Case Study - Heel Pain from Plantar Fasciitis and Bursitis

Plantar Fasciitis Symptoms – Causing Heel Pain

A 44 year old female presented to the Sydney heel pain clinic complaining of pain in the base of her heel consistent with plantar fasciitis. She described a frustrating heel pain that felt like a pebble in the shoe, and that had been troubling her for approximately 7 months. She was unable to inform the sports podiatrist of any particular reason as to why this heel pain gradually came on. She explains her activity to be dog walking on a daily basis and that she has performed this activity for several years. She explains that the heel pain is extremely prominent during the beginning of her walks but then begins to settle. She informs the podiatrist that she would always wear cross trainers or trekking shoes while walking the dogs. This patient has never experienced plantar fasciitis before and explains to the podiatrist that she boasts good foot and general health. She did explained to the practitioner that her heel pain was noticeable first thing in the morning after sleeping. The pain from the plantar fasciitis was also evident after long periods of sitting down. She had been rolling her foot on a Frozen can of Coke on a daily basis in order to relieve the pain.

Physical Assessment of Plantar Fasciitis

The sports podiatrist carried out through physical assessment in order to assess the severity of the heel pain and to diagnose / confirm the diagnosis of plantar fasciitis. When pressure was applied to the insertion of the plantar fascia onto the heel bone the patient reported significant pain consistent with her day to day heel pain. The pain was more medial and central on the heel bone and less on the lateral side of the heel or the outer heel. The patient also described some tenderness through the more distal fibres of the plantar fascia as it passes into the arch area. These are all the typical pain locations found in people with chronic plantar fasciitis.

The patient was able to perform a single leg heel raise without significant pain. When standing and balancing on one leg the patient reported pain under the base of the heel on the affected foot. The podiatrist carried out further physical tests around the foot and ankle joint and through the muscles and tendons affecting the area. No other abnormalities were detected. The patient did report calf cramping in the evenings, after she had been busy on her feet all day, but demonstrated good range of motion through the ankle.

The podiatrist carried out a biomechanical assessment on the treadmill and recorded the footage using digital software. Foot posture index including arch height and heel angle were measured and noted.

The podiatrist carried out of footwear assessment following the treadmill assessment and was able to determine that this person was not receiving sufficient support from her fatigued cross trainers. While this particular sports model was a reputable shoe maker the patient had been using this particular pair for more than 12 months and the midsole had consequently fatigued. The net effect was that the patient was walking on a daily basis in minimally supportive shoes. This would have been one if not the only likely cause of the patient’s plantar fasciitis.

The patient was referred for ultrasound imaging in order to exclude any other complex heel pain conditions aside from plantar fasciitis. There are other causes of heel pain that can appear on ultrasound images.

The patient returned to the Sydney heel pain clinic and the report was discussed. The imaging showed definite plantar fasciitis with a thickness of approximately 7 mm. Of interest, the patient had also developed a small adventitial bursa overlying the plantar fascia.

Plantar Fasciitis Treatment

The podiatrist installed the Sydney heel pain mobile phone application for the patient. This would allow the patient to be well informed and to avoid conflicting and contradictory treatment advice.

The treatment for this patient would include the following:

Supportive strapping using rigid sports tape
Footwear recommendations and the purchasing of new shoes.
The application of shockwave therapy on a weekly basis for 3 to 6 weeks.

Treatment Results – Heel Pain

After 4 sessions of shockwave therapy and after 4 weeks of using new supportive walking shoes the patient reported an improvement of approximately 50%. However, there was one small area of tenderness which did not seem to be improving as much as the other areas of heel pain. To this end the podiatrist referred the patient back to the imaging centre for a small injection of cortisone into the adventitial bursa. The needle was guided into the affected bursal tissue using ultrasound. Treatment was well tolerated and there were no complications.

One week later the patient returned to the Sydney heel pain clinic and reported that her heel pain at all but disappeared. There was some mild pain from the plantar fasciitis but this was improving on a day to day basis. She had been compliant with the use of the new shoes and had been consistent with the application of rigid sports tape. The patient requested one more session of shockwave therapy and the treatment was received and well tolerated. Immediate relief from the shock wave therapy followed the session. Further treatments were ceased to allow natural healing. The patient was advised that 1 more shock wave therapy session would be considered if the plantar fasciitis did not completely resolve or if there was residual heel pain.

The patient was asked to return to the Sydney heel pain clinic in two weeks time to discuss her progress. This person called the clinic to cancel the appointment 2 days prior to the review, explaining to the receptionist that she was completely pain free and did not need further treatment.

Please note that the information contained in this particular case study is specific to one person and should not be taken as general advice. If you have heel pain or if you think you have plantar fasciitis please consult with a suitably qualified sports podiatrist.

Written by Karl Lockett