A 49 year old man visits the Sydney Heel Pain clinic and informs the Sports Podiatrist that he has been struggling with arch pain for 6 months. He thinks he has Plantar Fasciitis and has been trying to treat this himself at home, with ice packs and a Strasbourg sock. He is a healthy man and takes no medications and has enjoyed social tennis for 20 years or more. The pain in the arch of his foot is only present in the right foot, and although he has had Plantar Fasciitis in the left foot in the past, his left foot is not troubling him. His previous Plantar Fasciitis actually caused heel pain, and his arch was un affected.
This gentleman has been sleeping with the Strasbourg sock for 6 weeks and he finds it very uncomfortable to use. It wakes him in the night and due to an increase in pain he finds himself removing it. Furthermore, the sock was only partially beneficial, and the patient found only a small improvement in his arch pain, when his foot hit the ground in the morning. Throughout the day, and the longer the day went on, his arch pain would get gradually worse. He describes a burning through the sole of the foot and a tight pulling sensation. Typically, he feels pain during toe-off, as his heel lifts away from the floor. He describes an intense pain in the arch of his foot if he stands on his tip-toes or hangs his heel off the step.
This patient has had to stop playing tennis as this was causing pain during the game, and an increase in pain the following day. A course of anti-inflammatory medication did not help and after completion, his arch pain persists. His GP referred him for an x ray and this came back all clear.
Firm pressure was applied to the sole of the foot, from the heel to the ball of the forefoot. As pressure was applied to the Plantar Fascia the patient reported pain, and this was similar to the arch pain that he would feel during walking or playing tennis.
There was also arch pain when the patient was asked to perform a single leg heel raise and these symptoms were consistent with Plantar Fasciitis. (As the long peroneal tendon also runs through the arch of the foot and when inflamed can give the same symptoms, it was important to exclude Peroneal tendonitis)
Ankle and sub talar joint range of motion were assessed and were found to be within normal rage. Leg length was measured and appeared to be of equal length. The joints of the foot moved well although there was some minor arthritic change the big toe joint on the right foot. Calf muscle range was fine and there was no real tightness.
Bisection lines were drawn on the heel and tibia and the patient was asked to walk and run on the treadmill while his foot function was recorded, with digital iPad software. Upon playback, in slow motion, it was quite clear that this patient pronated severely. His left and right foot showed signs of extreme ligament laxity and allowed and excessive amount of pronation. There was severe eversion at both heels. This was allowing excessive internal lower limb rotation and tracking issues at the knee joint. It was fairly likely that this patient’s arch pain was caused by this bio mechanical issue. The excessive pronation leading to stress and strain on the Plantar Fascia. The joints of the foot do not “lock” or function as efficiently in this over pronated position, and the muscles and tendons all work a little harder to compensate. They can only do so much in terms of giving extra support, before they fatigue and injury ensues. The Plantar Fascia is inelastic and will not lengthen with the flattening foot, so becomes strained. Most cases of Plantar Fasciitis cause heel pain, and arch pain is less common.
It was decided to take digital foot scans of this patient’s feet, so that prescription orthotics could be designed and manufactured. It was important to design these in such a way that they did not aggravate the Plantar Fascia by pressing too firmly against it. Heel correction on the orthotics was paramount.
This patient was advised that he must use his new orthotics all day, every day until his arch pain had subsided. Once his condition had settled he was advised to continue to use his orthotics in order to maintain good foot function and prevent further injuries such as Plantar Fasciitis and heel pain. He was told that his arch pain would probably take 6 to 8 weeks to settle.
In order to stimulate blood follow and accelerate healing this gentleman was treated with 2000 reps of Shock Wave Therapy, at 5HZ and 1 Bar of pressure. The treatment was well tolerated and gave immediate pain relief. The patient was advised that after approximately 5 days his arch pain would be apparent again, and at this point he would be ready for more treatment.
Shock Wave Therapy was applied at weekly intervals for 5 weeks, and the pressure was increased to 1.3 Bar. After each session, the patient reported that his arch pain felt better, and overall, week by week, his pain was less.
Rigid sports tape was applied to both feet to reduce pronation and to support the joints of the foot. This was used for 2 weeks to temporarily assist foot function, until the orthotics arrived at the clinic. The patient reported that this definitely helped and that he had less arch pain with the strapping in place.
The patient was fitted with his orthotics 2 weeks after his initial appointment. He reported no problems getting used to the orthotics and was compliant with their use. After using the orthotics for 6 weeks the patient was assessed and there was no arch pain on palpation of the Plantar Fascia. He reported some minor stiffness first thing in a morning but this was mild and was improving. The patient was instructed to return to the clinic for a check up if his arch pain returned.
Please note: If you are suffering with arch pain, heel pain or Plantar Fasciitis you should not take this case study as general advice, and seek professional advice from a Sports Podiatrist.
Written by Karl Lockett