Case Study April 2017 – PLantar Fasciitis Following Metatarsal Injury

A fit and healthy 42 year old lady presents with heel pain and arch pain of approximately 4 months. She describes symptoms consistent with Plantar Fasciitis which came on shortly after a metatarsal foot injury. This patient is a very keen martial arts practitioner and enjoys kick boxing and karate. She has no other medical ailments and has never had Plantar Fasciitis before, boasting good foot health. She takes no medications, although Voltaren has helped recently with the symptoms of Plantar Fasciitis.

This lady reports injuring her right foot during training back in December 2017. She kicked a punch bag with the top of her foot which resulted in an acute metatarsal injury. X ray was performed within a week of the incident and came back clear with no break or fracture. The foot swelled and was bruised and was sore for several weeks. During this time she was forced to walk on the outside edge of her right foot as she was unable to fully weight bear on this leg.

After approximately 4 weeks she started to feel heel pain, then arch pain along the Plantar Fascia but was unaware of the condition known as Plantar Fasciitis. She assumed the pain was referred pain from her original metatarsal injury. After 2 months, the metatarsal injury settled and the bruising and swelling subsided, but the Plantar Fasciitis persisted. The patient then realised that this heel pain was not related to the original metatarsal injury and so she sought help. The heel pain was extreme first thing in a morning and the arch pain was present all day.

NOTE: It is commonly found that patient’s with a variety of foot injuries, unrelated to Plantar Fasciitis, can develop the condition due to limping. The altered gait increases the load on the Plantar Fascia due to poor bio-mechanics, and also causes tightness in the calf muscles. This limited range of motion in the ankle / calf muscles is one of the main causes of Plantar Fasciitis.

PLANTAR FASCIITIS EXAMINATION

Mild pressure was applied to the medial band of the Plantar Fascia at the calcaneal attachment, which elicited a significant jump response from heel pain. Pressure was also applied to the central portion, again at the calcaneal attachment and the patient once again reported heel pain. Finger pressure along the mid fibres, running into the arch caused the patient to retract her foot as she confirmed extreme arch pain – all of this confirming an acute case of Plantar Fasciitis. There was no visible swelling and no bruising, and the patient informed the Podiatrist that she did not feel any throbbing whilst lying down or seated. Again, this would suggest that she had not torn her Plantar Fascia but that she was indeed suffering from an acute case of Plantar Fasciitis.

PLANTAR FASCIITIS ULTRA SOUND Vs X RAY

This lady was referred for an Ultra sound scan which is an excellent form of medical imaging for soft tissue injuries such as Plantar Fasciitis. The technique allows the Radiologist to assess the level of trauma and the amount of inflammation within the soft tissue. Unlike an x ray, which provides images of the ligament and bone – which can then allow one to observe anomalies such as heel spurs, the Ultra sound focuses on the soft tissue and can allow us to detect micro tears, laminar tears or deep surface tears within structures such as the Plantar Fascia. In cases of Plantar Fasciitis an Ultra sound should be the imaging of choice, as opposed to an X ray. It was confirmed that this patient did in fact have an acute case of Plantar Fasciitis in her right foot, but no tears were seen.

PLANTAR FASCIITIS TREATMENT

This patient was informed that her Plantar Fasciitis had been going on for too long and was unlikely to settle without professional intervention. She was advised that prescription orthotics made from carbon fibre, with sufficient padding, would control her foot function and reduce strain on the Plantar Fascia. She would need to use the orthotics in her shoes every day for approximately 2 months. With this additional support in her shoes, the Plantar Fascia would heal by itself without injections and without tablets or surgery.

Using a 3D digital foot scanner, the patient’s feet were captured and saved into Orthotech software. The orthotics would take 2 weeks to make and would incorporate a Plantar Fascial groove, to further reduce strain and assist the Plantar Fasciitis.

STRAPPING FOR PLANTAR FASCIITIS

As a temporary form of support it was decided to apply rigid sports tape to the patient’s foot. This would reduce strain on the Plantar Fascia until the orthotics were in place.

NOTE: In mild cases of Plantar Fasciitis, or very new cases with recent onset, applying strapping to the patient’s foot can provide sufficient support to allow complete healing. Orthotics are not always needed.

The strapping that was applied to this patient’s foot stayed in place for one week, and was then replaced by the Podiatrist. The patient reported some relief with the strapping in place, although her heel pain was still present overall.

THE APPLICATION OF COLD PACKS FOR PLANTAR FASCIITIS

Due to the inflammatory change within the Plantar Fascia it was decided that this patient must apply ice packs to her foot, to reduce the Plantar Fasciitis. The cold packs were to be applied every day at least once, especially in the evening for approximately 20-30 minutes. The ice packs help to reduce the inflammation and hence increase the rate of healing. They also reduce the heel pain that is present in the mornings as the foot is placed onto the ground.

2 WEEKS LATER

This lady came to the clinic and her orthotics were fitted into her day to day shoes. She had a seated job whereby her feet were not loaded, and hence there was no need to fit the orthotics into her office shoes. The orthotics were also fitted into her Asics sports shoes, the existing liner removed, and then checked on the treadmill. The orthotics fitted well into the desired shoes and were well tolerated. She was advised to ease into the orthotics and to remove them if she felt like she needed a break from them during the first week.

This patient was given very specific advice regarding shoes. Her foot type had been assessed and she was now equipped with the knowledge as to which shoes she should and shouldn’t wear, and which shoes would help her Plantar Fasciitis.

4 WEEKS LATER

This patient returned for a follow up and reported a 60% improvement in her condition. She had been compliant with the use of orthotics and her Plantar Fasciitis was improving. She was applying ice packs daily and was performing very specific calf stretches which the Podiatrist had instructed her on.

FINAL CHECK UP FOR PLANTAR FASCIITIS

A further  4 weeks on and the patient reported that her Plantar Fasciitis had gone. She felt mild “stiffness” in the mornings but no pain at all, and no pain at any other time. On palpation of the medial calcaneus, central calcaneus and mid fibres there was mild pain. Her Plantar Fasciitis had not completely subsided but had improved to the point where the patient was symptom free while weight bearing.

She was advised to continue with all treatments and was permitted by the Podiatrist to return to martial arts. Due to the martial arts being bare foot, she was advised to apply strapping during her training sessions and to pull back on training if her Plantar Fasciitis symptoms returned.

PLEASE NOTE: This case study is specific to one individual and should not be taken as general advice. If you have foot pain, heel pain, arch pain or Plantar Fasciitis you should consult with a suitably qualified Sports Podiatrist.







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