In January 2017, a 44 year old mother of two presented to the Sydney heel pain clinic in Miranda, complaining of heel pain. She describes a sharp pain under the ball of her heel that has been present for over 2 years.  She explained to the sports podiatrist, that the pain in her foot started soon after the birth of her second child. Approximately 2 weeks after giving birth the patient recalls an increase in her shoe size and an altered architecture through the arch of her foot. She explains that prior to the heel pain, the arch of the foot was slightly higher but that the pregnancy and the weight gain had caused the arche to collapse. She reports a gradual onset of heel pain which started as a dull ache and progressively got worse. She currently describes all the symptoms consistent with plantar fasciitis such as pain when getting out of bed in the morning, or in the middle of the night when attending to her children. The heel pain causes her to walk with a bad limp for at least 15 minutes until the condition settles slightly. Towards the end of the day the heel pain feels sharper and more intense and she describes a red hot poker in the sole of her foot. She reports to the podiatrist that she has tried to wear a variety of shoes but the only footwear she feels comfortable in are her running shoes. To this end, she spends her days in a pair of New Balance cross trainers. She reports that these running shoes reduce the heel pain by approximately 50%. This lady went to visit her regular doctor who informed her that she probably had what was known as heel spurs. He rejected her claims for an x-ray in light of the fact that it wouldn’t change anything. Instead, he told her to be patient and to continue wearing a trainers and that the conditions would settle down by itself in approximately 18 months. This patients husband was frustrated with the lack of assistance from the GP as he could see that his wife’s heel pain was excruciating. He encouraged her to visit a local physiotherapist for treatment.

The physiotherapist suggested that the cause of this patient’s heel pain was plantar fasciitis and that he would offer some acupuncture and massage therapy.  He also applied some rigid sports tape to give extra support to her feet.  The physiotherapist encouraged the patient to perform calf stretching with both of her heels hanging off the back of a step. She reports to the podiatrist that these exercises caused a massive increase in her heel pain and so she ceased this activity after approximately 4 days. The physiotherapist continued to apply deep tissue massage which did provide some short-term relief. However, after 6 weeks of treatment with the physiotherapist the patient’s heel pain was only marginally better and her frustration continued. She began online research and learnt a little about shock wave therapy and so presented to the podiatrist requesting this treatment. The sports podiatrist informed the patient that she may be a suitable patient for shock wave therapy but she would need to be assessed first.

Heel Pain Assessment

The sports podiatrist carried out a thorough physical assessment in order to determine the cause of this patients heel pain. She reported extreme pain on palpation of the plantar aspect of the heel around the plantar fascial  attachment.  There was also considerable pain when pressure was applied to the plantar fascia through the medial arch of the patients feet. This lady was informed that the cause of her heel pain and arch pain was in fact plantar fasciitis. It was explained to the patient that heel spurs are a little misleading and are not usually the cause of pain.

Physical Assessment For Heel Pain

The sports podiatrist carried out a thorough physical assessment with the patient standing up in a relaxed stance position. Further measurements were taken as she stood in subtalar joint neutral position. The podiatrist measured the height of the patients arches and noted an extremely low medial arch profile. Both subtalar joints were overly pronated. With the patient lying down, further muscle and joint testing was performed. It was clear that this patient had extremely loose ligaments causing joint hypermobility. She was informed that high levels of the hormone relaxin, during and after birth, was the likely cause of her loose ligaments. Her foot ligaments were no longer providing stability around the joints of her feet and ankles. While walking on the treadmill the podiatrist was able to observe severe over pronation and foot instability.

Heel Pain Treatment

The podiatrist explained to this patient that in order to reduce her heel pain it was important to support and realign her feet. The quickest and most reliable way to do this was via the use of prescription orthotics manufactured from carbon fibre and inserted into her running shoes, in place of the soft generic liners that come the shoes come with. To this end, the podiatrists took digital foot scans for the patient. The orthotics would take approximately 2 weeks to come back from the lab, and so the podiatrist agreed that it was important to continue applying rigid sports tape to both feet. This sports tape being rigid would mimic the job of healthy and more rigid foot ligaments. The podiatrist also advised the patient to immerse her feet in a bucket of iced water to reduce the swelling and heel pain. Due to the loose ligaments, the patient’s lower leg muscles had become extremely tight in an attempt to compensate for the weakness. Therefore, the patient was advised to perform very specific calf stretches with her foot in a neutral position.

