Case History of Achilles Tendonitis

In March 2018 a 55 year old lady presents to the Sydney heel pain clinic complaining of Achilles tendonitis of approximately 18 months. She feels a hot stabbing pain at the base of the Achilles tendon attachment, around the calcaneus. She reports to the sports podiatrist at Sydney heel pain clinic that there is also a stabbing pain and stiffness. She explains to the practitioner that the symptoms of her Achilles tendonitis came on following a holiday where she walked extensively. The patient was on a European trip and spent approximately 10 days walking around cobbled streets and flat roads using ballet flats and non-supportive shoes. She remembers feeling tightness in her calf muscles and was experiencing night cramps while on holiday in France. Throughout the day, her lower legs would feel tired and achy and she would find herself needing to stretch regularly. The Achilles Tendonitis came on approximately 4 days into her holiday and she remembers on one particular day feeling a snapping sensation in the lower part of her Achilles tendon. She was forced to sit down and quite quickly she returned to the hotel room to rest and apply ice packs to the Achilles tendonitis. The patient did not attend a medical centre nor did she consult with any doctor at this time. Instead she decided to take anti inflammatory medication and apply ice packs to the affected area. The anti inflammatory medication did not reduce the pain significantly therefore the patient decided to combine the medication with codeine. She reports that the pain reduced by approximately 50% and she was able to continue sightseeing so long as she wore her running shoes. The symptoms of the Achilles tendonitis persisted for the remainder of the holiday. Upon returning to Sydney, and after a long haul flight, the patient reports a sudden increase in the symptoms of her Achilles tendonitis, to the point where she was unable to bear weight on the affected leg. After her first night at home, she informs the sports podiatrist that when she woke she could see and feel inflammation around the back of her heel bone, where the Achilles tendon attaches. Once again, she was unable to bear weight on the affected leg as she was forced to hold on to the walls while she hobbled around her home. Her husband drove her to the local GP who organised an x-ray. Her GP did not mention Achilles tendonitis at this stage, but instead mentioned a heel spur. The patient returned to her GP who confirmed the presence of a heel Spur at the base of the Achilles tendon, around the back of the heel bone. The GP did not recommend further medication, but instead recommended that she seek the help of a sports podiatrist. This lady has experienced previous foot problems such as plantar fasciitis and shin splints, but she has never been diagnosed with Achilles tendonitis before.

Physical Assessment for Achilles Tendonitis

The sports podiatrist carried out a thorough physical assessment of the Achilles tendonitis in order to determine the severity of the condition and the exact location of the affected area. Her response was great, and the patient retracted her foot quickly when gentle finger pressure was applied to the Achilles tendon. It was noted that the medial portion of the Achilles tendon attachment was significantly more tender than the rest. The sports podiatrist confirmed that the patient demonstrated all of the common symptoms of insertional Achilles tendonitis, but that there was a chance that the Achilles tendon had become partially torn. The patient was also informed that at this stage that retro calcaneal bursitis could not be ruled out. Therefore, the patient was referred for ultrasound imaging in order to assess the Achilles tendon in more detail.

The patient returned to the Sydney heel pain clinic 4 days later to discuss the results of her ultrasound, and she reported no improvement in the symptoms of her Achilles tendonitis. The sports podiatrist explained to the patient that the report confirmed a small intrasubstance tear along the medial portion of the Achilles tendon, at the attachment into the calcaneus. There was no retrocalcaneal bursitis nor superficial adventitial bursitis.

Achilles Tendonitis Treatment

The sports podiatrist informed the patient that the treatment of her Achilles tendonitis would involve a few factors. The patient was fitted with a medium sized, full height rebound airwalker, immobilisation boot. The podiatrist inserted a 12 millimetre heel wedge inside the boot in order to elevate the heel and reduce further load on the Achilles tendon. A heel wedge was also inserted into the shoe of the patients other foot in order to attempt to lift the hip on that side and reduce the likelihood of lower back stiffness or pain. The patient was also informed that her Achilles tendonitis would take up to 12 weeks to heal and that she would remain in the immobilisation boot until she felt comfortable and able to walk without it. The sports podiatrist advised that patients with Achilles tendonitis usually improve quickly if they receive shockwave therapy to the affected area. The patient was reassured that treatment of the Achilles tendonitis and the tear, with immobilisation boot was extremely reliable, however should the tear fail to heal she may be referred to a surgeon for further discussion and treatment. She was also informed that the pain that she was experiencing was not a result of the heel spur and that she should feel better and make a full recovery once the tendon was treated successfully.

