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.
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