Case Study July 2016 – Plantar Fasciitis Causing Heel Pain in Oz Tag

Plantar Fasciitis Heel Pain

A 44 year old male presents with pain in the arch and the heel area of one foot following training for oz tag competition. The heel pain has been present for 3 weeks and came on very suddenly and the arch pain has been excruciating. The patient felt a snap in the arch of his foot during the game and was unable to weight bear for 2 days following. His doctor informed him that he had Plantar Fasciitis and an MRI was arranged. When the patient arrived with his MRI report it was confirmed that he did indeed have Plantar Fasciitis, but he also had a 1cm tear in the fascia, distal to the heel and along the mid arch area.

The patient informed us that the heel pain was so intense and that the Plantar Fasciitis so unbearable, that he had been placing his entire foot into a bucket of iced water. He did this on the day of the injury and each day for a week afterwards.

Physical assessment for Plantar Fasciitis

The patient was face up on the treatment table and firm finger pressure was applied to the medial aspect of the heel and central and medial slip of the Plantar Fascia. As to be expected with a case of Plantar Fasciitis, the patient had a positive “jump response” but did not retract his foot as much as would typically be seen. The iced baths clearly helping to reduce the inflammation and hence reduce the plantar fasciitis heel pain. Finger pressure was applied to the mid arch area, along the medial side of the foot and there was an area of tenderness that correlated with the location of the Plantar Fascial tear on the MRI report. The patient was informed that while he definitely had Plantar Fasciitis, his treatment plan had to be designed around the fact that he had been clinically diagnosed with a tear in the plantar fascia. Plantar Fasciitis without a tear can be treated more conservatively, but torn fascia needs a different form of intervention.

Surprisingly, this patient requested as much treatment as possible as he was keen to recover in time for oz tag finals in 3 weeks. He was informed that his heel pain will improve but may not resolve completely in 3 weeks as Plantar Fasciitis typically takes longer than this to heal. Most cases of Plantar Fasciitis will resolve inside approximately 6 weeks once treatment starts. Treatments such as shock wave therapy and dry needling can accelerate this process.

Treatment for Plantar Fasciitis involving a tear

The patient was informed that his treatment would involve the following:

  1. Shock Wave Therapy
  2. Strapping
  3. Immobilisation boot
  4. Ice packs
  5. Calf stretching

Shock Wave therapy for Plantar Fasciitis

Plantar Fasciitis usually recovers quicker with shock wave therapy. This patient was treated at 1.5 Bar, 5 HZ and 2000 reps which lasted approximately 4 minutes. The probe was placed under the ball of the heel and moved along the mid arch of the foot around the area of torn fascia. The treatment was well tolerated and the patient reported that his plantar fasciitis heel pain reduced slightly, immediately after the treatment.

Plantar Fasciitis Strapping

Low die taping was applied with rigid sports tape. Plantar fasciitis will usually feel better immediately with correct strapping and this patient reported less heel pain when weight bearing.

Immobilisation boot for Plantar Fasciitis

This patient was fitted with a cam walker and was asked to use the boot at all times, only removing it to sleep, shower and drive.

Ice packs for Plantar Fasciitis

Plantar Fasciitis and the associated heel pain will reduce with the use of ice packs. The ice serves to constrict blood vessels and reduce inflammation, which reduces pain and can accelerate healing. This patient had already benefited from placing his entire foot in a bucket of iced water and he was happy and willing to continue to do the same. He was asked to do this at least once a day, particularly in the evenings, before bed. He reported that the pain that he was getting first thing in a morning as his foot hit the floor reduced significantly with the use of ice. To this end, it was not necessary, nor was it a good idea for this patient to take anti – inflammatory medication.

Calf stretches for Plantar Fasciitis

It is not uncommon to find that patients suffering with Plantar Fasciitis and other forms of heel pain have tight calf muscles. The tightness is usually a reduced range of motion at the ankle joint due to stiffness in the soleus or gastrocnemius muscle groups that cross the ankle joint. This patient was shown a very specific way to stretch the tight muscles without straining the plantar fascia at the same time. He was asked to demonstrate the stretches back to the Podiatrist in the room, 3 times on each leg so that his technique was good. This patient did not have the typical reduced range of motion that is usually seen, but the use of the Immobilisation boot and his compensated gait pattern would likely lead to stiffness in the muscles groups concerned. Hence, he was informed that stretching had to be part of his daily routine.