Achilles Tendonitis and Tight Calf Muscles

The patient was informed that Achilles tendonitis is more often than not, a result of restricted calf muscle range. She was informed that the onset of her condition was a result of extended walking in non supportive footwear, which leads to fatigue and stiffness through the muscles of the lower leg. She was advised to carry out regular calf stretching in order to reduce load on the Achilles tendon, allowing it to heal. Patients who receives treatment for Achilles tendonitis from the podiatrist, can experience a lack of healing, or an extended healing time, if they fail to carry out calf stretches. The patient was given the Sydney heel Pain mobile app which includes a diagram and instructions of how to perform calf stretches.

Shock Wave Therapy for Achilles Tendonitis Dash Intrasubstance Tear

In order to ensure a speedy recovery of this lady’s Achilles tendonitis, and small intrasubstance tear, the podiatrist arranged 4 shockwave therapy sessions. She engaged in one session of Shockwave therapy every 5 days for approximately 3 weeks.

She was advised not to apply ice packs to the affected area as this would reduce blood flow and counteract the benefits of the shockwave therapy.

After the course of shockwave therapy, the patient was booked in for a 6 week follow up. Assessment revealed that after 6 weeks, there was an improvement in pain levels with palpation of the affected area. However, the patient still demonstrated all of the symptoms of Achilles tendonitis. She was advised that her treatment with the immobilisation boot should continue. The patient informed the sports podiatrist that her symptoms were improving. She was able to bear weight on the affected leg without the immobilisation boot for short periods of time without experiencing significant pain from the Achilles tendonitis, around the back of the heel bone. However, she did not walk for more than 15 minutes without the immobilisation boot as she would feel mild pain and significant stiffness. The patient was rebooked for a further four weeks. At this appointment the patient reported further Improvement with respect to the symptoms of her Achilles tendonitis, and she was eager to have the immobilisation boot removed. She informed the sports podiatrist that she was in fact able to walk with regular shoes and the heel lift, without experiencing any pain. She’s confirmed that the Achilles tendonitis was slightly tender first thing in the morning and there was a mild pain and significant stiffness each morning. The patient was advised that her Achilles tendonitis had not healed completely and that treatment must continue, but that she was able to remove the immobilisation boot. Instructions were that the patient should remain in supportive shoes with elevated heels at all times. She could now apply ice packs to the affected area each evening to reduce any protective inflammation around the calcaneus. The patient enquired about a follow-up ultrasound in order to assess the healing of the Achilles tendonitis and intrasubstance tear. A referral was handed to the patient but she was advised that the results of the ultrasound would not influence the management of her case and that she should continue to treat her foot based on her symptoms alone. The patient was advised to return to the clinic in a further 4 weeks if she felt any deterioration in her condition or an increase in her symptoms. No further appointments were noted, and it can be assumed that the patient made a full recovery due to her lack of communication with the Sydney heel pain clinic.

It should be noted that the information contained in this case study is specific to one patient. This case study should not be taken as general advice. If you have foot problems or if you think you have Achilles tendonitis you should contact a qualified sports podiatrist.

 
Written by Karl Lockett
Sport Podiatrist

A 32 Year Old Female Runner Presents to the Sydney Heel Pain Clinic for Shockwave Therapy to her Achilles Tendonitis

Shockwave therapy is becoming increasingly popular for the treatment of ailments such as Achilles tendonitis. shockwave therapy is used in order to stimulate healing and create revascularization of the tissue. There are also pain-relieving benefits relating to shock wave therapy, although this is not the main reason for the treatment. Sessions are usually given at 5, 6 or 7 day intervals. There are other treatments for Achilles tendonitis and shockwave therapy is usually done in addition to other therapies such as biomechanical assessments and footwear recommendations etc. If used as a stand alone treatment, shock wave therapy may not always be beneficial, especially if the practitioner has failed to identify other problematic factors. Patient education is crucial and at the Sydney heel pain clinic the patient is given a mobile phone application containing detailed information pertaining to their treatment.

