A fit and healthy 52 year old male presented to the Sydney heel pain clinic complaining of heel pain from plantar fasciitis in his right foot. This gentleman is a keen tennis player who plays competitively at the local tennis club. He trains two to three times per week and competes on a weekend. He has been complaining of heel pain from plantar fasciitis for approximately 6 or 7 months. He informs the podiatrist that the condition came on slowly but that approximately 3 weeks ago became extremely sore. The heel pain prevents the patient from walking without a limp. Each morning the pain from the plantar fasciitis causes a patient to hobble around his bedroom for the first 5 or 10 minutes until the blood flows and the acute pain reduces slightly. The heel pain then becomes more bearable and the patient is able to complete his morning routine with mild discomfort.
At this time of consulting with the patient, he had not reduced his training regime and was continuing to play his regular sessions of tennis. He describes to the podiatrist a situation that allows him to play tennis and get through the session once the foot has warmed up. However, approximately an hour or two after the session, and particularly when the patient has been seated, the heel pain returns with a vengeance as he becomes mobile again.
This patient was informed by his family doctor that his heel pain would take approximately 18 months to settle, and that there were no reliable treatment options for plantar fasciitis. He was referred for an x-ray which returned negative. No heel spurs work present. The patient requested some prescription medication to reduce inflammation and heel pain.
The patient experienced mild pain relief from the medication but decided to stop using the tablets after 2 weeks. He explains to the podiatrist that the medication felt like a band-aid solution and that he wanted a deeper understanding and more thorough treatment plan. After performing some online research he typically found conflicting information on a variety of web pages for plantar fasciitis treatment. Following this he decided to make an appointment at the Sydney heel pain clinic to avoid prolonging his condition any further.
The sports podiatrist carried out a thorough physical foot and lower leg assessment in order to confirm that the plantar fasciitis was the cause of the patients heal pain. The patient reported pain on palpation of all of the typical parts of the foot the correspond to plantar fascial irritation. Namely the medial aspect of the base of the heel bone. This is known as the plantar fascial attachment.
Typical of a tennis player the podiatrist informs the patient that he demonstrated a restricted range of motion through the ankle joint due to tight calf muscles. He was informed that calf stretching with the foot supinated would form part of his treatment plan for the plantar fasciitis. This particular patient demonstrated and extreme jump response when mild pressure was applied to the base of the heel, indicating an extremely acute case of plantar fasciitis. To this end the podiatrist decided not to carry out a biomechanical assessment on the treadmill but instead progressed to the treatment plan.
The podiatrist explained to the patient but there was a chance he had developed micro tears in the plantar fascia and that the quickest and most reliable way to treat him would be by the use of an immobilisation boot. The onset of the patient’s condition corresponds well with the incidence of a plantar fascial tear, namely that the condition was mild for approximately 6 months before becoming extremely acute approximately 3 weeks ago. It is likely that the patient developed a plantar fascial tear during a game of tennis at this time. An ultrasound referral would give a clearer understanding as to the level of pathology within the plantar fascia. The report would not affect the plantar fasciitis treatment plan.
The sports podiatrist applied rigid sports tape to the affected foot and fitted the gentleman with a full height immobilisation walking boot. He was given a referral to Medscan imaging and the report would come back to the clinic within the next 5 business days.
The Sydney heel pain mobile phone application was installed on the patient’s smart phone and he was instructed to read the literature pertaining to the treatment of his plantar fasciitis. He was asked to stop all other forms of treatment in view of the fact that some home treatments can cause problems.
The patient was advised to apply soft ice packs to the base of his heel on a daily basis and to elevate the foot during the process. Unfortunately in this particular case the patient was advised to stop all forms of physical activity on his feet.
The patient returned to the Sydney heel pain clinic 5 days later for a follow-up assessment and a discussion of the ultrasound report for his plantar fasciitis. The reports confirmed a deep surface tear measuring 17 mm by 3 mm. The patient was advised that he should remain in the immobilisation boot for at least another 3 to 4 weeks and possibly 6 to 7 weeks. Due to minimal blood flow to the plantar fascia the healing is slow even though the foot is immobilised and thoroughly supported.
The podiatrist booked the patient in for shockwave therapy a week later. The shock Wave therapy would increase blood flow and stimulate healing and the patient would undergo at least three to four sessions with weekly intervals. The shock Wave therapy does reduce the heel pain but this is simply a positive side effect.
After 4 weeks the patient was able to walk on the treadmill in the clinic without limping and therefore a biomechanical assessment was carried out in order to determine the cause of the patient’s plantar fasciitis and heel pain. This patient demonstrated an extremely rigid foot type with a very high arch and minimal shock absorption or pronation. To this end the patient was advised to use arch supports inside his tennis shoes which would unload the sole of the foot and reduce strain on the plantar fascia long term. He would need to use the arch supports diligently for the next month or two to ensure complete healing of the plantar fasciitis. A supinated calf stretch was demonstrated and the patient was advised to follow these instructions in the Sydney heel pain mobile app.
6 weeks later the patient returned to the clinic and was completely free of any symptoms. There was no longer any heel pain first thing in the morning and the patient was able to walk throughout the day with his trainers and arch supports without feeling any pain. The podiatrist designed a physical activity program for the patient in order that he could slowly become more active without exerting too much stress on his foot over a short period of time. This allowed the patient to return to tennis within a month.
The patient was advised to return to the clinic if his heel pain persisted or if he felt like his plantar fasciitis was returning.
Please be aware that the information contained in this case study is specific to one person. If you think you have heel pain or plantar fasciitis please consult with a suitably qualified sports podiatrist.
Written by Karl Lockett