A 38 year old male presents to the clinic complaining of Plantar Fasciitis and heel pain in his left foot, of approximately 7 weeks. He describes a pulling and tightness through the arch of his foot, which creates mild Arch Pain but a sharp pain and a dull ache under the centre of his heel. The heel pain is extremely sore first thing in a morning when he rises from bed and is present throughout the day. The pain settles after his morning shower and after walking around the house for approximately 15 minutes. Although the pain eases it never goes away completely. Mid afternoon he reports a rise in pain levels due to being on his feet for longer periods. When he stands up from his office chair he feels a sharp heel pain which forces him to hobble.
This patient reports that 10 weeks ago, he sprained his ankle while playing football and was under the care of a physiotherapist. His ankle swelled significantly and the patient was forced to alter his gait. In particular, he was forced to walk on the outside edge of his left foot, and was weight bearing on his forefoot more than he normally would. It is not uncommon for patient’s to develop secondary Plantar Fasciitis or other types of heel pain after an ankle sprain, or other foot injury. The altered gait leads to an overload of stress on the other parts of the foot, in particular the Plantar Fascia. Walking on the forefoot also tightens the calf muscles and directly loads the Plantar Fascia. The tightness in the calves causes a pulling on the heel and this is a contributing factor in the development of the heel pain.
This patient informs the Sports Podiatrist that he has had many ankle sprains in the past and that he has a tendency to “go over” on his left ankle, more than his right. This patient’s physiotherapist instructed him to perform calf stretches to assist in the recovery of his ankle injury. He was dropping his heel off the back of a step and holding it for 30 seconds. There is a chance that he strained his Plantar Fascia whilst performing these stretches or that he did too many stretches for too long, and this strained the fascia, causing it to pull on the heel.
This gentleman decided to roll his foot on a frozen coke can each afternoon and before bed. He reports temporary relief at the time but an increase in symptoms later that day and the next morning. He would take a beach towel and throw it around his forefoot and then lie back and pull the towel, to stretch his Plantar Fascia and calf muscles. Once again, temporary relief was the experience and no long term benefit after stretching daily for 2 weeks. His heel pain persisted and was present every day.
A work colleague informs him that he has the symptoms of Plantar Fasciitis and he then seeks the help of a Sports Podiatrist.
There was a typical jump response with the Plantar Fascia squeeze test. Pain was prominent on the medial aspect of the heel and also the central portion of the base of heel. There was also arch pain in the left foot as mild pressure was applied the sole. Patient was able to perform a single leg heel raise with only mild heel pain.
This gentleman was able to walk bare foot on the treadmill while we recorded his gait with the iPad digital software. He experienced pain on heel strike and mild heel pain during heel lift. His tight calf muscles were noted, causing an early heel lift. Mild pronation was noted at the right rear foot – less in the left foot due to ankle injury and stiffness.
This patient was suffering with Plantar Fasciitis as well as lateral ankle pain from the football injury. He was still unable to walk normally, due to the heel pain, without limping. To this end it was important to unload the whole foot and ankle via the use of an immobilisation boot. Full height boot with rocker sole and air pump for extra security. He was advised that he would be using the boot as much as possible for at least 3 weeks and that he could come out of the boot once he felt comfortable and able to do so.
This patient also commenced a course of Shock Wave Therapy, whereby 2000 reps were applied to the bae of the heel and the Plantar Fascia at a rate of 5 HZ and at 1.3 bars of pressure. He was informed that we would carry out 1 session per week with a minimum of 5 days and a maximum of 7 days in between each session.
He was instructed to apply ice packs to the injured ankle and the heel pain area at least once a day and preferably 3 times a day for 30 minutes. Patient’s with Plantar Fasciitis must not apply heat to the affected area, even if it gives short term relief.
Specific calf stretches were demonstrated so that the patient could gain an increase in ankle joint movement, without straining the Plantar Fascia during the stretch. Stretching was to be done in the morning before applying the boot and in the evening before bed, when the boot was removed.
After 4 weeks and 4 sessions of Shock Wave Therapy this patient was able to remove the immobilisation boot and transition into firm, supportive trainers. His heel pain although still present was very mild. The swelling and stiffness in his ankle had subsided and he had approximately 90% normal range at the joint. Continued support for the left foot was required, in particular for the Plantar Fascia. Cases of Plantar Fasciitis settle much quicker when the Plantar Fascia is unloaded. The patient was informed that we would now use rigid sports tape to support the fascia and that this would resolve his heel pain completely over the next 3-4 weeks. The strapping would be re-applied each week and the Shock Wave Therapy would continue for 2 more weeks. He was advised to continue applying ice packs to the heel and wear his trainers as much as possible.
At the 6 week follow up appointment the heel pain had subsided completely and the Plantar Fasciitis had healed.
NB: Please do not take this case study as general advice. Treatment for Plantar Fasciitis and other foot conditions is tailored specifically to different patient’s.
Written by Karl Lockett