Weekly check ups

The patient returned to the clinic once a week for treatment with the shock wave therapy unit and to have his strapping removed and replaced. The rigid sports tape will usually stay in place for at least 5 days, regardless of getting wet in the shower or the pool. Patients are shown how to re-apply the tape in a very simple but effective manner, if they do remove it and wish to replace it.

3 treatments were carried out with the shock wave therapy machine and the patient reported feeling better each week. After the 3rd treatment, and to the surprise of all involved, there was only very mild pain in the heel and the patient was excited to go to oz tag training that evening. It was apparent that the Plantar Fasciitis had almost fully recovered and it was likely that the tear had healed. There was some mild plantar fasciitis heel pain when finger pressure was applied but not enough pain to cause concern.

No follow up appointments were made for this patient. He was asked to return to the clinic if his pain persisted and if it got worse with oz tag.

Please note that the treatment for this patient should not be taken as medical advice for a foot condition that you may have. If you have heel pain or Plantar Fasciitis you should be examined and advised by an appropriate health care practitioner.

More information: How we treat heel pain

 

Written by Karl Lockett

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Plantar Fasciitis – Case Study 7 October

Plantar Fasciitis

Plantar Fasciitis is a condition commonly seen in male and female runners. A 46 year old male presents with pain in the base of his heel of approximately 5 months. He is a middle distance runner who has registered for a Marathon in Chicago, USA and he has been covering approximately 75K’s per week over 4 runs, as part of his training programme. He has been feeling heel pain and symptoms consistent with Plantar Fasciitis but reports that after 2 or 3 K’s of running he does not feel any pain at all as his foot “warms up” (this is common and normal). His heel pain is apparent in the mornings when his foot is placed on the ground and he feels pain after being sat down for periods of 30 minutes or more. His Plantar Fasciitis symptoms are worse on the days that he runs, particularly that same evening and the very next morning. He has never had Plantar Fasciitis before although he has been aware of some tightness in the arch of his foot. His heel pain is apparent in one foot only and his “good foot” is not sore at all. This patient has been to his physiotherapist once a week for 6 weeks and reports a slight, but short lived, reduction in pain following his sessions but insignificant improvement over all. His physiotherapist correctly diagnosed Plantar Fasciitis and advised this patient to apply ice packs to his heel and to roll his foot on a golf ball. This provided some relief but was not enough to eradicate the condition.

Physical Examination for Plantar Fasciitis

The patient was asked to lie face up on the treatment table and firm finger pressure was applied to the central and medial slip of the Plantar Fascia, under the base of the heel. As can be expected in cases of Plantar Fasciitis, the patient had a positive “jump response” and reported pain at the time of pressure being applied. The pain that the patient felt was the same as the pain that he feels when weight bearing. The patient was informed that he has Plantar Fasciitis, but that the fascia is not likely torn. There were some symptoms that he did not have which are usually present in patients who have torn their Plantar Fascia.

Joint and muscle testing

Most cases of Plantar Fasciitis involve a limited range of ankle joint dorsiflexion due to tightness in the calf muscles. However, this patient had a good range of motion and reported regular calf stretching and weekly sports massages. However, his troublesome foot did present with an extremely limited range of motion at the hallux (big toe joint). It is not uncommon to see patients with Plantar Fasciitis who also have a condition known as Hallux Rigidus or Hallux Limitus whereby dorsiflexion and free movement through this joint is restricted. As the first slip or medial slip of the Plantar Fascia inserts into this joint, the dysfunction affects the bio mechanics of the foot and causes and increased load on the Plantar Fascia.

