Part 2: Case Study – Plantar Fasciitis or Plantar Fibroma, Achilles Tendonitis – Continued

Biomechanical Assessment for Plantar Fasciitis and Achilles Tendonitis

In order to determine the cause of the patient’s plantar fasciitis and Achilles tendonitis the sports podiatrist carried out a biomechanical assessment with the patient standing, walking, and running on a treadmill in his bare feet. Bisection lines were drawn along the line of the tibia, Achilles tendon and the posterior aspect of the calcaneus. Quite commonly, the bisection lines on the back  of the Achilles tendon can become distorted in patients with Achilles tendonitis. The biomechanical assessment is useful for detecting over pronation through the subtalar joint. It should be noted that plantar fasciitis and Achilles tendonitis can occur in patients with and without over pronation. These two conditions can be commonly seen in all foot types. However, when it comes to treatment it is important for the podiatrist to understand the foot type. When designing orthotics, it is imperative that the podiatrist as a good understanding of the amount of supination pronation through the subtalar joint. The findings join this assessment significantly affect the prescription form. The sports podiatrist used digital software on an iPad in order to capture the patients biomechanics. The video footage was replayed in slow motion and using stop start frame technology the podiatrist was able to note detailed aspects of the patients by mechanics.

During the gait assessment, the patient reported pain from the plantar fasciitis as he is 4 ft accepted body load. There was no pain on heel strike but there was mild pain in heel left. It is not uncommon to find patients reporting arch pain from plantar fasciitis has the body weight is transferred from the heel to the forefoot, loading the plantar fascia. The patient reported mild stiffness through both Achilles tendons during the gait assessment, but this used quickly and he was able to walk and run without any pain. This is common with the case with Achilles tendonitis whereby the foot warms up on any stiffness or pain begins to subside, allowing the individual to continue with sport exercise and physical activity. However, some patients will report that the pain returns approximately an hour or two after the physical activity, and is particularly painful the following morning when I get out of bed. Patients with Achilles tendonitis will often report pain after being seated for a given period of time, when they stand up to walk away from their seat they begin to feel pain for the first few steps. Once again, the pain subsides after a short period of walking.

The sports podiatrist also carried out measurements with the patient standing in a subtalar joint neutral position. Measurements were also taken in a relaxed calcaneal stance position. Arch Heights were measured in both of these positions as was the bisection line on the back of the heel.

Findings

The podiatrist noted that there was minimal pronation through both subtalar joints during walking. While the patient was running, that was an increase in the amount of pronation which is to be expected, however there was a significant increase in pronation through the left foot compared to the right. There was a significant a Version at the heel, causing a bowstring effect through the Achilles tendonitis comma but it would not be fair to say that this is the cause of the Achilles tendonitis the same Anomaly did not appear through the right foot. It was also noted during walking that there was early heel lift through both feet, naturally increasing the strain to both Achilles tendons. Tight calf muscles and early heel lift are both commonly seen in patients with Achilles tendonitis, so it would be safe to assume that this was a more likely cause of the patient’s condition.

The podiatrist was also able to note an increase in the amount of external rotation through the left foot compared to the right foot, possibly coming from tibial torsion or an externally rotated hip. Further investigations were to be carried out.

The podiatrist informed the patient that his Asics Gel 2000 running shoes were appropriate and that is day today Street shoes, and work shoes were also sufficiently supportive.

Achilles Tendonitis Treatment

Just inform the patient but the treatment for his Achilles tendonitis would depend on several factors, some of which would also assist with the treatment of the plantar fasciitis. Primarily, it was imperative that the patient commands of course of regular calf stretches in order to increase the range of motion through the ankle and reduce the load on the Achilles tendon. The podiatrist demonstrated, and the patient followed, standing calf stretch in a lunge position. The patient was advised to hold each stretch for at least 30 seconds, and that’s three stretches should be performed on each leg. He was also informed to carry out these stretches at least three times a day. Patient suffering with Achilles tendonitis and plantar fasciitis alike, often feel significant improvement in that condition after a few days of stretching.

In order to further reduce load on the Achilles tendon patient was fitted with 2 x 9 millimetre heel wedges, that were to sit underneath the liner of his shoes. The patient was advised to avoid flat shoes, bare feet, and thongs. He was informed that by elevating his heel this would reduce the tension through the Achilles tendon and therefore allow the healing to commence. It is not uncommon to encounter new patients who have developed Achilles tendonitis via the overuse of flat shoes, without a heel lift.

Shock Wave Therapy for Plantar Fasciitis and Achilles Tendonitis

The sports podiatrist commenced a 6 week course of shock wave therapy to stimulate blood flow and accelerate the healing of the Achilles tendonitis.  The machine was also used across the Soles of both feet to treat the plantar fasciitis, slightly distal to the attachment at the heel bone. The Shock Wave therapy stimulates healing via revascularization comma and has an analgesic effect 2. Treatments were delivered approximately 5 days apart.

Results and discussion to follow

11 April 2018

 

 







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