This particular patient had been complaining of Achilles tendonitis for more than 6 months and had received a variety of treatments for the condition. She had engaged in 6 weekly sessions of acupuncture and dry needling and had been stretching her calf muscles diligently. She was also carrying out eccentric loading exercises, as per the advice of a physiotherapist. She reported that the Achilles tendonitis had become increasingly painful throughout the duration of these eccentric loading exercises, therefor she decided to stop. The patient decided to stop using her current running shoe and purchased a newer and stronger style of running shoe in order to give her feet more support. The change of running shoes did not seem to relieve the problem and the condition persists. The patient describes a sharp pain and a dull ache through the shaft of the Achilles tendon which causes pain first thing in the morning when she rises from her bed and also pain during her exercise regime. The patient reports to the sports podiatrist that she carries out 3, 5 km runs during the week and one 15 km run on a Saturday. Pain from the Achilles tendonitis is prominent during the start of the run but decrease within the first 5 minutes. She also reports significant pain for the for the two hours that follow the run. A colleague the patient works with suggested that she try shockwave therapy as she herself had treated her Achilles tendon with the same approach. To this end, the patient came to the Sydney heel pain clinic and requested Shockwave therapy for her Achilles tendonitis.

The sports podiatrist carried out a detailed biomechanical assessment to determine whether or not there were other factors to consider. Sports podiatrist did confirm that the patient had a relatively stable foot style and there did not seem to be pronation issues. The sports podiatrist recorded the patient’s foot function using digital software on an iPad and replayed it in slow motion, and reported to the patient that one of the causes of her Achilles tendonitis maybe a restricted range of motion through her lower calf muscle. She was advised that the shock wave therapy would be beneficial for her treatment but that the tightness through her lower calf muscles needed to be addressed also. She was advised to cease the eccentric loading exercises as these were affecting her pain levels and potentially overloading the tendons and that they were already acute and irritated. No other biomechanical anomalies were relevant. Stretching advice was given.

Shockwave Therapy Treatment – Achilles Tendonitis

The sports podiatrist carried out shockwave therapy for the Achilles tendonitis on the left ankle. The machine was set to 2000 repetitions 5 HZ and 1.5 bar of pressure. The treatment lasted for approximately 3 minutes and was well tolerated. As to be expected with Achilles tendonitis the tenderness from treatment was very short lived and the analgesic effect took place quite quickly. Following the treatment with the shockwave therapy machine, the patient was able to walk around the room with minimal pain. She reported to the sports podiatrist that the tendon felt loose and warm.

Shockwave Therapy Number 2 – One Week Later

The patient returned for shockwave therapy of her Achilles tendonitis approximately one week later. Once again the machine was set 2000 reps and 1.5 bar of pressure at 5 HZ. During this session the podiatrist was able to increase the pressure to 2 bars. The patient tolerated the treatment and once again reported instant benefits.

It should be noted that during the treatment program the patient was advised to continue her normal running routine. She was advised that her running routine would be changed if she failed to respond to the treatment.

The patient reported approximately 10% improvement in her condition following the first session of shockwave therapy. The treatment carried on in this fashion for 6 weeks, and the patient received 6 sessions of shock wave therapy in total. After this final session of shock wave therapy, the patient reported approximately 80% improvement in her condition and described to the sports podiatrist that in the mornings when getting out of bed she experienced no further symptoms. She had been continuing to maintain her normal running style and routine. The podiatrist informed the patient that her Achilles tendonitis would continue to improve, although the shockwave therapy had ceased. The patient was informed that the revascularization and the increase in blood flow would promote healing in the coming weeks and that her pain level should continue to drop.

The sports podiatrist arranged a follow up in a further 6 weeks. The patient returned for the 6 week follow up and reported to the podiatrist that the pain from her Achilles tendonitis had completely subsided and that she did not require any additional shock wave therapy.

Please be advised that the information contained in this case study is specific to one particular patient. If you have Achilles tendonitis or if you think you need shockwave therapy please consult with a suitably qualified sports podiatrist.

