In February 2017, a 41 year old female presented to the Sydney heel pain clinic complaining of plantar fasciitis in her left foot. She informed the podiatrist that six months ago she sprained her ankle, following which she was unable to walk properly on her left leg. The patient spent several weeks pushing off the outside of her left foot and off her tiptoes in order to avoid the pain from the damaged ankle ligaments. After 6 weeks of limping, she reported a tight feeling through the arch of her foot and a burning sensation through the sole of her left foot. Following this, she started to feel symptoms that are common in patients with plantar fasciitis, such as pain under the ball of the heel. She would feel a sharp stabbing pain through the base of the heel and a tight pulling sensation through the arch. As is common in plantar fasciitis, she also experienced significant pain first thing in the morning when her foot hit the ground. She would walk gingerly for 20 minutes each morning until the pain from the plantar fasciitis started to subside slightly. Approximately 4 weeks prior to this appointment with the podiatrist, she informs the practitioner that her ankle pain had subsided and that she had made a full recovery from the sprain. However, she was now left with excruciating heel pain from the plantar fasciitis. It is worth considering at this stage, that plantar fasciitis can develop as a secondary condition, following injury to other parts of the foot or lower leg. The altered biomechanics leads to stress and strain in the parts of the foot being loaded, as the injured part of the foot is avoided. This patient is otherwise healthy and does not report any chronic or relevant health problems. She takes no medication and is usually an active mother of two young children.
Prior to the ankle sprain, and the plantar fasciitis, this patient enjoyed weekly sessions of netball and tennis with work colleagues and friends. However, since the onset of these foot problems she has given up physical exercise altogether. There has been a slight increase in body weight due to inactivity, and the patient is aware that the additional body weight can aggravate the plantar fasciitis by adding load to the foot,
In order to diagnose plantar fasciitis and put a treatment plan in place it was important for the podiatrist to carry out a detailed physical assessment of the patients foot. Gentle pressure was applied to the base of the heel through the arch of the foot and along the line of the plantar fascia. As is usually the case with plantar fasciitis, this patient reported pain as pressure was applied to the medial slip of the plantar fascia around the base of the heel.
In order to determine the cause of this patient’s plantar fasciitis, and to determine any biomechanical anomalies that might prevent healing, the podiatrist carried out a biomechanical assessment with the patient walking on a treadmill in her bare feet. The podiatrist analysed the patients gait, and recorded the walking style using digital software on an iPad. As the footage was replayed in slow motion, the podiatrist was able to observe an externally rotated left foot compared to the right which pointed straight forward. Theis externally rotated position of the left foot allowing over pronation through the subtalar joint. There was insufficient re-supination and a lack of windlass mechanism through the great toe. The right foot functions more normally and demonstrated moderate amounts of pronation and proper re-supination. The patient was informed that the onset of her plantar fasciitis was probably due to a biomechanical problem with her left foot.
Further assessment revealed a suspected longer left leg, compared to the right. Several tests were carried out and the podiatrist concluded that the left leg was approximately 8 mm longer than the right. This leg length discrepancy would probably explain the externally rotated left foot, causing plantar fasciitis.
The patient was informed that one of the quickest and most reliable ways to rectify plantar fasciitis is to insert prescription orthotics into her day-to-day shoes. The orthotics would be designed from carbon fibre which is extremely thin and lightweight but also very strong and supportive. The extra support inside the patient’s shoes would mean that her plantar fasciitis would probably recover within 6 to 8 weeks. She was also referred for a CT scan, in order to determine the exact leg length discrepancy. The patient was also provided access to the Sydney heel pain mobile application, which she could keep on her iPhone. The application provides information on plantar fasciitis and helps to educate the patient. The patient would then be in a position to avoid some of the things that we know can stress the plantar fascia. the application also provides information on things that we know can encourage healing. The patient was informed that there was a very specific stretching technique enclosed within the mobile application which she should follow daily in order to ensure that her plantar fasciitis recovers quickly.
(Following the CT scan, this patient report concluded that she in fact had a 6mm leg length discrepancy, being 4 mm longer through the tibia and 2 mm longer through the femur). To this end she was supplied with a 3 mm heel lift for the inside of her right shoe. The 3mm heel lift would be changed for a 4 mm and maybe a 5 mm in due course, depending on progress and tolerance.
The patient was fitted with her prescription orthotics and was asked to return to the clinic after 4 weeks so that the podiatrist could reassess her plantar fasciitis. During this time the patient had been wearing the 3mm heel left inside her right shoe. She reported to the podiatrist that her plantar fasciitis had improved but that she still felt some pain under the heel and through the arch of her foot. The podiatrist assured the patient that this was normal and that it would probably take another 2 to 4 weeks for the pain to go away completely. The patient also reported that she felt more level through her hips and lower back and that the back pain that she had always had for some time had now subsided.
The podiatrist offered the patient shock wave therapy but she declined advising the podiatrist that she was happy with progress and would continue to follow the instructions in the Sydney heel pain mobile application. This would include the application of cold ice packs to the affected heel on a daily basis and of course continuing to carry out the recommended stretches.
The patient was rebooked for a follow up in a further four weeks, but she called the clinic the day before the appointment to cancel, informing the practice manager that her plantar fasciitis had resolved and that she no longer felt pain in the heel or arch.
Information here in this case study is not general advice: if you have heel pain or plantar fasciitis you should seek the help of a podiatrist or other healthcare practitioner.
Written by Karl Lockett