A 48-year-old lady presents to the clinic complaining of Arch Pain of approximately 12 weeks following a period of being idle. She reports that she has not exercised for a number of years and has consequently gained weight. She is 12 kilos over her desired weight and hence decided to get fit again by walking. Her Arch Pain came on within a week of walking and she reports that she went from no walks to six mornings a week, without a gradual return to activity.
She was wearing Asics gel Kayano trainers which were approximately a year old and were showing signs of wear and tear. The mid sole had softened and was not resistant to manipulation by hand when tested. It was more pliable than it was as new, and too flexible to offer sufficient support for her body weight.
This lady was also type 2 diabetic and was using metformin to control blood sugar levels which were stable. She did not suffer from any complex medical conditions and reported that she did not usually suffer from inflammation in her joints or tendons.
The Arch Pain that she was feeling was in her left foot only and her right foot was asymptomatic. She informs the Podiatrist that she feels the pain as she starts her walk each morning but that after a kilometre or so the pain reduces to a level that allows her to walk relatively comfortably. The Arch Pain that she feels returns when she gets home and sits down. Within 5 minutes there is a throbbing sensation in the sole of her foot, between the heel and ball of foot, centrally. The Arch Pain persists throughout the day and fluctuates between being bearable and almost excruciating. If she sits down for more than a few minutes then the Arch Pain becomes apparent and then will increase as she stands up from her seat, causing her to limp. She would limp for approximately a minute or so until the foot warmed up.
In the evenings, the Arch Pain would feel worse due to the number of steps taken throughout the day, regardless of the type of shoes that the patient had been using. This patient had alternated between arch based thongs and her Asics trainers but could not find relief. She resorted to over the counter anti-inflammatories which reduced her Arch Pain slightly but did not rid her of the pain completely. Her GP was not particularly competent with Arch Pain treatments or foot health in general so had referred her to our clinic to see a sports Podiatrist.
This patient hobbled to the treatment table as she stood up from the chair in the consultation room, as her Arch Pain was so bad after being seated. She lay supine on the bed as pressure was applied to the sole of the foot. Pressure was applied at the heel first and then at 1cm intervals until the toes were reached. There was no heel pain reported but there was significant Arch Pain felt when finger pressure was applied to the Plantar Fascia approximately 2cm distal to the heel. The patient was informed that she had Plantar Fasciitis in the sole of her foot and that this was a common cause of Arch Pain. It was explained to the patient that she had strained her Plantar Fascia because she had increased her level of activity too quickly and had been wearing shoes that did not offer sufficient support.
Bisection lines were drawn on the patient’s feet and legs and she was asked to walk on a treadmill so that her gait could be recorded. Joint and muscle testing was performed to look for issues that could have allowed the Arch Pain to develop. Hip position and hip rotation were assessed. Her knee joint and position was looked at and her ankle joint was also measured. Sub talar joint movement and forefoot examination was also carried out.
It was noted that this patient had an internally rotated tibia on the left leg which was leading to compensatory external hip rotation on the left side and subsequent limited internal rotation at the hip – due to tight gluteal and piriformis muscles. The end result was an externally positioned left foot (out-toed) which received a greater pronatory force. This had led to an increase in load on the Plantar Fascia of the left foot and subsequent Arch Pain.
It was explained to the patient that in order to reduce her Arch Pain we had to unload the Plantar Fascia. This would be achieved by the Podiatrist applying rigid sports tape to the foot which would stay on for approximately 5 days. The patient would return to the clinic to the have the tape removed and replaced. She was instructed to purchase new walking shoes that would provide more support. This patient required a firm neutral shoe and was asked to buy a pair of Brooks Dyad. These would suit her foot function and body weight.
The patient was asked to apply soft ice packs to the sole of her foot every night for approximately 30 minutes. She was encouraged to avoid walking in thongs or without shoes at all.
At the follow up appointment 5 days later the strapping was removed and the patient was treated with 1000 reps of Shock Wave Therapy, at 5 hz and 1.2 Bar. The treatment was well tolerated and the normal pain relieving response was noted following the session. It was explained to the patient that this treatment would stimulate blood flow and increase the rate of recovery. Strapping was again applied to the foot which provided the support needed to unload the Plantar Fascia. The patient reported no Arch Pain once she was weight bearing with the strapping on the left foot.
At the 3rd appointment the patient reported that her Arch Pain was improving gradually and that she felt better with the strapping on her foot. She did feel some occasional throbbing the day after the Shock Wave Therapy treatment, as can be expected, but this was short lived. The 4 days that followed were almost pain free but it was explained to the patient that this did not mean that she had healed. This was a normal response to Shock Wave Therapy.
“Zapping and strapping” continued for 5 weeks until the patient reported minimal pain in general.
At 5 weeks, the sole of the foot was re-examined and pressure was applied to the Plantar Fascia. Approximately 2cm distal to the heel the patient reported very mild Arch Pain but not enough to cause concern. She was advised to gradually start exercising again, but to avoid hills and inclines. If her Arch Pain returned she should come back to the clinic immediately to see the Podiatrist.
Please note that the information in this case study relates to one particular patient and if you have Arch Pain or any type of foot problem you should consult with a Sports Podiatrist.
Written by Karl Lockett