A 36 year old male attended the Sydney heel pain clinic complaining of Plantar fasciitis in his right foot and Achilles tendonitis in his left. This healthy individual had been experiencing bilateral heel pain for over 18 months and was struggling to find any resolve. He describes pain in the base of his right heel and around the back of his left ankle. The heel pain from the Plantar fasciitis seemed to be troubling this gentleman more than the Achilles tendon problem on the left side. He describes the Plantar fasciitis as being excruciating and at times he is forced to hobble. Each morning when he rises from his bed he is forced to bear most of his weight on his left side in order to avoid a sharp stabbing pain under the base of his right heel. He reports to the sports podiatrist that on some days he needs to hold on to his bedside cabinet or lean against the wall while he’s walking. This individual patient describes common symptoms of Plantar fasciitis in that following his morning shower the Plantar heel pain begins to ease. After he has walked around his bedroom while preparing to leave the house, he reports a further improvement in symptoms.
This patient reports a further increase in symptoms if he has been seated for more than 5 or 10 minutes. At other times of the day there are extended pain free periods. When the pain increases he describes a stone bruise sensation or a sharp stabbing feeling like a hot knife. He has never suffered with heel pain before and has never been diagnosed with Plantar fasciitis.
With respect to the Achilles tendonitis the patient describes stiffness and pain but no stabbing sensations. His symptoms are less aggressive in the left ankle than the right foot. Mornings are also symptomatic and as with the Plantar fasciitis, the patients symptoms improve the more he warms up and begins to move.
In terms of physical activity this patient reports to the sports podiatrist that he has always been fit and active. He is not overweight and does not report any chronic illness or ill health. Typically this patient would attend gym classes and enjoyed treadmill and cross training machines. He also enjoys social touch football and occasional games of tennis. Prior to the onset of this patients Plantar fasciitis and Achilles tendonitis, he agreed to join some friends at a local basketball tournament. He recalls that following the third game of basketball he began to feel an increase in calf muscle tightness and overall foot pain in general. He described a burning in the soul of his feet and a dull ache through both ankles. Quite soon after this, he recalls a very sudden onset of pain under the base of his left heel which he later discovered was due to Plantar fasciitis. The calf muscle tightness was coupled with cramping and quite soon this led to the increase in symptoms through the left ankle, which developed into Achilles tendonitis.
This patient did not restrict his physical activity during this time but instead continued with the basketball tournament until it’s close.
This patient decided to refrain from all physical activity following the onset of these injuries and spent the next four weeks resting as much as possible. He found only a slight improvement in symptoms and therefore made an appointment with his local doctor. He was referred for x-rays and was referred to a reputable Sydney based sports medicine doctor. The sports medicine doctor did confirm the presence of Plantar fasciitis and Achilles tendonitis and to this end referred to patient for ultrasound imaging. The ultrasound imaging reports further confirmed the diagnosis but also confirmed the presence of a deep surface tear in the right Plantar fascia.
The sports medicine doctor prescribed a course of medication to reduce pain and inflammation and advise the patient to perform stretching and strengthening exercises on a daily basis. The same exercises were to be performed on both feet in order to treat both conditions.
The patient was diligent and performed the stretches and exercises religiously but found no relief. He reports to the sports podiatrist that the pain from his Plantar fasciitis increased dramatically following repetitive exercises on the right foot.
The patient did not return to the sports medicine doctor but instead began to carry out online research. He purchased a night splint in an attempt to treat the Plantar fasciitis in the right foot. He also began rolling his foot on a frozen bottle of water on a daily basis. He decided not to stretch or strengthen the foot as this would only make things worse. Furthermore, this patient purchased a pair of stability running shoes from athlete’s foot and wore these every day. He decided not to walk using thongs or slippers or in his bare feet. He would use his trainers to and from the office and change into his business shoes when at work. In doing so he found there was some slight improvement with the Achilles tendonitis but minimal improvement with respect to the Plantar fasciitis. The night splint was disregarded due to discomfort, which is common.
This patient was unable to continue with the medication due to side effects causing reflux and stomach pain.
With the patient seated and non weight bearing the sports podiatrist applied mild pressure to the base of the heel around the attachment of the Plantar fascia, in order to determine the severity of the Plantar fasciitis. With mild pressure centrally and medially, the patient demonstrated a significant jump response and retracted his foot immediately. Firm pressure was applied through the arch of the foot and it was noted by the podiatrist that the distal arch was tender but the proximal arch also very sore. This painful area correlated with the location of the deep surface tear.