The patient returned after 2 weeks to help her prescription orthotics inserted into her running shoes and to have a heel pain assessed.  She reported that the pain was approximately 20% better due to the use of ice baths. However, she was performed that the real relief from heel pain would come once she was supporting her feet with the rigid carbon fibre orthotics.  The orthotics were fitted into the patient’s running shoes and she was observed walking on the treadmill. Foot and ankle alignment appeared suitable and the patient reported no discomfort from the orthotics.

Due to the fact that this patient had acute and chronic heel pain and was extremely sore she was treated with 2000 reps of shock wave therapy at 5HZ and one bar of pressure. She returned to the clinic for weekly sessions of shock wave therapy for 6 weeks.

Each week that the patient returned to the clinic she reported an overall improvement in her heel pain. The most painful time of day was first thing in the morning or in the middle of the night, however the improvement in pain throughout the day was most obvious. After 6 weeks of shock wave therapy treatment was ceased.  The patient was asked to return to the heel pain clinic in a further 6 weeks. After using the orthotics for 12 weeks the patient reported that her heel pain had subsided completely. There was mild pain on palpation by the podiatrist but this was minimal and considered acceptable. She felt no pain in the heel or arch while walking on the treadmill in bare feet. The patient was requested to continue stretching, and applying ice packs if the pain returned, and to continue using prescription orthotics for a further four weeks. After this 4 weeks, she was advised to gradually introduce other types of footwear. If her heel pain returned or if her plantar fasciitis deteriorated she was instructed to return to the clinic for further assessment.

Please be aware that the information contained in this case study is specific to one particular patient and it should not be taken as general advice. If you suffer with heel pain or plantar fasciitis you should seek the advice of a suitably qualified podiatrist or other healthcare professional.

 

Written by Karl Lockett

Achilles Tendonitis History

In April of 2017, 44-year-old self employed builder arrived at the Sydney heel pain clinic complaining of Achilles tendonitis in his right leg. He reports chronic pain in his Achilles tendon of more than 6 months, and acute pain for approximately 4 weeks. He describes heat and a pulling sensation and the feeling of burning in the back of his Achilles tendon while walking. He informs the podiatrist that his Achilles tendon is sore to touch and is particularly painful towards the end of the day after he has been on his feet for extended periods.  He is suspicious that his Achilles tendonitis developed after he changed his work boots from one brand to another.  He has both pairs of work boots in the clinic today. This patient is approximately 6 feet 1 inch tall and weighs 112 kilos. He informs the podiatrist that he is pre-diabetic but takes no medication and his blood sugar levels are controlled with appropriate diet.  He has never suffered with Achilles tendonitis before but informed the podiatrist that he did once experience a grade 1 calf muscle tear in his right leg. This patient reports extreme pain when climbing up and down ladders or when walking up steps and stairs. He finds temporary relief when he applies a cold ice pack to the back of his leg surrounding the Achilles tendonitis. He also informs the podiatrist that he frequently attempts to stretch the Achilles tendon by lowering his heels off the back of a step when at work. While this provides short-term relief, his Achilles tendonitis is not improving and has become much more painful over the last 4 weeks. This patient did report the problem to his doctor but there was no treatment plan put in place. His doctor informed him that if his Achilles tendonitis did not resolve within 2 months he would offer him some prescription medication or refer him for an injection of cortisone.

Physical Assessment For Achilles Tendonitis

The podiatrist applied mild compression and lateral pressure to the shaft of the Achilles tendon proximal to the heel, to assess the severity of the Achilles tendonitis. During palpation, the patient reported a pain similar to the pain that he experiences throughout his day to day life. Visually, the right Achilles tendon appeared slightly thicker than the left. The patient was informed that he did in fact have all the symptoms associated with Achilles tendonitis and that further assessment was needed in order to determine a successful treatment plan.

Work Boots And Their Effect On Achilles Tendonitis

Both the podiatrist and the patient were suspicious about the onset of this patient’s Achilles tendonitis coinciding with the change in work boots. It became apparent that his original work boots were more robust and inflexible then the replacement pair of boots. His replacement boots had a slightly lower heel drop and were made from a lighter compound which compressed more easily under load. The podiatrist was easily able to twist and manipulate the boot and it felt lighter in his hands. The patient was advised that there was a good chance that his Achilles tendonitis had developed due to the lack of support in his newer work boots. It was explained to the patient that heavier and more rigid work boots that don’t flex so easily, offer more support and are advised in circumstances such as his, where patients are on their feet for extended periods. His Achilles tendonitis would heal quicker after he purchased new boots offering more support.