 
Written by Karl Lockett
Podiatrist

Biomechanical Assessment for Plantar Fasciitis and Achilles Tendonitis

In order to determine the cause of the patient’s plantar fasciitis and Achilles tendonitis the sports podiatrist carried out a biomechanical assessment with the patient standing, walking, and running on a treadmill in his bare feet. Bisection lines were drawn along the line of the tibia, Achilles tendon and the posterior aspect of the calcaneus. Quite commonly, the bisection lines on the back  of the Achilles tendon can become distorted in patients with Achilles tendonitis. The biomechanical assessment is useful for detecting over pronation through the subtalar joint. It should be noted that plantar fasciitis and Achilles tendonitis can occur in patients with and without over pronation. These two conditions can be commonly seen in all foot types. However, when it comes to treatment it is important for the podiatrist to understand the foot type. When designing orthotics, it is imperative that the podiatrist as a good understanding of the amount of supination pronation through the subtalar joint. The findings join this assessment significantly affect the prescription form. The sports podiatrist used digital software on an iPad in order to capture the patients biomechanics. The video footage was replayed in slow motion and using stop start frame technology the podiatrist was able to note detailed aspects of the patients by mechanics.

During the gait assessment, the patient reported pain from the plantar fasciitis as he is 4 ft accepted body load. There was no pain on heel strike but there was mild pain in heel left. It is not uncommon to find patients reporting arch pain from plantar fasciitis has the body weight is transferred from the heel to the forefoot, loading the plantar fascia. The patient reported mild stiffness through both Achilles tendons during the gait assessment, but this used quickly and he was able to walk and run without any pain. This is common with the case with Achilles tendonitis whereby the foot warms up on any stiffness or pain begins to subside, allowing the individual to continue with sport exercise and physical activity. However, some patients will report that the pain returns approximately an hour or two after the physical activity, and is particularly painful the following morning when I get out of bed. Patients with Achilles tendonitis will often report pain after being seated for a given period of time, when they stand up to walk away from their seat they begin to feel pain for the first few steps. Once again, the pain subsides after a short period of walking.

The sports podiatrist also carried out measurements with the patient standing in a subtalar joint neutral position. Measurements were also taken in a relaxed calcaneal stance position. Arch Heights were measured in both of these positions as was the bisection line on the back of the heel.

Findings

The podiatrist noted that there was minimal pronation through both subtalar joints during walking. While the patient was running, that was an increase in the amount of pronation which is to be expected, however there was a significant increase in pronation through the left foot compared to the right. There was a significant a Version at the heel, causing a bowstring effect through the Achilles tendonitis comma but it would not be fair to say that this is the cause of the Achilles tendonitis the same Anomaly did not appear through the right foot. It was also noted during walking that there was early heel lift through both feet, naturally increasing the strain to both Achilles tendons. Tight calf muscles and early heel lift are both commonly seen in patients with Achilles tendonitis, so it would be safe to assume that this was a more likely cause of the patient’s condition.

The podiatrist was also able to note an increase in the amount of external rotation through the left foot compared to the right foot, possibly coming from tibial torsion or an externally rotated hip. Further investigations were to be carried out.

The podiatrist informed the patient that his Asics Gel 2000 running shoes were appropriate and that is day today Street shoes, and work shoes were also sufficiently supportive.

Achilles Tendonitis Treatment

Just inform the patient but the treatment for his Achilles tendonitis would depend on several factors, some of which would also assist with the treatment of the plantar fasciitis. Primarily, it was imperative that the patient commands of course of regular calf stretches in order to increase the range of motion through the ankle and reduce the load on the Achilles tendon. The podiatrist demonstrated, and the patient followed, standing calf stretch in a lunge position. The patient was advised to hold each stretch for at least 30 seconds, and that’s three stretches should be performed on each leg. He was also informed to carry out these stretches at least three times a day. Patient suffering with Achilles tendonitis and plantar fasciitis alike, often feel significant improvement in that condition after a few days of stretching.

In order to further reduce load on the Achilles tendon patient was fitted with 2 x 9 millimetre heel wedges, that were to sit underneath the liner of his shoes. The patient was advised to avoid flat shoes, bare feet, and thongs. He was informed that by elevating his heel this would reduce the tension through the Achilles tendon and therefore allow the healing to commence. It is not uncommon to encounter new patients who have developed Achilles tendonitis via the overuse of flat shoes, without a heel lift.

