treated with 5 sessions of shockwave therapy at weekly intervals.

He reported further improvement after each treatment with shockwave therapy. After the 5th session a big improvement was noticed by the patient, and he reported that there was minimal pain when his heel hit the ground in the mornings. The lack of morning pain in the heel is always a good sign and it indicates that the inflammation is settling down. Physical examinations of this patient’s left foot also revealed that it was time to cease treatment. There was minimal heel pain and very mild Arch Pain on palpation of both areas.

He was advised to keep stretching and following the advice that was initially given at the start of the treatment, to prevent heel pain in the future. Furthermore, he was asked to contact the clinic if his condition returned.

Please note: The information in this case study is specific to one particular patient and should not be taken as general advice. There are several causes of Plantar Fasciitis and if you are having foot problems you should consult with a Podiatrist or suitable healthcare practitioner.