In April of 2017 a 41 year old male presented to the Sydney heel pain clinic in Miranda complaining of plantar fasciitis. He described pain under the base of his heel that had been present for 9 months. This gentleman was in good physical health and was a keen runner who enjoyed middle distance running 3 to 5 days a week. This patient reported no history of foot or ankle problems aside from a fractured toe 7 years ago. During his running career he had encountered no heel pain and has never have plantar fasciitis before. The patient reports that he is unaware of anything that could have contributed to his heel pain. His running program was consistent, his running shoes were the same, and he was exercising at the same pace and frequency as he had always done for the last 3 to 4 years. This gentleman enjoys running each morning before work covering approximately 7 km each run. His running shoes are Asics Gel Nimbus, and he has worn this particular pair of shoes for the last 6 months. This gentleman reports that the pain from his plantar fasciitis is worse first thing in the morning and after periods of being sat down. During his run, he feels pain for the first kilometre which subsides quickly. The remainder of his run is relatively pain-free and he’s able to complete his route. This patient reports symptoms that are very common with plantar fasciitis, and his condition causes pain in the heel for the hour or two that follows his run. He describes pain while sitting at his chair in the office, and pain when he stands up to walk to the fax machine. Patients with plantar fasciitis often report these types of symptoms.
Due to the frustration with this plantar fasciitis, the patient decided to carry out some vigorous stretches through the sole of his foot. For approximately one week he carried out the classic calf stretches while standing upright leaning against a wall. Being a keen runner, he was keen to rid himself of this pain and return to his regular exercise without this hindrance. To this end he was carrying out this stretching program up to 5 times a day. However, after six days of stretching, there was a slight increase in pain from the plantar fasciitis. Please note, patients with plantar fasciitis often find that this is the case due to poor stretching technique.
The sports podiatrist at the Sydney heel pain clinic carried out a thorough physical assessment and confirmed that this patient did in fact have plantar fasciitis. Firm pressure was applied to the base of the heel and the medial slip of the plantar fascia in the patient’s right foot, and this elicited pain consistent with the symptoms that he felt on a day to day basis. The patient was informed that plantar fasciitis is not a lifelong ailment, as in osteoarthritis, and that with the correct treatment plan he would make a full recovery within 6 to 8 weeks. However, in order to determine the best treatment plan it was necessary for the podiatrist to carry out a biomechanical assessment.
In order to determine the cause of this patient’s plantar fasciitis it was important for the podiatrist to assess the patient walking and running barefoot on a treadmill. Bisection lines were drawn on the back of the heel and the Achilles tendon. The patient was asked to walk and then run on the treadmill while the podiatrist recorded his gait cycle using digital software on an iPad. The video was replayed in slow motion while observations were made and biomechanical anomalies noted. In many cases, patients with plantar fasciitis will demonstrate an early heel lift due to calf muscle tightness, and this was clearly the case with this particular patient. Furthermore, this patient demonstrated severe over pronation in both feet due to ligament laxity. Assessment of the ankle, knee and elbow also revealed ligament laxity. It was explained to this patient that the cause of his plantar fasciitis was multifactorial. The weakness in the ligaments leading to hypermobility and compensation by the calf muscles. Furthermore, the tightness in the calf muscles adding additional stress to the heel during gait. Both of these factors would lead to stress and strain on the plantar fascia which results in plantar fasciitis.
This patient was advised that his plantar fasciitis would make a full recovery within 6 to 8 weeks once his biomechanical anomalies were addressed and the treatment plan was put in place. He was advised that a strict calf stretching program would be crucial and that he would need to remove soft liners of his running shoes and replace them with motion control prescription orthotics, which would reduce the strain on the plantar fascia and allow it to heal naturally without injections or tablets. The calf stretching technique would be very important and he was shown exactly how to perform this exercise. He was advised that his plantar fasciitis would not recover and would probably deteriorate if his stretching technique was poor. The podiatrist took 3D digital foot scans of the patients feet and completed a prescription design form. The patient was advised that his orthotics would be ready for fitting in 2 weeks time and that these would be inserted into his running shoes. In order to apply some support to the feet while waiting for the orthotics the podiatrist applied rigid sports tape to both feet to reduce pronation and to minimise the stress on the plantar fascia.
Two weeks later, the patient returned to have his orthotics fitted to his running shoes to treat his plantar fasciitis. The patient had been compliant with calf stretching and reported a small improvement in his condition even though he had continued with his running program. The carbon fibre orthotics were fitted into his Asics Gel trainers and were tested on the treadmill while the podiatrist took an additional video. Foot and shoe alignment appeared to be satisfactory and the patient reported no discomfort with his orthotics. The patient was advised to gradually introduce his orthotics and to not use them too much too soon. He was advised to refrain from running with the orthotics for the first 7 days. Following the introductory period, he was advised to wear the orthotics all day every day in order that his plantar fasciitis could recover quickly. He was also advised to apply cold ice packs to the affected area.
After 4 weeks the patient returned for a follow up appointment and reported approximately 60% improvement in his plantar fasciitis. The podiatrist confirmed that the treatment Plan would continue and no changes were made. AT the 8 week check-up the patient reported that the pain from his plantar fasciitis had subsided. He did report some mild stiffness in the mornings but this would subside quickly. Once again, the patient was informed to continue with the treatment plan but to return to the clinic if his improvement plateaued. He was also advised to continue the use of his orthotics after the plantar fasciitis had fully recovered, due to his inherent foot weakness / lax ligaments.
Please do not take the above information as general advice. The information contained here in this case study is specific to one individual. If you suffer with plantar fasciitis you should contact a sports podiatrist or other medical professional.
Written by Karl Lockett