Shock Wave Therapy for Plantar Fasciitis and Achilles Tendonitis

The sports podiatrist commenced a 6 week course of shock wave therapy to stimulate blood flow and accelerate the healing of the Achilles tendonitis.  The machine was also used across the Soles of both feet to treat the plantar fasciitis, slightly distal to the attachment at the heel bone. The Shock Wave therapy stimulates healing via revascularization comma and has an analgesic effect 2. Treatments were delivered approximately 5 days apart.

Results and discussion to follow

11 April 2018

Written by Karl Lockett

Can we differentiate between Sever’s disease and plantar fasciitis?

A 12-year-old boy presents to the Sydney heel pain clinic complaining of pain through the sole of his right foot of approximately 6 months, and his mother has been informed that he has either Sever’s disease or plantar fasciitis. He complains of pain around the base of the back of the right heel and is an active young boy who plays approximately 6 periods of physical exercise each week. This patient reports heel pain during physical activity and in particular the following morning. He does not feel any pain in his left heel. The right heel is slightly redder and is also warmer than left. The pain has caused him to limp during sport and he hobbles out of bed the following morning. His mum, did some on line research and concluded he was showing the signs of plantar fasciitis, but also wasn’t sure if he had Severs disease. The symptoms of these 2 conditions being very similar. Her sister once had plantar fasciitis and hence she was concerned that there was a familial or genetic tendency with these conditions. To this end, she went to see the family doctor who advised that the young boy probably had Sever’s and that he was possibly too young to have plantar fasciitis. Sever’s is very common between the ages of 7 and 14 and is common in physically active children.

In desperation, the child’s mother went to an on-line store and purchased a plantar fasciitis sock, which the boy was to wear to bed each night. As is commonly the case, the patient was unable to wear the sock for more than 3 hours, and he would wake up around midnight with excruciating heel pain, removing the sock. On occasions where the sock was a little looser, the patient was able to sleep through, and he did then report that the heel pain was a little easier the next day. However, the pain during the day time persisted.

Physical Assessment – Plantar Fasciitis or Sever’s Disease?

The sports podiatrist was suspicious of Sever’s disease but knew it was important to rule out plantar fasciitis, and hence carried out a thorough physical assessment. Firm pressure was applied to all aspects of the calcaneus, including the epiphysis, posteriorly and the attachment of the plantar fascia. The patient felt heel pain in all areas and it was decided to refer for ultra sound scan.

The ultra sound report came back and confirmed inflammation of the plantar fascia at the calcaneal attachment, hence plantar fasciitis. However, due to the pain on the back of the heel, along the line of the growth plate, and considering the child’s age and level of activity, it could be concluded that he also had Sever’s disease.

Biomechanical Assessment

The sports podiatrist carried out a bio mechanical assessment in order to determine the cause of the plantar fasciitis and Sever’s disease. With the patient standing barefoot the podiatrist took foot posture index measurements, in neutral and relaxed calcaneal stance positions. Arch heights were noted in both positions.

1. Subtalar joint axis was measured
2. Calf range was assessed
3. Quadriceps and hamstrings were assessed
4. Midfoot range of motion was assessed
5. Hip joint rotation was assessed
6. Tibial torsion was measured

Findings

The sports podiatrist was able to detect some biomechanical anomalies. The range of motion in the calf muscles was significantly reduced bilaterally. This restricted range of motion through the ankle joint creates pulling on the back of the heel which causes plantar fasciitis and Sever’s disease both. The patient also demonstrated ligament laxity, which causes over pronation while walking and running. During gait, the podiatrist observed significant calcaneal eversion, hence severe over pronation in both feet. This was confirmed during supine assessment of the subtalar joint Axis which was medially deviated. In a neutral calcaneal stance position, the patient demonstrated good medial arch contour. However, in a relaxed calcaneal stance position the medial arch dropped significantly and measured close to 10 mm bilaterally. Over pronation, leads to fallen arches which leads to elongation of the foot on the hole. This in turn can cause stretching and straining of the plantar fascia as the foot lengthens. These biomechanical findings are possible causes of plantar fasciitis, but not necessarily Sever’s disease.

