A 32 year old female runner presented to the Sydney heel pain clinic complaining of heel pain from plantar fasciitis, that had been troubling her or approximately 18 months. The patient explains to the podiatrist that she is a recreational runner and simply enjoys a 3 or 4 km run, approximately 2 to 3 times a week. She describes a slight increase in weight gain approximately 2 years ago due to some medication she was using for a thyroid gland issue. After gaining approximately 8 kilos in body weight she remembers feeling heel pain in both of her feet. Online research pointed to plantar fasciitis and the patient has been suspicious of this condition ever since. The patient was advised to perform calf stretches and foot exercises in order to rebuild strength in the lower leg area. The patient was diligent in performing these routines but reported an increase in heel pain. She ceased this rehabilitation and began to search for other alternatives to treat her plantar fasciitis. After approximately 6 months of heel pain and without any joy in relieving the symptoms, she consulted with a Sports Medicine Doctor in Sydney. Imaging was arranged and reports confirmed bilateral plantar fasciitis. The left plantar fascia measuring 7 mm, right plantar fascia measuring 8 mm in thickness. The Sports Medicine Doctor offered similar advice to that of the online articles that the patient had already come across. She advised the Dr that she did not want to perform further rehabilitation because it increased her heel pain and prolonged the plantar fasciitis. To this end, the Dr offered cortisone injections.
The patient received ultrasound guided injections of cortisone into both of her heels. She described an immediate relief in pain that lasted for approximately 5 days. Her heel pain returned and she was back where she started.
The sports podiatrist at Sydney heel pain clinic applied pressure to the plantar medial aspect of both heels are noted a significant jump response from the patient, typical of acute plantar fasciitis. The patient described the pain level on a VAS to be 8 out of 10. She also described to the podiatrist that the pain level is elevated in this way on a day to day basis and that when she lies down both of her heels are throbbing.
During this physical assessment the patient reports to the podiatrist that she has significant pain each morning upon rising and that she has been hobbling around her bedroom to reach her bathroom.
Due to the extreme pain levels from the plantar fasciitis the podiatrist decided to arrange a repeat ultrasound. It was explained to the patient that her condition may have deteriorated since the injections and that there was a chance she may have developed tears in the fascia. It is not unusual to encounter soft tissue tearing following the administration of cortisone. The report was conclusive, and the patient had developed micro tears in both plantar fascia.
The patient was advised that the treatment of her plantar fasciitis would be multi-factorial. It was explained to the patient that supporting and unloading the plantar fascial was essential. To this end the patient was fitted with a full height immobilisation boot on her right foot. The boot would be moved to the left foot in due course.
In addition to this, rigid sports tape was applied to both feet in order to prevent displacement of the joints. This would further reduce the load on the plantar fascia. Please note unloading the facia here is the opposite of exercising or attempting to strengthen the foot. – crucial for patients with heel pain.
The patient was advised to apply soft ice packs to the base of her heels every night before bed for approximately 20 minutes. She was advised to avoid using heat. This usually assists with the heel pain that patients encounter first thing in a morning.
The patient was also advised and informed of the importance of calf stretching, not strengthening. Stretching the calf releases the heel and therefore further unloads the plantar fascia – also crucial in cases of plantar fasciitis and heel pain.
The Sydney heel Pain mobile phone application was installed allowing the patient access to the full range of rehabilitation advice including diagrams and an outline of the calf stretching technique.
The patient returned to the Sydney heel pain clinic for a review of heel pain and to assess the progress in healing of her plantar fasciitis. The patient reported approximately 60% improvement in the pain in her right heel. She reported that her left foot was manageable and tolerable so long as she was compliant with advice that included the regular application of rigid sports tape and the use of correct footwear. Ice packs and stretching techniques had also helped. The patient was now advised that the moon boot would be shifted to the left foot and that Shockwave therapy would commence on the right foot.
The patient returned for weekly sessions of Shock Wave therapy to her right foot and repeat applications of rigid sports tape. After 2 weeks the moon boot was removed from the left foot due to a significant reduction in pain. Shockwave therapy was then commenced and the patient returned to the clinic for weekly sessions on the left foot. In total the patient had 6 sessions on her right foot and 6 sessions on her left foot. The patient reported less heel pain after each session. Her plantar fasciitis was improving steadily, as to be expected.
Treatment was then reduced to strapping, stretching , ice packs and firm shoes.
Rehabilitation time with this particular patient was approximately 6 to 8 weeks in total. This was to be expected due to the complexity of the condition, affecting both feet.
The patient returned 4 weeks on from the shock wave therapy sessions to discuss reintroduction to physical activity and running. She was given long term advice on running style and was reminded of the factors that can trigger heel pain and plantar fasciitis.
Please note the information contained in this case study is specific to one particular patient. If you have heel pain or plantar fasciitis and please consult with a suitably qualified sports podiatrist.
Written by Karl Lockett