Bio mechanical assessment

Bisection lines were drawn on the patients heels and shins and he was observed running on a treadmill without shoes. Digital software was used to record his foot function and running style. Thirty seconds of footage was recorded so as not to increase his Plantar Fasciitis symptoms. During playback, it was evident that his Hallux Rigidus was affecting his gait. Without sufficient dorsiflexion he was unable to “toe-off” through his big toe joint and there was early re-supination. The bio mechanics in his “good foot” were unremarkable and there was normal pronation and toe-off. It was explained to the patient that his Plantar Fasciitis was likely a result of his dysfunctional big toe joint. This patient had a long stride and was a heavy heel striker. He had been running in an Asics Gel Kayano 21 and he was asked to run again on the treadmill with these shoes on. There was sufficient motion control and support in these shoes during gait, as was observed using the digital software.

Plantar Fasciitis Treatment

In addition to advice on running style and foot placement, this patient was advised that he will need treatment for his Hallux Rigidus and his Plantar Fasciitis. Without treating the Hallux, the Plantar Fasciitis would not likely recover. Hallux Rigidus usually involves osteo arthritic change within the joint and is a degenerative condition. To this end, treatment with a firm pair of orthotics, designed with a Morton’s extension under the troublesome big toe joint was necessary. The patient was informed that the orthotics would also unload the Plantar Fascia and that this would allow healing. He was informed that he would need to wear the orthotics all day, every day, and especially for running, for a period of approximately 6 to 8 weeks. Once healed, and after the Plantar Fasciitis symptoms had subsided, he was asked to use his orthotics more often than not, and to always use them for running. This would prevent a recurrence of the Plantar Fasciitis and would act to reduce the deterioration of the arthritic big toe joint. As the patient did not suffer with over pronation his orthotics were designed with a “mild” prescription and were not overly corrective. His “good foot” needed nothing more than a mild arch support.

As most runners are, this patient was frustrated by this injury and wanted to do as much as possible to assist recovery. He requested shock wave therapy and was treated during his initial consultation and then once a week for 5 weeks. Rigid sports tape was applied to the foot in order to unload the Plantar Fascia. This was changed weekly and the patient reported relief and overall improvement with this technique. He was asked to continue applying ice packs to the heel and to elevate the foot each evening. Orthotics were fitted at week 3 and strapping was continued so as to provide additional support. At week 5 the patient had been using his orthotics for 2 weeks and as expected he was not pain free but his symptoms had improved significantly. He was informed that Plantar Fasciitis does not recover quickly but requires compliance, consistency and patience.

At week 6 (3 weeks with orthotics) the patient reported “tuning a corner” in his healing. His “morning pain” had almost gone completely and pain with finger pressure in the treatment room was a lot less.

Shock wave therapy was ceased at week 6 and the patient was asked to continue with the treatment programme, as healing would continue. He was advised to stop running if his heel pain / Plantar Fasciitis did not resolve completely, until his symptoms subsided. If he was still improving while continuing to run, then his training programme could continue.

As with all cases of Plantar fasciitis he was asked to return to the clinic for further consultation if the heel pain returned or continued. No further follow ups were noted but an annual checkup will be required.

 

Written by Karl Lockett

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CASE STUDY 26 September 2016- HEEL PAIN IN ONE FOOT

A 53 year old female presents with pain in the bottom of her heel of approximately 3 years. She describes the pain as being under the “ball of her heel” and she feels this pain when her foot hits the ground every morning. She also feels the pain when she stands up to walk from her office chair at work and after other long periods of being seated. Her heel pain has been on and off for the last 3 years and has been bearable at times although it has never really subsided completely. Recently, she had increased her level of exercise to partake in an annual run as part of the Sydney Running Festival – the Blackmores half marathon. As her mileage increased so did her pain levels, and frequency of pain. She described her heel pain as being constant and was starting to “take over”.

The patient informed us that she thought she had Plantar Fasciitis, after reading information on line, although she had no imaging to confirm this. Her doctor had arranged an x ray and there was no visible sign of a Heel Spur.

Assessment

A physical examination involved palpation of the plantar fascia at the heel and through the arch. The patient felt extreme pain when pressure was applied to the medial band of the fascia, just distal to the heel – consistent with most cases of Plantar Fasciitis. Her jump response was high and she retracted her foot quickly. She was quite right with her assumption that she in fact was suffering with Plantar Fasciitis and she was informed that she had a severe case, which may involve micro tears.

