A 42-year-old nurse presents to the Sydney heel pain clinic in Miranda complaining of plantar fasciitis. She reports that she has been in severe pain for 6 weeks but has been experiencing discomfort in her right foot for more than 9 months. Her doctor has informed her that she has tibialis posterior tendonitis, but the patient is adamant that she has plantar fasciitis. This patient is a psychiatric nurse and spends lots of time on her feet in hospital. She walks over 10000 Steps per day and feels pain when doing so. She finds that she needs to sit down and rest for long periods of time, only to find out the pain from the plantar fasciitis is worse after resting. The doctor has recommended that she go for an MRI, but due to the cost of this procedure she decided to seek treatment instead. She also reports cramping in the calf muscles and tightness down the back of each leg. She has attempted to change her shoes in order to relieve the pain from the plantar fasciitis but this has not proved successful. Each morning when the patient rises from bed, she reports extreme heel pain in her foot and on a scale of 1 to 10 the pain is almost 10 on some days. After her morning shower and after walking for some time the pain becomes slightly easier but she still finds herself hobbling throughout the day. The patient points to the area of pain, along the mid arch and the medial side of the leg, and a long medial side of the ankle and through the lower shin. She has taken anti-inflammatories to reduce the pain but this has not helped. She also elevates her feet in the evening and applies ice packs and this does give some temporary relief. This patient is approximately 30 kilos overweight and is type 2 diabetic. She confesses that her body weight is a contributing factor to her heel pain and knows that if she loses weight she may help reduce the symptoms of the plantar fasciitis and the tib post tendonitis. However, she’s frustrated as she’s unable to exercise due to the extreme pain.
Physical Examination for Tib Post Tendonitis
The sports podiatrist carries out a detailed physical assessment in order to determine the severity of pain that the patient is experiencing. Firm pressure is applied to the navicular bone, which is where the tib post tendon attaches. Pressure was also applied more proximally and medially around the ankle and lower leg following the line of the tib post tendon. The patient reports extreme pain as pressure is applied. However, the pain is also equally as bad on the other leg. The podiatrist informs the patient that she has bilateral tibialis posterior tendonitis.
Physical Assessment for Plantar Fasciitis
Firm pressure is applied to the plantar aspect of the heel around the attachment of the plantar fascia, which is common site of pain in patient’s with plantar fasciitis. Firm pressure is applied centrally and also medially.
Usually, patient’s with plantar fasciitis will report pain on palpation of these areas. Pressure was also applied to the mid arch of the foot. This patient did not report any pain has a pressure was applied to the base of the heel centrally or medially. The sports podiatrist informed the patient that she didn’t have the symptoms of plantar fasciitis and that her pain is more than likely coming from the tip post tendonitis.
Once again, the patient was informed that she did not have plantar fasciitis, and that a detailed biomechanical assessment was to be carried out in order to determine the cause of the tibialis posterior tendonitis.
The patient presented with extremely tight calf muscles which is a cause of tibialis posterior tendonitis, and is also a common cause of plantar fasciitis. Bi section lines were drawn on the patient and she was asked to walk on a treadmill while footage was recorded using digital software on an iPad. The footage was replayed in slow motion and the sports podiatrist was able to note the biomechanics of the patient’s feet. The podiatrist was able to observe ligament laxity in the elbows, wrists and ankles / feet, – which allowed over pronation bilaterally. The over-pronation was more than likely one of the underlying causes of stress and strain on the tibialis posterior tendon. The sports podiatrist also took arch height measurements in a neutral and relaxed stance position and was able to observe at least 10 mm of navicular drop. The sports podiatrist was also able to observe severe calcaneal eversion, which causes bowstring effect of the Achilles tendons bilaterally.
The practitioner put in place a treatment plan which would help reduce the stress and strain on the tibialis posterior tendon, and would also reduce the strain on both feet in general. While the patient was not conclusively diagnosed with plantar fasciitis at this stage, her loose ligament type and tight calf muscles, would definitely be a contributing factor down the line in the development of plantar fasciitis and Achilles tendonitis. Primarily the patient was advised to carry out a vigorous calf stretching programme which would reduce the pulling sensation on the posterior aspect of the calcaneus, and therefore reduce early he left during gait. This would unload the peroneal tendons and the tibialis posterior tendons equally. It would also reduce the load on the plantar fascia – reducing the likelihood of plantar fasciitis.
The podiatrist observed that the patient was wearing soft and comfortable shoes which were extremely flexible and therefore not supportive. She was advised to purchase some specific walking shoes offering much more rigidity and support. She was advised to commence a 3 week course of dry needling, similar to acupuncture, to relieve tension in the calf muscles. She was also advised to apply ice packs on a daily basis to the affected tendon, around the medical ankle and mid arch of the affected foot.
The patient was also issued with 2 x 9 millimetre he lifts to place inside her shoes. This would further reduce strain on the affected tendon.
Pain levels were monitored by the patient and reported to the podiatrist at each appointment. A pain level of 1 to 10 was used to monitor pain, 1 being minimal and 10 being maximum pain. After 3 sessions of dry needling and after approximately 10 days of treatment the patient reported that the pain level had reduced to approximately 5 out of 10. The pain was still slightly worse in the morning, as is typical with plantar fasciitis, but throughout the day the pain was reducing. The morning pain was also settling down faster than before.
After 6 sessions of dry needling and after approximately 3 weeks of stretching and applying ice, the patient reported a pain level of 2-3 out 10 throughout the day, and 1 out of 10 pain first thing in the morning. The patient reported more stiffness than soreness in the mornings when rising from bed.
Please be mindful that the information contained in this case study is specific to one particular patient and should never be taken as general advice. If you think you have plantar fasciitis, heel pain or tibialis posterior tendonitis then you should seek the help of a suitably qualified sports podiatrist.
Written by Karl Lockett