Presentation- Possible Plantar Fasciitis?
A 30 year old female presented at the Sydney Heel Pain Clinic with heel pain in her left foot and symptoms indicative of plantar fasciitis. The patient told the sports podiatrist that she’d had trouble with heel pain for around 18 months, however it had become increasingly painful in the last 3 or 4 months. The patient had been a regular participant in kickboxing for most of her adult life, but recently she had increased her training sessions in preparation for an upcoming tournament. Her sport required her to train and compete in bare feet, with no option to wear shoes. She was otherwise very fit and healthy. The patient was a busy mum with two children, so naturally she was concerned about her heel pain worsening and getting in the way of her day-to-day routine.
Pain Symptoms Indicative of Plantar Fasciitis
The patient’s description of her heel pain was largely indicative of plantar fasciitis. She mentioned that the pain was worst first thing when getting up out of bed, and felt like a pebble or stone in her heel. After some time being up and about, the pain would be less severe. When asked about her pain during training, the patient told the sports podiatrist that when she trained at her regular gym, it was manageable. She went on to tell the sports podiatrist that her gym was well-equipped with foam matting, however she had recently been having some personal training sessions at another gymnasium, where the floor was harder rubber matting. Whilst training on the rubber mats, her pain was worse, and immediately after those sessions, she found herself hobbling back to her car. As part of her routine, she was also running three 5km runs a week. She had recently invested in a pair of quality Brooks running shoes, which she chose based on her online research. The patient told the sports podiatrist that whilst wearing the shoes, she was able to run reasonably comfortably. The sports podiatrist felt that the patient’s symptoms and signs were pointing towards a plantar fasciitis diagnosis, however given the high impact of the physical activity the patient was participating in, he was also wondering whether she may have a heel stress fracture.
Plantar Fasciitis Home Remedies Tried by the Patient
The patient told the sports podiatrist that she had researched different types of heel pain on the internet, and based on the information that she had discovered, she had been trying some treatments for plantar fasciitis at home. She had been icing her feet with ice packs. She was also performing some calf stretches for plantar fasciitis that she had read about. The patient was interested in using sports tape for strapping for plantar fasciitis, but was unsure of how to do this correctly.
The patient finally decided to visit the sports podiatrist for a correct diagnosis and treatment because she was worried that her heel pain was becoming increasingly worse. She worried that it may prohibit her from continuing to train and compete, or stop her from being able to keep up with her young family.
Examination to Diagnose Plantar Fasciitis or Heel Stress Fracture
The sports podiatrist was suspicious of plantar fasciitis, with a differential diagnosis of a heel stress fracture. As such, he carried out a detailed physical examination in order to confirm his diagnosis. Upon palpation of the sore foot, the patient reported severe pain in the plantar heel area, around where the plantar fascia attaches to the heel bone. There was no notable swelling, nor was there any pain around the outside of the heel. The patient was able to perform a single leg heel raise on the sore leg without pain. The sports podiatrist also assessed the range of motion in the foot and ankle joint. The flexibility of the muscles, ligaments and tendons in the lower leg and foot was examined. The sports podiatrist’s investigations revealed tight calf muscles in the patient’s legs, but more so in the left foot.
Medical Imaging for Plantar Fasciitis Diagnosis
The sports podiatrist told the patient that while her clinical signs and symptoms were consistent with a diagnosis of plantar fasciitis, he would like her to have an ultrasound and xray. The ultrasound would allow the podiatrist to confirm a true case of plantar fasciitis, and also to exclude any other soft tissue injuries that may be contributing to the pain. The xray would determine whether or not a heel stress fracture was present. (Post 6 weeks since onset of pain)
Biomechanical Assessment for Plantar Fasciitis
A biomechanical assessment and gait analysis on the in-house treadmill were also conducted as part of the assessment for plantar fasciitis. This involved placing markers on the patient’s lower leg and foot and then recording footage of the patient running on the treadmill. This allowed for an analysis of foot strike in slow motion. The patient’s medial foot arch height and heel angle were measured.
Footwear Assessment for Plantar Fasciitis
Following the biomechanical assessment, the sports podiatrist assessed the patient’s footwear. The new Brooks runners that the patient had purchased were indeed an appropriate choice for her feet and provided adequate support. This was likely why the patient was reasonably comfortable during her runs as opposed to when undertaking her barefoot training.
Diagnosis: Plantar Fasciitis
The patient returned to the clinic the following week with her images, so that the sports podiatrist could review them and make a diagnosis of plantar fasciitis or otherwise. The ultrasound confirmed a definite case of plantar fasciitis, with a plantar fascia thickness of approximately 7mm in the affected foot. The xray confirmed that there was no heel fracture present.
Commencement of Treatment for Plantar Fasciitis
Once a diagnosis of plantar fasciitis was confirmed, treatment could begin. Treatment for plantar fasciitis is partly dependent on the results of the treadmill assessment. The aim of this patient’s treatment for plantar fasciitis was to reduce stress and load on the plantar fascia and relieve her pain, whilst allowing the plantar fascia ligament to heal at the same time.
The sports podiatrist recommended a treatment plan with three main aspects:
- Stretching for the patient’s tight calf muscles
- Shockwave therapy
The patient was shown some stretches for her tight calves by her sports podiatrist. Increasing flexibility in the calves would help to relieve her pain and allow healing by unloading the plantar fascia. The sports podiatrist recommended that she complete her stretches three times daily, and especially prior to and following her training sessions – with her foot in a supinated position
Shockwave therapy is a clinically tested and proven treatment for plantar fasciitis. It often provides the patient with immediate pain relief, stimulates tissue regeneration and encourages blood flow to the targeted area. Over the course of the following four weeks, the patient would receive four shockwave therapy treatments for her plantar fasciitis – up to a maximum of 6.
In order for the plantar fascia to recover, the patient was recommended to stop training on the hard rubber matting. She was advised on how to strap her feet correctly in a way that would support her foot arches day to day, and also for the training sessions that she was going to be doing on the foam mats.
The sports podiatrist recommended to the patient that since she would be undergoing treatment, she should not participate in barefoot kickboxing for the net 6 weeks. The patient was able to liaise with her kickboxing coach and sports podiatrist together, to formulate a training regime including hand-only boxing (wearing her runners) and swimming, so that it would not be so high-impact for her feet. This also freed up some time in the patient’s training schedule, allowing her to incorporate two yoga sessions a week, which also assisted her flexibility ( No downward dogs )
Plantar Fasciitis Treatment Outcomes
The patient received her first shockwave therapy treatment on the same day as her follow-up consultation. The treatment was well tolerated. She described pain relief immediately following her treatment.
The next treatment was one week after the first. This second treatment also gave the patient immediate pain relief. The patient also reported she was feeling good about her training routine and that she felt her pain was generally improving.
In the next two weeks, the patient received two more shockwave therapy treatments for her plantar fasciitis.
The sports podiatrist scheduled a follow-up appointment with the patient two weeks after her fourth shockwave therapy treatment. The patient said that her heel pain had almost subsided completely. At this appointment, she was advised that she could return to kickboxing, however she would need to be vigilant in warming up adequately and strapping her feet. She was told to limit kickboxing to one session a week initially, and she would add another session every fortnight provided she was still pain free.
Please be advised that the case study described above is unique this individual patient. Treatment details are not intended to be, nor should they be taken as general medical advice. If you are experiencing symptoms of plantar fasciitis, or heel pain you should consult with a qualified sports podiatrist for a correct diagnosis.
Podiatrist – Omar Mohamad
Sydney Heel Pain Clinic – North Sydney
Written by Karl Lockett