A 36-year-old male arrives at the podiatry clinic with suspected plantar fasciitis of more than 2 months. He is unable to walk into the consultation room without limping. He informs the podiatrist that his heel pain started suddenly during a game of basketball, whereby he felt a “click” in the sole of his foot, around the base of the heel. He was forced to stop playing immediately due to the intense pain. He is a healthy individual with no medical complaints and good foot health. He has never had heel pain or plantar fasciitis before. On the same evening of his trauma he was forced to take medication to reduce the inflammation and the pain in his foot. The following day he was forced to take the day off work and he made an appointment to see his local physiotherapist who diagnosed him with a stress fracture, not plantar fasciitis. The physiotherapist recommended that he visit his general practitioner and request MRI to confirm this diagnosis. The general practitioner instead referred to patient for an x-ray of his foot. Upon inspection of the X-ray by the podiatrist there was no evidence of fracture. Please note that plantar fasciitis does not always show on x-ray.
The patient returned to the physiotherapist and informed him that there was no fracture. The physiotherapist informed the patient that there may however be a stress fracture and that stress fractures do not always appear on x-ray. To this end the physiotherapist recommended that the patient use gel cushions in his shoes and to try to wear soft trainers as much as possible. The physiotherapist also recommended the application of cold ice packs as well as heat packs to increase blood flow. However, the patient found that following the application of heat, the pain in the heel would increase. This is quite typical of patients who are suffering with plantar fasciitis. After 10 days of treatment at home the patient became frustrated and began some online research himself. It was here that the patient discovered conditions such as plantar fasciitis.
Physical Assessment For Plantar Fasciitis
The sports podiatrist at the Sydney heel pain clinic carried out a series of tests which help to determine and diagnose plantar fasciitis. The patient was asked to stand in a relaxed position without shoes. He was then asked to perform calf raises on both feet. The patient was able to perform calf raises but there was pain under the right foot during this exercise. He was then asked to perform the same exercise on a single leg. He was able to do this easily on his left leg but could not perform one single calf raise on his right leg due to extreme pain in the base of his right heel. The podiatrist then applied firm pressure to the base of the heel in the area where the plantar fascia attaches. This caused extreme pain in the patient’s foot and he retracted his leg instantly. Firm pressure was also applied to the plantar fascia distal to the heel through the arch of the foot. While this caused some pain in the patient’s foot it was not as localised or acute as the pain in the base of the heel. The patient was informed that he did not have the symptoms of a stress fracture but more likely was suffering with a condition known as plantar fasciitis.
Other Findings in Addition to Plantar Fasciitis
Further testing was carried out and it was found that in addition to plantar fasciitis, this patient also had Achilles tendonitis in the same foot. This may be a result of compensated gait whereby the patient has been limping for the past 8 weeks, causing strain through the Achilles tendon in the same leg. However, it is also possible that the Achilles tendonitis had developed due to the same biomechanical anomaly that caused the plantar fasciitis.
Plantar Fasciitis Treatment
This patient was informed that his condition was more acute that most patients with chronic plantar fasciitis. He was informed that his condition may be complicated by the presence of small intra-substance tears within the plantar fascia. This patient was referred for an ultrasound of his Achilles tendon and plantar fascia in the right leg. However, regardless of the results from the ultrasound it was important to treat the patient as he was unable to walk without limping and his condition was not improving. To this end, the patient was informed that he must be fitted with an immobilisation boot. The immobilisation boot would hold the ankle at 90 degrees and prevent the foot from moving. The patient was not over the moon about such treatment but agreed that he had to do something to fix his plantar fasciitis. The patient gave consent to be fitted with an immobilisation boot.
The patient was informed that the blood flow to the plantar fascia was quite poor, and to this end healing of the plantar fasciitis would take some time. The patient was made aware that he would be using the boot for a minimum of 4 weeks and possibly 6 to 8 weeks. Prior to the boot being fitted the podiatrist applied rigid sports tape to the foot. This would hold the joints of the foot together and prevent elongation or displacement of the foot. Patients with plantar fasciitis tend to heal quicker with the use of rigid sports tape inside the boot.
As is typical with plantar fasciitis, this patient was informed that the application of cold packs to the base of his heel on a daily basis would be highly recommended. Because plantar fasciitis is an inflammatory heel condition, the patient was informed that he should not apply heat. Patients with plantar fasciitis or other foot conditions that require the use of an immobilisation boot, will usually develop tightness in both calf muscles, after using the boot for sometime. Due to this unavoidable tightening, the patient was instructed to perform calf stretches on a daily basis.
To summarise, the treatment for this patient’s plantar fasciitis would comprise rigid sports tape, immobilisation boot, calf stretches, and the application of ice packs. He was booked in for a follow up that would take place in 3 weeks. He was also informed that after 3 weeks of using the immobilisation boot, we would consider commencing a course of shockwave therapy.
Ultra sound results: Small instar-substance tear in the plantar fascia measuring 7mm X 4mm and Achilles Tendonitis in the right leg.
Please note: This case study is not general advice for plantar fasciitis. If you have heel pain you should consult with a podiatrist or other medical practitioner.
Written by Karl Lockett