In January 2017, a 44 year old mother of two presented to the Sydney heel pain clinic in Miranda, complaining of heel pain. She describes a sharp pain under the ball of her heel that has been present for over 2 years. She explained to the sports podiatrist, that the pain in her foot started soon after the birth of her second child. Approximately 2 weeks after giving birth the patient recalls an increase in her shoe size and an altered architecture through the arch of her foot. She explains that prior to the heel pain, the arch of the foot was slightly higher but that the pregnancy and the weight gain had caused the arche to collapse. She reports a gradual onset of heel pain which started as a dull ache and progressively got worse. She currently describes all the symptoms consistent with plantar fasciitis such as pain when getting out of bed in the morning, or in the middle of the night when attending to her children. The heel pain causes her to walk with a bad limp for at least 15 minutes until the condition settles slightly. Towards the end of the day the heel pain feels sharper and more intense and she describes a red hot poker in the sole of her foot. She reports to the podiatrist that she has tried to wear a variety of shoes but the only footwear she feels comfortable in are her running shoes. To this end, she spends her days in a pair of New Balance cross trainers. She reports that these running shoes reduce the heel pain by approximately 50%. This lady went to visit her regular doctor who informed her that she probably had what was known as heel spurs. He rejected her claims for an x-ray in light of the fact that it wouldn’t change anything. Instead, he told her to be patient and to continue wearing a trainers and that the conditions would settle down by itself in approximately 18 months. This patients husband was frustrated with the lack of assistance from the GP as he could see that his wife’s heel pain was excruciating. He encouraged her to visit a local physiotherapist for treatment.
The physiotherapist suggested that the cause of this patient’s heel pain was plantar fasciitis and that he would offer some acupuncture and massage therapy. He also applied some rigid sports tape to give extra support to her feet. The physiotherapist encouraged the patient to perform calf stretching with both of her heels hanging off the back of a step. She reports to the podiatrist that these exercises caused a massive increase in her heel pain and so she ceased this activity after approximately 4 days. The physiotherapist continued to apply deep tissue massage which did provide some short-term relief. However, after 6 weeks of treatment with the physiotherapist the patient’s heel pain was only marginally better and her frustration continued. She began online research and learnt a little about shock wave therapy and so presented to the podiatrist requesting this treatment. The sports podiatrist informed the patient that she may be a suitable patient for shock wave therapy but she would need to be assessed first.
The sports podiatrist carried out a thorough physical assessment in order to determine the cause of this patients heel pain. She reported extreme pain on palpation of the plantar aspect of the heel around the plantar fascial attachment. There was also considerable pain when pressure was applied to the plantar fascia through the medial arch of the patients feet. This lady was informed that the cause of her heel pain and arch pain was in fact plantar fasciitis. It was explained to the patient that heel spurs are a little misleading and are not usually the cause of pain.
The sports podiatrist carried out a thorough physical assessment with the patient standing up in a relaxed stance position. Further measurements were taken as she stood in subtalar joint neutral position. The podiatrist measured the height of the patients arches and noted an extremely low medial arch profile. Both subtalar joints were overly pronated. With the patient lying down, further muscle and joint testing was performed. It was clear that this patient had extremely loose ligaments causing joint hypermobility. She was informed that high levels of the hormone relaxin, during and after birth, was the likely cause of her loose ligaments. Her foot ligaments were no longer providing stability around the joints of her feet and ankles. While walking on the treadmill the podiatrist was able to observe severe over pronation and foot instability.
The podiatrist explained to this patient that in order to reduce her heel pain it was important to support and realign her feet. The quickest and most reliable way to do this was via the use of prescription orthotics manufactured from carbon fibre and inserted into her running shoes, in place of the soft generic liners that come the shoes come with. To this end, the podiatrists took digital foot scans for the patient. The orthotics would take approximately 2 weeks to come back from the lab, and so the podiatrist agreed that it was important to continue applying rigid sports tape to both feet. This sports tape being rigid would mimic the job of healthy and more rigid foot ligaments. The podiatrist also advised the patient to immerse her feet in a bucket of iced water to reduce the swelling and heel pain. Due to the loose ligaments, the patient’s lower leg muscles had become extremely tight in an attempt to compensate for the weakness. Therefore, the patient was advised to perform very specific calf stretches with her foot in a neutral position.
The patient returned after 2 weeks to help her prescription orthotics inserted into her running shoes and to have a heel pain assessed. She reported that the pain was approximately 20% better due to the use of ice baths. However, she was performed that the real relief from heel pain would come once she was supporting her feet with the rigid carbon fibre orthotics. The orthotics were fitted into the patient’s running shoes and she was observed walking on the treadmill. Foot and ankle alignment appeared suitable and the patient reported no discomfort from the orthotics.
Due to the fact that this patient had acute and chronic heel pain and was extremely sore she was treated with 2000 reps of shock wave therapy at 5HZ and one bar of pressure. She returned to the clinic for weekly sessions of shock wave therapy for 6 weeks.
Each week that the patient returned to the clinic she reported an overall improvement in her heel pain. The most painful time of day was first thing in the morning or in the middle of the night, however the improvement in pain throughout the day was most obvious. After 6 weeks of shock wave therapy treatment was ceased. The patient was asked to return to the heel pain clinic in a further 6 weeks. After using the orthotics for 12 weeks the patient reported that her heel pain had subsided completely. There was mild pain on palpation by the podiatrist but this was minimal and considered acceptable. She felt no pain in the heel or arch while walking on the treadmill in bare feet. The patient was requested to continue stretching, and applying ice packs if the pain returned, and to continue using prescription orthotics for a further four weeks. After this 4 weeks, she was advised to gradually introduce other types of footwear. If her heel pain returned or if her plantar fasciitis deteriorated she was instructed to return to the clinic for further assessment.
Please be aware that the information contained in this case study is specific to one particular patient and it should not be taken as general advice. If you suffer with heel pain or plantar fasciitis you should seek the advice of a suitably qualified podiatrist or other healthcare professional.
Written by Karl Lockett