A 27-year-old male attended the Sydney heel pain clinic complaining of plantar fibroma, but demonstrated symptoms of plantar fasciitis and Achilles tendonitis. He had arch pain in both feet and felt most of his pain just in front of the heel at the transition into the arch of the foot. He was experiencing equal levels of pain in both feet which had been ongoing from more than 6 months. The patient is a nurse, therefore has an understanding of foot anatomy and conditions that cause pain in the sole of the foot such as plantar fasciitis. However, this individual did not experience pain under the base of the heel, which is common with plantar fasciitis, therefore he requested an ultrasound from the doctor. Due to the extended periods of time that this person spends on his feet, being a nurse and walking large distances around the hospital, he also felt general foot pain, calf strain and some pain in the Achilles tendon which he attributed to Achilles tendonitis. The sonographer performing the ultrasound investigated the Achilles tendon in addition to the plantar fascia at the base of the heel. Interestingly, the report came back and confirmed Achilles tendonitis, plantar fasciitis and also plantar fibroma in both feet.
This patient would spend at least 8 hours a day on his feet and walk approximately 16000 steps each day. Due to the extreme heel pain, and pain from the plantar fasciitis, he discarded his current nursing shoes and replaced them with Brooks Addiction, black walking shoes. He reported a slight decrease in pain initially, but after 2 days the benefits were minimal. The sonographer informed to the patient that an injection of cortisone would be highly beneficial for the plantar fasciitis, and that PRP injections would be beneficial for the Achilles tendon. The patient was averse to injection therapy what but did accept the doctors’ invitation to use oral medication to reduce inflammation. The anti-inflammatories did reduce some of the pain from the Achilles tendonitis but did not seem to help with the plantar fasciitis. The patient felt frustrated and was also confused. Was the pain due to the plantar fasciitis or the plantar fibroma?
The patient had not exercised for more than 3 months, and reported a slight increase in body weight due to this inactivity. Ordinarily, he would play basketball with work colleagues twice a week, and would enjoy trail running on occasions. He informed the sports podiatrist that the increase in body weight was possibly adding to the pain from the plantar fasciitis and Achilles tendonitis. Online research lead to some home remedies that were inclusive of rolling his feet on a frozen water bottle each evening before bed. While this created some short-term relief, he informed the podiatrist that they would be an increase or a spike in pain in the few hours that followed. In terms of stretching, the patient was regularly performing step stretches, whereby he would lower his heels from a step before contract in the calf muscles and raising them. These exercises were performed several times each day for approximately 4 days before the patient stopped due to a significant increase in arch pain. Please note, it is quite Common for patients with plantar fasciitis to experience a significant increase in pain when performing these types of exercises. The same can be said for patients with Achilles tendonitis also. While these common exercises can be beneficial to some patients, they do pose a risk to patients with acute conditions.
The sports podiatrist carried out a physical assessment to determine the severity of the plantar fasciitis. Firm finger pressure was applied to the attachment of the plantar fascia at the base of the heel, but there was minimal / no pain reported. Further forward and into the arch of the foot, when pressure was applied to the plantar fascia the patient retracted his foot due to the pain. Equal amounts of pressure were applied and equal pain was present bilaterally. Pain was more severe medially. The podiatrist reassured the patient that his symptoms were classic for plantar fasciitis and that his pain levels seemed to indicate that the plantar fascia had not become torn. The patient was informed that there were in fact several treatment options for plantar fasciitis and that he would make a full recovery. He was also informed that patient education was crucial, and to this and the Sydney Heel Pain mobile application was installed on the patient’s mobile phone. This would ensure speedy and full recovery of the plantar fasciitis.
Ultrasound gel was applied to the sole of the foot and using a sterile glove the sports podiatrist assessed the sole of the foot from the base of the heel towards the toes. Approximately 5 centimetres from the attachment at the heel a small nodule could be felt in the sole of the right foot. The same findings appeared on the left foot, approximately 4 centimetres from the attachment of the base of the heel. This nodule was approximately 10 mm in length and 10 millimetres in width. The ultrasound report confirmed that the plantar fibroma were present. The patient was informed that the plantar fibromas do not always cause pain, and that the arch pain he was reporting was more than likely a result of the plantar fasciitis. However, plantar fibroma can be painful if firm pressure is applied. The arch support inside a shoe, if too high, can certainly apply pressure to the plantar fibroma which can be painful. Large and painful fibromas can be treated surgically or with injection therapy.
The sports podiatrist carried out of physical assessment around the back of both heels and into the lower calf area along the line of the Achilles tendon, and was able to confirm the classic symptoms of Achilles tendonitis. Fortunately, there was no pain at the insertion of the Achilles tendon onto the back of the heel bone. There was no thickening or redness of the Achilles tendon, however there was pain on lateral pressure and compression of the tendon.
The sports podiatrist informed the patient that he definitely had pain from the Achilles tendonitis and the plantar fasciitis. However, it was likely that the plantar fibroma were asymptomatic. The treatment for both of these inflammatory foot conditions would be multifactorial and would consist of one or a combination of the following: Shock wave therapy, dry needling, stretching, orthotic therapy and strapping. In order to determine which of these treatments would be suitable, the patient was rebooked into the clinic for a thorough biomechanical assessment. Further treatment options would be discussed at the follow up appointment.
Please note that the information contained in the first part of this case study is specific to one individual and should not be taken as general foot care advice. If you think you have plantar fasciitis or Achilles tendonitis you should consult with a suitably qualified sports podiatrist.
Written by Karl Lockett