Biomechanical Assessment – Why Did This Achilles Tendonitis Appear?

In order to determine the underlying biomechanical anomalies that contributed to the onset of this patients Achilles tendonitis, it was important to carry out a biomechanical assessment with the patient walking on a treadmill in his bare feet. Bisection lines were drawn on his skin on the back of his heel and Achilles tendon. The podiatrist captured his gait cycle using digital software on an iPad. The footage was replayed in slow motion and observations were noted. This patient demonstrated a stable foot type and it was apparent that his feet did not over pronate. The lines on the back of his heel and Achilles tendon remaining vertical. (It should be noted here, that some patients will develop Achilles tendonitis, when the foot over pronates and the Achilles tendon becomes distorted, but this was not the case with this patient and his Achilles tendonitis had developed due to other factors.)

The podiatrist was able to observe an early he left on the patients’ right leg, in comparison to his left. This early heel lift is usually a result of tightness and a shortening of the calf muscle. In this particular case, the shortening of the calf muscle was probably a result of the patient’s old muscle tear. The patient was advised that his calf muscles would need some attention and that this bio mechanical issue was the likely cause of his Achilles Tendonitis.

Achilles Tendonitis Treatment

Achilles tendonitis is a condition that has limited healing due to insufficient blood flow. To this end, the patient was booked in for six sessions of Shockwave therapy, which would stimulate blood flow and accelerate healing. The first of his treatments was carried out immediately and was well tolerated. 2000 reps were applied to the Achilles tendon at 2 bars of pressure and a maximum of 6 Hz. The patient felt immediate relief after standing and walking around the treatment room.

The podiatrist carefully demonstrated one specific calf stretching technique that the patient was advised to do several times a day. He was also fitted with 2 x 9mm heel lifts inside his work boots. The heel lifts would reduce the tension through the Achilles tendon allowing the inflamed tendon on the right leg to settle. The patient was instructed to install the Sydney heel pain mobile app for his smartphone. The app contains important information surrounding the treatment of his Achilles tendonitis, including the calf stretching technique, footwear advice, and shockwave therapy.

Achilles Tendonitis Progress

As is usually the case with Achilles tendonitis patients, following the Shockwave therapy the patient reported approximately 5 days of pain relief. On day 6 and 7 the pain started to return as the effects of the treatment began to wear off. The patient was assured that this was normal and that he was now ready for his next treatment. Overall, during week 1, the patient reported a very small improvement in pain but an overall feeling of increased mobility through the lower leg. Weeks 2,3 and 4 brought about similar results and further improvement. The patient was compliant with stretches and the use of his heel lifts. He had also purchased another pair of work boots that were much more suitable. At the 5-week check-up, the patient reported that his Achilles tendonitis was approximately 70% better. Again, he had been compliant with stretching and home remedies as per the mobile app, and had continued to cease the stretches whereby he lowered his heels off a ledge. The final shockwave therapy treatment was applied at week 6.  As the pain from the Achilles tendonitis was much more bearable, the podiatrist was able to increase the treatment to 3.4 bars of pressure and 7 Hz. The treatment was well tolerated. The patient was informed that this would be his last treatment but that he should continue with the heel lifts and the treatment advice. There would be further healing to take place over the next 4 to 6 weeks. The patient was asked to return in six weeks for one final check-up of his Achilles tendonitis.

At this appointment, the patient informed the podiatrist that the pain from his condition had all but subsided. He confessed that occasionally there would be some mild pain after a very physical day, but the pain would reduce very quickly. He no longer felt pain first thing in the mornings but did report some mild stiffness occasionally. He was advised to slowly reduce the use of the heel lifts and to ensure that he continued to stretch his calf muscles thoroughly during this transition.  Once again, he was informed that further healing would continue to take place, even though the shock wave therapy treatment had finished. He was informed that he did not need to come back to the Sydney heel pain clinic but the podiatrist requested he contact the clinic immediately if there was any deterioration and his condition.

Patient: NOT NAMED

Podiatrist: Karl Lockett

Please note the information contained in this case study is specific to one particular person. If you suffer with Achilles tendonitis you should seek the help of a sports podiatrist or suitably qualified medical practitioner.

