A 42-year-old male presents to the Sydney heel pain clinic complaining of heel pain, and describes to the sports podiatrist at his suffering with plantar fasciitis in one foot and Achilles tendonitis in the other. He is a keen runner and has been participating in triathlons for some time. He has never had Achilles tendonitis before and has only recently become familiar with plantar fasciitis and these conditions that can cause heel pain. He reports to the podiatrist that the heel pain is present first thing in the morning when he gets out of bed. He also describes pain upon commencement of his exercise regime. This gentleman will run for proximately 10 kilometres each evening after work and will complete a 20-km run each weekend. During the first 5 km of his run there is a noticeable pain from the Achilles tendonitis but this subsides quickly and he’s able to complete his exercise. Similarly, the plantar fasciitis also feels painful in the beginning of his run but then gets easier after the first kilometre. Approximately 2 hours later, the pain in the Achilles tendon and the plantar fascia increases significantly causing him to limp. This heel pain has been ongoing for approximately 9 months and is not improving.
This gentleman went to see his regular physiotherapist who quiet rightly diagnosed Achilles tendonitis and plantar fasciitis. However, the rehabilitation program that was prescribed by the physiotherapist seemed to aggravate both conditions. The patient was performing single leg heel raises and step stretches for the plantar fascia. He was also rolling his foot on a tennis ball but this seemed to increase the symptoms associated with the plantar fasciitis. The physiotherapist also performed some deep tissue massage for the Achilles tendonitis and this seemed to help somewhat but the improvement was short-lived. The physiotherapist also advised that plantar fasciitis can respond to strapping. The strapping was replaced every 4 days for approximately 3 weeks and while this gave some short-term relief from the plantar fasciitis the heel pain persists. The Achilles tendon on the symptomatic side seemed to be thicker than the asymptomatic side without Achilles tendonitis. The patient was frustrated and went to visit his general practitioner, who concurred with the diagnosis of plantar fasciitis and Achilles tendonitis and prescribed some medication to reduce inflammation and pain. The prescription medications did not reduce the patient symptoms and is heel pain persisted.
The sports podiatrist carried out a thorough physical assessment in order to measure the severity of the plantar fasciitis and Achilles tendonitis. Firm pressure was applied to the base of the heel around the insertion of the plantar fascia, centrally and medially. As is common with plantar fasciitis, this reproduced the pain that the patient had been describing. More distally, through the mid arch of the foot along the medial slip of the plantar fascia there was some tightness and tenderness but the plantar fasciitis in this region was less severe.
Pressure was applied to the Achilles tendon proximal to the insertion and as can be seen in most cases of Achilles tendonitis, this reproduced a familiar pain. There was also some thickening of the Achilles tendon in this region. Distally, at the insertion of the Achilles tendon on to the posterior aspect of the heel bone, that was no heel pain. The podiatrist concurred, non-insertional Achilles tendonitis.
The podiatrist carried out a detailed biomechanical assessment in order to determine the cause of the plantar fasciitis and the Achilles tendonitis. Bisection lines were drawn on the posterior aspect of the patient’s lower leg and heel bone. The patient was asked to walk and jog on the treadmill while the podiatrist recorded video using digital software on the iPad. The videos were re played in slow motion and analysed, while notes were taken. The podiatrist was able to observe severe over pronation in the right foot leading to distortion of the Achilles tendon, on the right leg, with Achilles tendonitis. On the left foot, pronation was minimal, but the podiatrist was able to observe an early heel lift due to a restricted range of motion in the calf muscle and ankle joint. Lying prone, the podiatrist explored leg length and determined a short left leg. However, further assessment revealed that this was a functional leg length discrepancy due to a pelvic rotation.
The sports podiatrist explained that the treatment for this patient’s plantar fasciitis and Achilles tendonitis would be multi-factorial. Primarily, it would be important to realign the pelvis and to correct this functional like length discrepancy. To this end, the patient was referred to a well-known and reliable chiropractor to perform some pelvic adjustments. In addition to the pelvic adjustments, the patient was advised that he should stretch his gluteal muscles and strengthen his core with Pilates style exercises. The patient would require several treatments with the chiropractor in order to determine long-term stability of the pelvic region. In addition to this, the patient was advised that he would need to perform regular calf stretches in both legs in order to maintain a good range of motion through the calf muscle and ankle joints, therefore reducing stress on the heel. Patients with heel pain, especially plantar fasciitis and Achilles tendonitis usually respond well to calf stretching techniques.
The podiatrist also explained to the patient that in cases of heel pain, it is important to control foot function with the appropriate model of running shoe. The patient was given a very specific model of running shoe to use in order to reduce his heel pain. These running shoes would provide adequate support which would allow and ensure healing of the plantar fasciitis and Achilles tendonitis. The shoes would incorporate at least 10 millimetre drop and would contain firm EVA to reduce flexion and offer more stability. There would be less softness and cushioning in the shoes.
The sports podiatrist also performed Shockwave therapy to the plantar fascia and the Achilles tendon. The patient was booked in for 3 sessions of Shock wave therapy. Patients with plantar fasciitis rarely need more than 6 sessions, as is with Achilles tendonitis. The sports podiatrist also applied rigid sports tape to both feet in order to offer stability and support. The strapping would be changed weekly, at the time of Shockwave therapy appointment.
The patient was advised that if the support from the stopping and the new running shoes was insufficient to assist with recovery, then the next step would be sports orthotics.
Please note: If you have heel pain from plantar fasciitis or Achilles Tendonitis you should seek the help of a sports podiatrist. This case study is not general advice.
Written by Karl Lockett