Case Study March 2017 – Plantar Fasciitis In A Patient with Auto-Immunity by Karl Lockett, Sports Podiatrist

A 55 year old lady presents to the Sydney Heel Pain Clinic complaining of Plantar Fasciitis which is causing pain in the heel and arch, of her left foot. She informs the Sports Podiatrist that the pain has been present for approximately 3 months, and seems to coincide with a flare up in her auto-immunity condition. She is under the care of a rheumatologist who has prescribed specific medication for her condition, and up until recently, her inflammatory episodes were under control. She informs the Sports Podiatrist that she has not changed her diet or level of physical activity and hence she is at a loss as to why the Plantar Fasciitis has developed. Her last blood test revealed rheumatoid factor of 45 although her specialist did not label her condition as rheumatoid arthritis.

The heel pain is more noticeable in the mornings when she gets out of bed, or in the middle of the night when she goes to the bathroom. Throughout the day, she feels like she has a pebble in her shoe, under her heel, and at times it feels like a “red hot poker” shooting into the bottom of her foot. She has never seen a Sports Podiatrist before although she feels her feet have not been great for some time. This patient informs the Sports Podiatrist that her Plantar Fasciitis and heel pain is only in the left foot, although she feels that she is dominant on the right side. She usually enjoys her morning walks with the dog but has ceased this activity due to the pain. Occasionally, she is able to push through the heel pain and after a short distance is able to walk quite comfortably. However, of late, this has not been the case and so her rheumatologist modified her medication and referred her to the Sports Podiatrist. She was informed that her symptoms do in fact resemble Plantar Fasciitis and so a physical assessment would be required.

PHYSICAL EXAMINATION FOR PLANTAR FASCIITIS

The Sports Podiatrist applied firm pressure along the medial side of the heel bone and observed a jump response from the patient. She confirmed that this pain resembled the heel pain that she felt when she walked in a morning. Distal to the heel, into the arch, there was further pain along the Plantar Fascia which also caused the patient to wince. At the mid point of the arch, the Sports Podiatrist felt a small pea sized lump which was also visible to the naked eye. Interestingly, the nodule did not elicit pain on palpation but was mildly sore when very firm pressure was applied. The patient was informed that these plantar nodules were quite common in people with auto-immunity. They are often observed under Ultra sound as ganglions or fibroma’s. The patient was informed that she did in fact have Plantar Fasciitis and this was causing her heel pain and arch pain.

BIO-MECHANICAL ASSESSMENT BY SPORTS PODIATRIST

The Sports Podiatrist requested the patient walk bare foot on a treadmill so that her foot function could be assessed. This was done with bisection lines drawn on the back of the heel bone and tibia. The patient’s walking style was recorded using digital software and was replayed in slow motion. One of the causes of Plantar Fasciitis and other conditions that cause heel pain or arch pain is over-pronation through the sub-talar joints and mid-foot. It was clear from the replay that this patient suffered from severe over-pronation which allowed her feet to collapse under body weight. The Podiatrist explained that this over-pronation puts a great deal of stress on the foot, the Plantar Fascia in particular. Other muscles in the foot and lower leg also work over time, in order to compensate for the weakness in the foot ligaments, and this causes tightness. It was likely that this over-pronation was responsible for the strain on the Plantar Fascia which led to the Plantar Fasciitis and heel pain.

Further assessment revealed extreme tightness in the calf muscles. The posterior shin muscles were also very tight and tender. The Sports Podiatrist carried out some standing foot measurements and found bi-lateral flat feet. The left medial arch measuring a mere 12mm in height, and the right only 14mm. Foot posture index revealed an 18 degree eversion at the left heel and 14 degrees at the right.

PLANTAR FASCIITIS TREATMENT BY SPORTS PODIATRIST

Firstly, due to the flare up in this patient’s auto-immune condition, she was advised that she must re-visit and maintain communication with her specialist. It was likely that she would need to adjust and monitor her medications for some time in order to bring the inflammation under control. Plantar Fasciitis is common in patient’s with these medical conditions and it is important to address the internal workings of the body, in addition to the physical load on the feet. The Sports Podiatrist also explained that it was important to address the bio-mechanical weakness in the patient’s feet. Her flat foot condition and over-pronation would prevent or delay healing and would probably cause other foot and leg issues later in life.

ORTHOTICS FOR PLANTAR FASCIITIS

Using a 3D camera and digital software, scans were taken of this patient’s feet while her sub-talar joints were held in a neutral position. This would allow for the manufacture of prescription orthotics. The orthotics for this patient’s feet would be designed with a 15mm aperture in the mid arch, to take pressure off the plantar nodule. The orthotics would be made from a semi-rigid Carbon Fibre material which is lightweight and low bulk in the shoes. The dorsal surface of the device would be padded with slow release poron. These would be worn every day for 2 to 3 months, or until the Plantar Fasciitis had settled. Once the heel pain had subsided and the arch pain had reduced significantly, the patient would be able to walk without the orthotics occasionally. However, she was advised by the Sports Podiatrist that she would always need the orthotics due to her ligament weakness.

PLANTAR FASCIITIS FOOTWEAR

The Sports Podiatrist also advised this patient to purchase some firm neutral shoes to suit her body weight and foot type. A brooks Dyad was the recommendation and the liner would be removed to allow for the orthotics. The firm mid-sole in this shoe would provide great support, and in conjunction with the orthotics, would allow the Plantar Fasciitis to settle without the need for injections.

The patient was also advised to perform regular calf stretches on a daily basis, as these would release the heel and take pressure off the foot. Most patient’s with Plantar Fasciitis or other conditions that cause heel pain will have tight calf muscles and regular stretching is always found to be beneficial.

6 WEEK FOLLOW UP

The patient reported to the Sports Podiatrist that she got used to her orthotics quickly and was happily using them every day. She was compliant with calf stretching and was applying ice packs to the heel and arch every night before bed. She was very happy with the footwear recommendation and felt very secure in the Brooks Dyad shoes.

The Plantar Fasciitis symptoms had subsided although had not gone completely. She reported approximately 70% improvement, which was to be expected in a patient with auto-immunity. The specialist had also modified her medications and this seemed to be helping with inflammation in general, especially hands and wrists.

The patient was advised to continue with treatment and return for a 12 week check up in a further 6 weeks.

NOTE: If you have heel pain, arch pain or Plantar Fasciitis symptoms you should consult with a Sports Podiatrist. This case study is specific to one particular patient and is not general advice.







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