Plantar Fasciitis Treatment

One of the most important things with plantar fasciitis treatment, is patient education. Quite often patients are engaging in treatments which they think help, but which actually irritate the condition long term. The podiatrist at the Sydney Heel Pain clinic installed a mobile phone application entitled Sydney Heel Pain mobile app, onto the patient’s phone, which includes all the information required to successfully treat plantar fasciitis. The app also contains information on treatment of Sever’s disease, and includes instructions on calf stretching technique. In addition to the mobile phone application, the patient’s mother was informed that the treatment for these two conditions would be multifactorial. One of the most important things would be the calf stretching and the use of appropriate footwear. The patient was given specific footwear models to wear during sport and schooling. The podiatrist also carried out some deep tissue massage and some dry needling on the posterior aspect of the calf. Both feet were strapped with rigid sports tape, and 2 x 9 mm heel wedges were inserted inside the patient’s shoes in order to elevate the heel. This would take pressure off the growth plate in the calcaneus, which would reduce the symptoms of the Sever’s disease. The heel wedges were to be used as a short to medium term treatment, and the patient’s mother was informed that they would not be used for more than two to three months, and could be removed once symptoms had subsided. The patient was advised to refrain from running a sporting activity for the next 3 weeks. The patient was asked to return to the clinic on a weekly basis so that further massage, dry needling and sports tape application could be carried out.

After 3 weeks, the symptoms of the plantar fasciitis, and Sever’s disease had reduced significantly but as is to be expected there was still some residual pain. Due to the significant improvement, the sports podiatrist decided not to change the treatment plan but to continue with the same. After a total of 5 weeks of treatment, the symptoms of the plantar fasciitis had subsided completely and there was no pain on palpation of the plantar fascia insertion. The symptoms of the Sever’s disease were still present, although were described as minimal. To this end it was decided to allow the patient to return to sporting activity, providing that he continue to strap his feet and use both of the heel wedges in his sports shoes. At the follow-up appointment two weeks later, it was reported back to the podiatrist that the patient was able to participate in sport although there was mild pain during activity. The following morning there was a slight increase in pain due to the previous activity the day before, but the pain was bearable and not significant enough to warrant exclusion from physical activity. The patient and his mother were advised that it would take some time for the boy to grow out of this condition and that Sever’s disease is a conditioned to be managed and tolerated.

Please note this case study should not be taken as general advice. If you have plantar fasciitis or Sever’s disease you should seek the help of a suitably qualified medical practitioner.

Written by Karl Lockett

Differential diagnosis including plantar fasciitis and Achilles tendonitis

Plantar fasciitis is an extremely common condition seen amongst podiatrists in the clinic today. However, occasionally patients can be misdiagnosed due to pain in other parts of the foot anatomy and conditions that give symptoms similar to that of plantar fasciitis. These conditions include, but are not limited to, those that can cause heel pain. Achilles tendonitis, and peroneal tendonitis are other conditions to consider.

Case Study – Plantar Fasciitis and Peroneal Tendonitis

A 36-year-old female arrives at the Sydney heel pain clinic complaining of heel and arch pain. She informs the podiatrist that she thinks she is suffering with plantar fasciitis but is not 100% sure. She describes pain in the base of the heel and pain in the arch of the foot. It becomes apparent that she does not have pain along the calf muscle or the Achilles tendon, such as can be seen in patients with Achilles tendonitis. This patient is approximately 10 kilos overweight but does not suffer with any other health conditions. She has been experiencing severe foot pain for more than 6 months and is becoming increasingly frustrated with her inability to exercise. She has ceased all physical activity but informs the sports podiatrist that she was a keen runner and cyclist. She has limited her exercise to swimming but is not enjoying this type of activity. She has never experienced heel pain before and until recently she was unaware of conditions such as plantar fasciitis. This patient was given treatment advice by a local sports medicine doctor, but found no improvement following the consultation. To this end she was referred to the imaging centre for an MRI. The MRI confirmed plantar fasciitis and tendonitis of the peroneus longus.

Note:

Due to the anatomy of the plantar fascia, running distally from the base of the heel through the arch of the foot and into the base of the toes, which crosses the line of the peroneus longus tendon, it is not uncommon for patients to be misdiagnosed. The diagnosis of plantar fasciitis is often given, when in fact there is also or instead, peroneal tendonitis. The treatment of these two conditions is obviously very different.