 
Written by Karl Lockett

 

In April of 2017 a 41 year old male presented to the Sydney heel pain clinic in Miranda complaining of plantar fasciitis. He described pain under the base of his heel that had been present for 9 months. This gentleman was in good physical health and was a keen runner who enjoyed middle distance running 3 to 5 days a week. This patient reported no history of foot or ankle problems aside from a fractured toe 7 years ago. During his running career he had encountered no heel pain and has never have plantar fasciitis before. The patient reports that he is unaware of anything that could have contributed to his heel pain. His running program was consistent, his running shoes were the same, and he was exercising at the same pace and frequency as he had always done for the last 3 to 4 years. This gentleman enjoys running each morning before work covering approximately 7 km each run. His running shoes are Asics Gel Nimbus, and he has worn this particular pair of shoes for the last 6 months. This gentleman reports that the pain from his plantar fasciitis is worse first thing in the morning and after periods of being sat down. During his run, he feels pain for the first kilometre which subsides quickly. The remainder of his run is relatively pain-free and he’s able to complete his route. This patient reports symptoms that are very common with plantar fasciitis, and his condition causes pain in the heel for the hour or two that follows his run. He describes pain while sitting at his chair in the office, and pain when he stands up to walk to the fax machine. Patients with plantar fasciitis often report these types of symptoms.

Due to the frustration with this plantar fasciitis, the patient decided to carry out some vigorous stretches through the sole of his foot. For approximately one week he carried out the classic calf stretches while standing upright leaning against a wall.  Being a keen runner, he was keen to rid himself of this pain and return to his regular exercise without this hindrance. To this end he was carrying out this stretching program up to 5 times a day.  However, after six days of stretching, there was a slight increase in pain from the plantar fasciitis. Please note, patients with plantar fasciitis often find that this is the case due to poor stretching technique.

Physical Assessment for Plantar Fasciitis

The sports podiatrist at the Sydney heel pain clinic carried out a thorough physical assessment and confirmed that this patient did in fact have plantar fasciitis. Firm pressure was applied to the base of the heel and the medial slip of the plantar fascia in the patient’s right foot, and this elicited pain consistent with the symptoms that he felt on a day to day basis.  The patient was informed that plantar fasciitis is not a lifelong ailment, as in osteoarthritis, and that with the correct treatment plan he would make a full recovery within 6 to 8 weeks. However, in order to determine the best treatment plan it was necessary for the podiatrist to carry out a biomechanical assessment.

Biomechanical Assessment for Plantar Fasciitis

In order to determine the cause of this patient’s plantar fasciitis it was important for the podiatrist to assess the patient walking and running barefoot on a treadmill. Bisection lines were drawn on the back of the heel and the Achilles tendon. The patient was asked to walk and then run on the treadmill while the podiatrist recorded his gait cycle using digital software on an iPad. The video was replayed in slow motion while observations were made and biomechanical anomalies noted. In many cases, patients with plantar fasciitis will demonstrate an early heel lift due to calf muscle tightness, and this was clearly the case with this particular patient. Furthermore, this patient demonstrated severe over pronation in both feet due to ligament laxity. Assessment of the ankle, knee and elbow also revealed ligament laxity. It was explained to this patient that the cause of his plantar fasciitis was multifactorial. The weakness in the ligaments leading to hypermobility and compensation by the calf muscles. Furthermore, the tightness in the calf muscles adding additional stress to the heel during gait. Both of these factors would lead to stress and strain on the plantar fascia which results in plantar fasciitis.

Treatment Plan for Plantar Fasciitis

This patient was advised that his plantar fasciitis would make a full recovery within 6 to 8 weeks once his biomechanical anomalies were addressed and the treatment plan was put in place. He was advised that a strict calf stretching program would be crucial and that he would need to remove soft liners of his running shoes and replace them with motion control prescription orthotics, which would reduce the strain on the plantar fascia and allow it to heal naturally without injections or tablets. The calf stretching technique would be very important and he was shown exactly how to perform this exercise. He was advised that his plantar fasciitis would not recover and would probably deteriorate if his stretching technique was poor. The podiatrist took 3D digital foot scans of the patients feet and completed a prescription design form. The patient was advised that his orthotics would be ready for fitting in 2 weeks time and that these would be inserted into his running shoes. In order to apply some support to the feet while waiting for the orthotics the podiatrist applied rigid sports tape to both feet to reduce pronation and to minimise the stress on the plantar fascia.

Orthotics for Plantar Fasciitis

Two weeks later, the patient returned to have his orthotics fitted to his running shoes to treat his plantar fasciitis. The patient had been compliant with calf stretching and reported a small improvement in his condition even though he had continued with his running program. The carbon fibre orthotics were fitted into his Asics Gel trainers and were tested on the treadmill while the podiatrist took an additional video. Foot and shoe alignment appeared to be satisfactory and the patient reported no discomfort with his orthotics. The patient was advised to gradually introduce his orthotics and to not use them too much too soon. He was advised to refrain from running with the orthotics for the first 7 days. Following the introductory period, he was advised to wear the orthotics all day every day in order that his plantar fasciitis could recover quickly. He was also advised to apply cold ice packs to the affected area.