Bio Mechanical Assessment

This patient was measured and markers were drawn on to her feet and lower legs. She was observed walking and running on a treadmill and analysed using digital recording software. This patient had an unstable foot type. A weakness in her foot and ankle ligaments allowing her feet to over pronate, or collapse severely.

Footwear Assessment

The patients running shoes were examined as were her office shoes and her casual footwear. None of her footwear was appropriate! Her running shoes offered insufficient heel height and a lack of dual density material around the medial heel and arch, which allowed joint hypermobility and soft tissue stress when running. Even though this patient was seated at work she walked 15 minutes each way, to and from the office / train station and would reach 8,000 steps by 5pm.

Imaging

Due to extremely high levels of pain which can be indicative of tears in the Plantar Fascia this patient was referred for an ultra sound scan. The report concluded that although no tears were present there was thickening of the fascia on the symptomatic foot, measuring 8mm compared to 2.5mm on the “good foot”.

Treatment

Plantar Fasciitis treatment will vary from one patient to another and this particular patient was informed that she might need to use an immobilisation boot, due to her pain levels being so high. However, for the 6 days between her initial consultation and her returning to the clinic with her ultra sound scan, she made significant footwear changes and did not remove the strapping that was applied at the time. She ceased running and was feeling 30% less pain.

3D foot images were captured in order to prepare prescription orthotics and the patient returned a week later to have them fitted to new running shoes and new office shoes. She was asked to apply ice packs to her heel every day and to use her running shoes as much as possible, in the evenings and at weekends.

At the 1 week follow up the patient had settled in to her orthotics and felt a lot less pain while walking in them, although her “morning pain” was still present.

At 2 weeks the morning pain was easing and she described a pain level of 6 out of 10, compared to 10 out of 10 before treatment started.

At 4 weeks there was further improvement but the patient was eager to return to running and wanted to accelerate the healing process. She was treated with a cycle of extracorporeal shock wave therapy at 1.5 BAR for approximately 4 minutes. This was repeated at weekly intervals for a total of 6 treatments, increasing to 2.7 BAR.

At week 10 the patient reported minor stiffness in the mornings but no pain at any other times. She was advised to start running short distances, on level ground again with 3 days rest in between each run and to carefully increase the distance and frequency of running.

PLEASE NOTE: This case study and the treatments for this patient should not be taken as general advice. Please consult with a Sports Podiatrist or a suitably qualified medical / allied health practitioner to get the correct advice for your own condition.

 

Written by Karl Lockett

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Case Study 20 August 2016 – Acute Achilles Tendonitis

A 28-year-old male presents to the clinic complaining of excruciating pain at the back of his right leg – near the Achilles tendon area. He reports that the pain came on after a session of playing soccer 3 days ago, after having a 4-month break. He has been limping on the right foot since, and experiences frequent throbbing at the sore region. He has been advised to use NSAIDs by his local doctor, which have been helpful in reducing pain temporarily.

Upon visual examination, the Achilles tendon is swollen and red about 6 cm from its insertion on to the back of the heel bone, as is commonly seen in Achilles Tendonitis. On physical examination, palpation on the middle of the tendon elicits significant pain. No bulbous mass on the tendon or its insertion is noted – which would otherwise indicate a more chronic pathology. The patient is informed that he has Achilles Tendonitis.

A thorough biomechanical assessment is conducted, whereby the patient is asked to walk and run on a treadmill, as his walking and running form is analysed and video recorded. It is noted that he is a heavy heel striker, and pronates mildly through his ankle and sub talar joints. Furthermore, he has tightness in his calf muscles and therefore has a limited range of ankle joint dorsiflexion.

All of the above increase the pull through the Achilles tendon and exacerbate his condition by adding strain.

A footwear assessment reveals that the back soles in his running shoes are worn out and compressed significantly.

It is explained to the patient that he has an acute onset of aggressive Achilles Tendonitis – which is inflammation of the tendon resulting from micro-tears caused by overloading the tendon with a tensile force that is too heavy and/or too sudden. An Ultrasound report confirms that there are no tears.

