A 48 year old female presented to the Sydney heel pain clinic in Miranda complaining of plantar fasciitis and Achilles tendonitis in her left foot. She had been suffering with these two conditions for approximately 3 months and reports to the podiatrist that the pain from these conditions was affecting her ability to exercise. The pain from the plantar fasciitis exceeds the pain levels within the Achilles tendonitis, although the patient is continually frustrated with both.This lady is extremely active and she reports to the podiatrist that she exercises almost everyday. She enjoys running, hiking, cycling, and netball. She reports that the pain from the Achilles tendonitis and the plantar fasciitis is very apparent first thing in the morning when she puts her foot down and walks from her bed. She does not recall doing anything different and is unable to suggest a reason for the onset of her foot pain. She is a healthy individual and takes no medication, suffering with no chronic illnesses or medical conditions. She is not overweight and boasts good general health. In order to reduce the pain from the plantar fasciitis and Achilles tendon she purchased new sports shoes and also inserted generic arch supports. While she reports mild relief from the arch supports both of these conditions are still extremely painful and persistent. She has not been to see her GP, nor has she been to see a sports podiatrist, physiotherapist or any other Allied Health practitioner. There has been no imaging taken. She has never suffered with plantar fasciitis before nor has she experienced pain in her Achilles tendon. This patient is extremely anxious as she would like to return to normal physical activity as soon as possible. She reports to the podiatrist that she has heard good things about shockwave therapy and she requests to receive this treatment today. The podiatrist advises that shockwave therapy is extremely good and works very well for plantar fasciitis and Achilles tendonitis, however a detailed history must be taken first and a thorough physical examination carried out.
Physical Examination for Plantar Fasciitis
The podiatrist requests the patient walk on the treadmill for approximately 5 minutes in order to increase blood flow to the foot. The patient is then asked to perform single leg heel raises and her pain level noted. The patient was able to perform heel raises with mild pain through the arch of the foot and the base of the heel. Pain was more significant during single leg, than double leg raise. Firm pressure was applied to the base of the heel along the medial slip of the plantar fascia. The patient reported pain during palpation. This is common in patients with plantar fasciitis. Pressure was also applied to the line of plantar fascia running distally from the base of the heel through the arch of the foot. Not all patients with plantar fasciitis will experience pain in this area, however the patient reported mild pain and tightness. The patient was informed that she was experiencing symptoms typical of plantar fasciitis.
Physical Examination for Achilles Tendonitis
Once again, the patient was asked to perform single and double leg heel raises and her pain level was noted. While there was mild pain during plantar flexion, the patient was able to perform the heel raises without excruciating pain. Pain was worse with a single leg as opposed to a double leg heel raise. Most patients with Achilles tendonitis will experience mild pain or tightness during this test. During the pinch test as lateral pressure was applied to the Achilles tendon, the patient reported pain proximal to the heel over a distance of approximately 2 centimetres. She was informed that in addition to her plantar heel pain she also had Achilles tendonitis.
The patient was observed walking barefoot on a treadmill and her gait cycle was recorded using digital software on an iPad. The podiatrist assessed for biomechanical anomalies and observed muscle, joint, and general foot function. The podiatrist also recorded the patient as she ran in her regular running shoes. Both videos were played in slow motion and notes were taken. It became apparent that the patient was running in a relatively soft and neutral shoe, which had become worn, fatigued and had compressed significantly. The patient was informed that her plantar fasciitis and possibly her Achilles tendonitis had developed due to a lack of support from her running shoes. The podiatrist suggested that she should probably have changed her footwear some time ago.
Treatment for these Two Stubborn Conditions
1: The sports podiatrist recommended a very specific running shoe, that the patient was to purchase as soon as possible.
2: The patient was given the Sydney heel pain clinic mobile phone application to install. A large part of treatment for these conditions is patient education, and the mobile phone app contains several pages of information, which advises very specific and beneficial suggestions, and lists the things that the patient must avoid or reduce.
3: Strapping was applied to the affected foot.
4: 2000 repetitions of shockwave therapy were applied to the plantar fascia, at a maximum speed of 8 HZ and 2.5 bar of pressure. The same procedure was followed along the shaft of the Achilles tendon with a maximum pressure of 3.1 bar. The Shock Wave therapy was well tolerated and the pain from the plantar fasciitis reduced following treatment. Pain from the Achilles tendonitis also fell away significantly and the patient was able to walk around the clinic more comfortably.
Plantar Fasciitis Progress
The patient returned for weekly sessions of Shockwave therapy and received 4 sessions in total. Each week as the plantar fasciitis improved the podiatrist was able to increase the pressure from 2.5 bar. The 4th and final session of Shockwave therapy saw a pressure of 3.4 bar. Pressure for the Achilles tendonitis reached 3.7 bar. Treatment was well tolerated each time and the patient reported an incremental improvement at each weekly session.
The patient reported after 4 weeks at the pain level each morning, when she started to walk around her bedroom, had dropped off to approximately 2 out of 10. To this end, treatment was stopped and the patient was asked to return for a follow up in 4 weeks. Doing this for weeks she was permitted to perform light exercise providing that has symptoms did not return and that her plantar fasciitis did not deteriorate. Any increase in pain from the Achilles tendonitis would also act as a trigger to cease activity. After four week follow-up, the patient inform the podiatrist that she was once again engaged in a regular exercise program, and that she had minimal pain from the plantar fascia and Achilles tendon. She did report some mild stiffness in the Achilles tendon each morning, but this was mild and short-lived. She was dismissed from the clinic and advised to return to the podiatrist if her symptoms returned.
Please note that the information contained in this case study is specific to one particular patient. If you think you have plantar fasciitis or Achilles tendonitis you should consult with a suitably qualified sports podiatrist.
Written by Karl Lockett
Sydney Heel Pain Clinics