Patients with Achilles tendonitis can also experience pain that radiates into both sides of the heel bone, and sometimes further down which can be felt in the base of the heel. Once again, patients with Achilles tendonitis can sometimes think that they are suffering with plantar fasciitis when in fact these two conditions are both very different.

Likewise, patients with plantar fasciitis can also experience pain that radiates along both sides of the heel bone, towards the Achilles tendon. Once again, these patients may interpret these symptoms as Achilles tendonitis when in fact this is not the case. In both of the above cases it is not usually necessary for the sports podiatrist to request medical imaging. Physical assessment should be sufficient in order to differentiate between these two conditions and make an accurate diagnosis.

Physical Assessment for Plantar Fasciitis, Achilles Tendonitis, Peroneal Tendonitis

The sports podiatrist carried out a physical assessment and was able to diagnose plantar fasciitis and peroneal tendonitis. Firm pressure was applied to the base of the heel around the attachment of the plantar fascia. This reproduced a familiar pain which the patient had been experiencing and the sports podiatrist confirmed that she did in fact have symptoms of plantar fasciitis. Firm finger pressure was also applied through the arch of the foot along the medial, central and lateral slips of the plantar fascia. Proximally, and distally, this did not elicit pain or symptoms that the patient had been experiencing. However, when firm pressure was applied through the mid portion of the foot the patient retracted her leg due to the pain. The podiatrist then changed direction of palpation, and applied gentle force from the lateral to the medial aspect of the foot from the cuboid bone to the navicular bone, which follows the line of the peroneus longus tendon. It was through this area that the patient reported significant pain. The sports podiatrist informed the patient that she also had peroneal tendonitis in addition to her plantar fasciitis. The MRI report confirmed this. With the patient lying prone, firm pressure was applied to the medial aspect of the calf muscle distally and along the shaft of the Achilles tendon. Pressure was also applied around the insertion of the Achilles tendon onto the posterior aspect of the heel bone. No pain was reproduced. The podiatrist informed the patient that she did not have Achilles tendonitis.

Treatment for Plantar Fasciitis, Peroneal Tendonitis

The sports podiatrist explained to the patient that plantar fasciitis can often be treated with strapping or orthotics. Peroneal tendonitis is a condition that can also respond to the above. Other factors to consider are things like footwear, stretches and ice packs. However, due to the extreme pain that the patient described during physical assessment, and based on her inability to walk comfortably without limp, the sports podiatrist informed the patient that her condition seemed to be too acute for the above treatments to be effective. The patient had also informed the podiatrist that when stationary, she felt throbbing and heat. To this end, the podiatrist inform the patient that the quickest, and most effective and the most comfortable treatment for her, was the use of an immobilisation boot.

Sydney Heel Pain Mobile Application for Plantar Fasciitis and Achilles Tendonitis

The sports podiatrist explained to the patient that a large part of her recovery would be determined by her being compliant with treatment. She was informed that it was important that she avoid doing things that irritate the plantar fascia and the peroneal tendon, and start doing things that assist healing. Because plantar fasciitis and Achilles tendonitis both cause heel pain, she was instructed to install the Sydney Heel Pain mobile app on her phone. The app would contain all of the necessary information that she needed. The treatment advice contained in the application would also be beneficial for the treatment of the peroneal tendonitis. The information included, but was not limited to, things such as footwear choice, stretching and the application of ice packs.

6 Week Review

This patient came back to the clinic for a review of her plantar fasciitis after 6 weeks. The boot was removed and she walked around the room freely, without any pain. She informed the podiatrist that she had on occasion removed the boot and walked for approximately 2 to 3 hours, and did not feel much pain. The podiatrist concluded that the peroneal tendonitis and the plantar fasciitis had both improved significantly. The patient was happy with progress and was booked in for a follow up appointment a week later where by a biomechanical assessment could be carried out to determine the cause of her conditions.

This case study is not general advice. If you have plantar fasciitis, Peroneal tendonitis or Achilles Tendonitis you should consult with a sports podiatrist.

Written by Karl Lockett