Treatment

Due to the severity of the inflammation, the focus of treatment is to unload and completely immobilise the Achilles tendon to initiate healing. This is done by fitting an immobilisation boot to his right leg. He will wear the boot until his symptoms decrease or resolve, usually within 4-8 weeks. A heel lift is also added inside the boot to elevate the heel and reduce tension on the Achilles tendon.

He is also advised to ice the area and stretch his calf muscles every night, with the correct stretch technique demonstrated.

The injured tendon is also treated with the Extracorporeal Shockwave Therapy machine to increase blood flow and stimulate tissue regeneration, aiding in faster recovery. This is done at weekly intervals for 5 weeks. Shock wave therapy is a very reliable treatment option for Achilles Tendonitis and other conditions that require blood flow such as Plantar Fasciitis.

Achilles Tendonitis – Follow up

Pain completely subsided within the estimated 6-8-week period. In the long term, he was advised to change his running form, as well as incorporating more frequent calf stretching exercises.

Please note that there are several treatment options for heel pain and similar conditions such as Plantar Fasciitis, Achilles Tendonitis / Tendinosis, Sever’s disease and Bursitis. The most appropriate treatment option for each individual patient can only be selected after a physical examiniation and biomechanical assessment has been carried out.

For more information on other conditions such as Plantar Fasciitis please visit www.sydneyheelpain.com.au/what-is-plantar-fasciitis/

 

Written by Karl Lockett

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Case study 27 June, 2016 – Sever’s Disease

A 12 year old boy presents to the clinic with pain at the back of his heels, which has been present over 4 months. He is a very active boy who runs and plays soccer 8 hours a week. He reports that the pain is much worse after prolonged activity. He understands his symptoms are growing pains, however is very frustrated that he is unable to participate in sports due to the pain.

He has tried voltaren gel and finds that it makes a small difference temporarily. He has also changed his walking patterns to protect the heels.

On visual examination there is moderate swelling and redness at the back of both heels. On physical examination the painful area is squeezed, which is very uncomfortable for the child and elicits his symptoms.

He has Sever’s (also known as calcaneal apophysitis), which is inflammation of the heel bone growth plate, caused by excessive forces. It is very common in physically active growing children aged between 7 to 14 years of age. It is explained to him and his mother that the pain is something he will grow out of past the age of 14, when the plate fuses into bone. However, pain and discomfort can be reduced so he is more comfortable during this phase, and can resume his sporting activities with no or minimal pain.

His running style is assessed, and a thorough biomechanical assessment is conducted. It is noted that he has an early heel lift – indicating he has tight calf muscles. The range of his calf muscles is checked and it is confirmed, they are tight.

The tightness of the calf muscles puts a lot of stress through the Achilles tendon which connects to the back of the heel bone – causing the tendon to pull on the growth plate of the bone, hence causing inflammation.

His footwear is also not appropriate for his foot function, or his condition. The stress on the heels remains while using his running and everyday shoes.

Treatment

A short term treatment plan consisting of resting, icing and elevating the heels with a pair of heel raises placed inside the shoes was put in place. The child was also asked to reduce training load over the next few weeks to allow recovery of the inflamed growth plate.

In the long term, the correct technique of performing calf stretches was demonstrated. His running style was also modified, as his previous running style was putting a lot of strain through the calf muscles and achilles tendon. Footwear changes were also made.

He did not need orthotics as he had no biomechanical issues that needed to be addressed.

At his 4 week follow up, marked improvement was noticed as he was very compliant with the treatment plan. That weekend he ran and reported no pain during or after the run.

He was asked to maintain good calf range and return to the clinic if pain returned.

 

Written by Karl Lockett

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Case study 9 June 2016 – Plantar Fasciitis

A 35-year- old female presents with heel pain in her right foot, which has been present over 6 months. She runs frequently but does not remember sustaining an injury. She reports of increased running activity in the last 2 months. Her job also involves her standing on her feet for extended periods of time.

She thinks the pain is due to a heel spur at the bottom of her foot as shown on an X-ray. Her heel hurts with the first few steps in the morning and subsides shortly after.

Upon visual examination there is no swelling or redness around the heel. On physical examination the medial slip of the Plantar Fascia is very sore.

