A 44 year old male of slight build presents to the heel pain clinic and gives a detailed history of his Plantar Fasciitis. He is a healthy man, 179cm tall and only 82 kg’s and is a keen runner. There are no known medical conditions and he takes no medications, just supplements such as Endura sports drink. He describes a good foot health history and has never injured his feet or ankles before. He has never had Plantar Fasciitis or Arch Pain before and is now feeling frustrated as the condition has been going on for some time. Despite his efforts to resolve this acute case of Plantar Fasciitis he has been feeling arch pain and heel pain for approximately 12 weeks. The pain is present every day and is very noticeable each morning when he walks. Getting out of bed is unpleasant and he has to hobble to the bathroom for at least 5 or 10 minutes before the pain eases. Throughout the day he also feels the pain if he has been sitting down, and then begins to walk. Once again, the pain eases within minutes.
He describes the heel pain as a stone bruise under the central part of his heel, which is very typical of Plantar Fasciitis. On occasions, it also feels like a stabbing pain under the heel. He also describes a tightness in the arch of his foot and when he runs there is a sudden onset of arch pain. He reports that the first few km’s of his run are uncomfortable but when he is warmed up the arch pain eases and he can continue quite happily. The heel pain also reduces within minutes and so he is able to complete his 15k’s.
After the run, when the patient has rested for approximately an hour, the pain returns. This is very typical of Plantar Fasciitis and the pain often comes back quite acutely. This patient would apply an ice pack to his foot and this would temporarily relieve his heel pain. However, the arch pain would persist.
In desperation, he went to visit his GP who quite rightly diagnosed Plantar Fasciitis and therefore suggested that an X ray would be of no use. The GP suggested some home remedies such as rolling the foot on an iced water bottle and stretching. The stretching seemed to increase the arch pain and the heel pain also persisted. The patient was performing heel drops off the back of a step and was pulling his toes back with a towel. It is highly likely that these stretches increased the load on the Plantar Fascia and hence were prolonging his condition. He returned to his GP who then referred him for an injection of cortisone.
The injection was performed blind and the patient reported no complications following the procedure. This patient reported that for 3 weeks there was reduced heel pain but there was no change in the arch pain. He continued to run 3 times a week seeing as the running was bearable. Within 3 weeks the heel pain returned and was feeling as painful as it was prior to the injection. The arch pain also continued and although this patient was applying ice packs daily he was still unable to walk without a limp.
This patient decided, against all his will, to refrain from running and this seemed to help a little. After 2 weeks of not running the pain was no longer acute as long as he walked with his sports shoes on and providing he took over the counter anti-inflammatories. However, each morning and after being seated he would still hobble.
It was decided by the Podiatrist at Sydney Heel Pain Clinic to refer this patient for an Ultra sound scan. He seemed to have some symptoms that indicated he had a tear in his Plantar Fascia. A treatment plan would be put together once we had the report back from the imaging centre.
The report did in fact confirm Plantar Fasciitis with an intra substance tear measuring 4mm x 3mm, approximately 28mm from the attachment at the heel. Most cases of Plantar Fasciitis that we see do not involve tears but stubborn cases that are acute often do.
This patient was immediately fitted with an immobilisation boot to unload his Plantar Fascia. He walked back and forth in the treatment room for several minutes, with no heel pain and reported no arch pain at all.
He was advised that he would need to be in the Immobilisation boot for at least 3 weeks and that he should wear it at all times when standing and walking. He was advised to remove the boot when sleeping, showering and driving. The patient was instructed to apply ice packs to his heel each evening before bed and to refrain from all the home remedies that he was doing prior to coming to see us. He was assessed for a specific foot type and given a list of 3 specific shoes that suited his foot function. These would become his running shoes, but he would also be using these in the short term when he was ready to come out of the boot.
He was given a list of things that help the Plantar Fascia to heel, and a list of things that we believe aggravate it and prolong the arch pain. There is a lot of confusion for patient’s when trying to decide which treatment’s to engage in and which remedies are beneficial for Plantar Fasciitis, and so he was given clear instructions in a 4 page document.
After 3 weeks the immobilisation boot was removed and the patient was reassessed. On palpation of the medial heel and plantar arch the patient reported mild pain. He also mentioned that his morning pain was considerably reduced.
It was decided to use some rigid sports tape to strap and support the foot and also allow further healing. Calf muscle range was assessed and a specific stretching technique was demonstrated. Regular calf stretches were to be avoided as these can prolong Plantar Fasciitis.
Ice packs were to be continued. One week later there was further improvement and no more sessions were required. The patient was advised how to return to running and was asked to come back to the clinic if his heel or arch pain returned.
Please note: This case study is not general advice and if you have Plantar Fasciitis or any type of heel pain you should see a suitably qualified practitioner.
Written by Karl Lockett