With the patient lying prone the podiatrist was able to examine the Achilles tendon. Typical of patients with Achilles tendonitis, the patient reported significant pain when lateral pressure was applied with finger and thumb. Around the painful area there was redness and some mild heat. The tendon felt slightly thicker and less pliable. This is commonly the case in patients with chronic Achilles tendonitis.
The sports podiatrist decided not to carry out a biomechanical assessment due to the severity of the patients Plantar fasciitis. The patient was advised that biomechanical assessment would be carried out at some point in the near future after significant improvement in symptoms. At the time of consultation the patient would not be able to walk or run naturally on the treadmill without limping. This would distort the findings and render the assessment useless.
It was explained to the patient that the treatment of his Plantar fasciitis would involve the use of a full height rebound walking boot. Due to the severity of his condition and the tear within the facia this would be the quickest and the most reliable way to relieve the pain and treat the facia. The Plantar fascia would heal quickly and naturally with the use of the walking boot. The patient did enquire about the use of orthotics but the podiatrist discouraged this treatment option due to the severity of his condition. He was advised to use the boots as much as possible throughout the day for at least three to four weeks. The immobilisation boot could be removed for sleeping, showering and driving.
The patient tested the boot in the clinic and immediately reported a significant improvement in pain levels from the Plantar fasciitis. His foot was stable inside the boot and did not move, and the pain level was close to 1/2 out of 10 on the vas score.
It was explained to the patient that after approximately 3 to 4 weeks there would be a change in the treatment plan and this may involve strapping, stretching, shockwave therapy or orthotic therapy.
The sports podiatrist advised the patient that his Achilles tendonitis would improve quickly if treated with shockwave therapy. One session per week for approximately 6 weeks. The shockwave therapy would stimulate blood flow and promote healing of the tissue. The patient was also provided with a 9 mm heel wedge and this was placed underneath the liner of his functional running shoe, left foot only. Elevating the heel reduces the strain on the Achilles tendon and allows it to recover.
Calf stretching was demonstrated and the patient was advised to perform these on both legs every evening before bed. (following the removal of the boot at night)
After 4 weeks the patient was able to take short walks without the boot as the symptoms from the Plantar fasciitis had improved significantly. The sports podiatrist applied firm pressure to the base of the heel and through the arch of the foot and while the pain was still noted, the patient reported that the pain was much less. At this 4 week point the patient also reported an improvement of approximately 50% in the pain from his Achilles tendonitis on the left foot. He had been diligent with calf stretching and was using his running shoes with the heel lift inside.
During this appointment at the four week review the sports podiatrist carried out a detailed biomechanical assessment with the patient walking on the treadmill. He was also asked to run as naturally as possible on the treadmill while his gait cycle was captured using digital software. The sports podiatrist replayed the digital software footage and notes were taken. All biomechanical anomalies were noted and it was decided to arrange prescription orthotics. The patient was asked to remain in the moon boot until the orthotics arrived 10 days later, from the lab. He was compliant with this request. 10 days later he returned to collect his prescription orthotics and as planned the walking boot was removed. The prescription orthotics were fitted into the patients shoes and it was explained to the him that these supports would now provide all of the necessary control to reduce the strain on the Plantar fascia and allow the Plantar fasciitis to recover completely.
The patient reported further improvement in the Achilles tendonitis at this stage and the treatment was ceased after the 6th session. The heel lift was removed from the patients left running shoe in order that he maintain equal heel height and equal hip position.
The patient was booked in for a follow up two weeks on from the orthotic fitting so that the sports podiatrist could monitor the improvement in the Achilles tendonitis and the Plantar fasciitis. The patient did not report any side effects or problems from the orthotics. He advised the sports podiatrist that they were being used on a day-to-day basis and were comfortable. While walking with the orthotics the patient did not feel pain from the Plantar fasciitis or the Achilles tendonitis. He did report some mild morning stiffness and mild pain in the Achilles tendonitis and Plantar fascia respectively, each morning when rising from bed. The symptoms would settle quickly and were not severe.
The podiatrist gave clear instructions on a reintroduction to physical activity in order to prevent a return flare up of the Plantar fasciitis or Achilles tendonitis. He was asked to re-introduce physical activity slowly with sufficient rest days in between each session to begin with. He was advised to increase the workload gradually.
As with all Sydney heel pain clinic patients this individual was instructed to return to the clinic if his Plantar fasciitis deteriorated or if the symptoms of his Achilles tendonitis increased. No further appointments were noted.
Please note that the information contained in this case study is specific to one particular person. It should not be taken as general advice. If you have been diagnosed with Plantar fasciitis or Achilles tendonitis then you should seek the help of a suitably qualified medical practitioner or sports podiatrist.
Written by Karl Lockett