She has Plantar Fasciitis – which is a very common condition causing inflammation of the Plantar Fascia, a ligamentous structure which attaches to the heel bone. It is explained to her that the heel spur is not causing her heel pain, but rather the pulling of the inflamed Plantar Fascia on to the heel bone.

A thorough biomechanical assessment is conducted and significant pronation of both feet is noted on gait analysis. The range of motion at calf muscles is also checked, and they are very tight – which exacerbates her condition.

The patient reports that she has been stretching her calf muscles and the bottom of her foot regularly. The stretches have not helped. She gets pain while doing the stretches, as the technique is incorrect, which is putting strain through the Plantar Fascia. Furthermore, her footwear is not appropriate for her foot function, which delays the recovery of her condition.

TREATMENT

A treatment plan was put into place to suit the patient’s personal circumstances. In the short term, the patient’s heel was treated with the Shockwave Therapy to increase blood flow to the area and stimulate healing. This was done at weekly intervals for 6 weeks. Patient was asked to stop all incorrect stretches, which were further irritating her condition. The correct technique to perform calf stretches was demonstrated and patient was asked to maintain good range. She was also advised to apply ice packs to the plantar heel area to reduce inflammation.

In the long term, a pair of custom-made prescription orthotics were placed in her shoes to unload the plantar fascia and allow it to recover, as well as controlling her excessive pronation. She will continue to wear the orthotics beyond the termination of her symptoms, as she is on her feet all day for work and the use of orthotics will provide support to the feet and prevent these problems from happening again. The patient was also advised to make footwear changes.

Heel pain subsided within the usual 6 week period and patient was asked to contact the clinic if pain retuned.

 

Written by Karl Lockett

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Case Study 30 May 2016 – Achilles Tendonitis

A middle aged male presents with Achilles pain in both feet of approximately 4 years. He thinks he has Plantar Fasciitis due to the fact that he has heel pain, which he experiences every morning, but he hasn’t been to see a specialist nor does he have an understanding of the 2 conditions. His Achilles Tendonitis is causing pain above the heel, through the section of the Achilles Tendon that can be pinched with finger and thumb. He does not appear to have Achilles Tendinosis as his tendon is not tender to touch at the back of the heel bone.There is no heel spur at the back of the heel. The tendon appears swollen and a little thicker than usual and is also quite stiff to touch.

The patient plays soccer twice a week and wakes up very sore in the Achilles tendons. He hobbles for 15 minutes each day before the pain becomes bearable. He also feels pain throughout the day after he has been driving or sitting for a period of 20 minutes or more.

The patient has an auto-immune condition – Ankylosing Spondylitis, which can cause inflammation in the Achilles tendon.

The patient has been stretching his calves and also eccentrically loading the tendons for 6 months and this has not helped. He has seen his chiropractor who has performed mobilisations and foot adjustments. After analysing his gait – his footwear is not appropriate for his foot function and this would hinder recovery of his Achilles Tendonitis. The stress on the tendon remains while using his day to day shoes, and also his football boots.

Treatment

Footwear change.

Shock wave therapy probe was applied to both tendons – 2000 reps on each leg. This was done at weekly intervals for 5 weeks. The patient was measured and supplied with simple heel wedges inside his shoes to relieve stress on the Achilles Tendon. He was asked to refrain from soccer until the pain had almost gone.

At the first follow up appointment a week later the patient reported he had experienced no pain throughout the day and that the pain first thing in the morning had started to subside. By the second week all pain had gone completely – however there was still some visible swelling and the pain was still there if the tendon was pinched. By the 3rd week both Achilles Tendons were supple and felt soft again. After week 4 the swelling had subsided and there was no pain to pinch – only pressure – which is a normal response. The patient was asked to play soccer at training by week 5 which he did. He felt no pain, just a little stiffness during training and he woke up with no symptoms the next morning. That weekend he played half of the soccer match at full pace and felt fine during and after the game, and the following morning.

Patient was asked to maintain good calf range with very specific calf stretches and also apply ice packs to the Achilles area. He did not need orthotics to control any bio-mechanical issues nor dry needling as his calf muscles responded well to the stretch.

 

Written by Karl Lockett

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