Follow Up at 4 and 8 Weeks

After 4 weeks the patient returned for a follow up appointment and reported approximately 60% improvement in his plantar fasciitis. The podiatrist confirmed that the treatment Plan would continue and no changes were made. AT the 8 week check-up the patient reported that the pain from his plantar fasciitis had subsided.  He did report some mild stiffness in the mornings but this would subside quickly. Once again, the patient was informed to continue with the treatment plan but to return to the clinic if his improvement plateaued. He was also advised to continue the use of his orthotics after the plantar fasciitis had fully recovered, due to his inherent foot weakness / lax ligaments.

Please do not take the above information as general advice. The information contained here in this case study is specific to one individual. If you suffer with plantar fasciitis you should contact a sports podiatrist or other medical professional.

 

Written by Karl Lockett

A 36-year-old male arrives at the podiatry clinic with suspected plantar fasciitis of more than 2 months. He is unable to walk into the consultation room without limping. He informs the podiatrist that his heel pain started suddenly during a game of basketball, whereby he felt a “click” in the sole of his foot, around the base of the heel. He was forced to stop playing immediately due to the intense pain. He is a healthy individual with no medical complaints and good foot health. He has never had heel pain or plantar fasciitis before. On the same evening of his trauma he was forced to take medication to reduce the inflammation and the pain in his foot. The following day he was forced to take the day off work and he made an appointment to see his local physiotherapist who diagnosed him with a stress fracture, not plantar fasciitis. The physiotherapist recommended that he visit his general practitioner and request MRI to confirm this diagnosis. The general practitioner instead referred to patient for an x-ray of his foot. Upon inspection of the X-ray by the podiatrist there was no evidence of fracture. Please note that plantar fasciitis does not always show on x-ray.

The patient returned to the physiotherapist and informed him that there was no fracture. The physiotherapist informed the patient that there may however be a stress fracture and that stress fractures do not always appear on x-ray. To this end the physiotherapist recommended that the patient use gel cushions in his shoes and to try to wear soft trainers as much as possible. The physiotherapist also recommended the application of cold ice packs as well as heat packs to increase blood flow. However, the patient found that following the application of heat, the pain in the heel would increase. This is quite typical of patients who are suffering with plantar fasciitis.  After 10 days of treatment at home the patient became frustrated and began some online research himself. It was here that the patient discovered conditions such as plantar fasciitis.

Physical Assessment For Plantar Fasciitis

The sports podiatrist at the Sydney heel pain clinic carried out a series of tests which help to determine and diagnose plantar fasciitis. The patient was asked to stand in a relaxed position without shoes. He was then asked to perform calf raises on both feet. The patient was able to perform calf raises but there was pain under the right foot during this exercise. He was then asked to perform the same exercise on a single leg. He was able to do this easily on his left leg but could not perform one single calf raise on his right leg due to extreme pain in the base of his right heel. The podiatrist then applied firm pressure to the base of the heel in the area where the plantar fascia attaches. This caused extreme pain in the patient’s foot and he retracted his leg instantly. Firm pressure was also applied to the plantar fascia distal to the heel through the arch of the foot. While this caused some pain in the patient’s foot it was not as localised or acute as the pain in the base of the heel. The patient was informed that he did not have the symptoms of a stress fracture but more likely was suffering with a condition known as plantar fasciitis.

Other Findings in Addition to Plantar Fasciitis

Further testing was carried out and it was found that in addition to plantar fasciitis, this patient also had Achilles tendonitis in the same foot. This may be a result of compensated gait whereby the patient has been limping for the past 8 weeks,  causing strain through the Achilles tendon in the same leg. However, it is also possible that the Achilles tendonitis had developed due to the same biomechanical anomaly that caused the plantar fasciitis.

Plantar Fasciitis Treatment

This patient was informed that his condition was more acute that most patients with chronic plantar fasciitis.  He was informed that his condition may be complicated by the presence of small intra-substance tears within the plantar fascia. This patient was referred for an ultrasound of his Achilles tendon and plantar fascia in the right leg. However, regardless of the results from the ultrasound it was important to treat the patient as he was unable to walk without limping and his condition was not improving. To this end, the patient was informed that he must be fitted with an immobilisation boot. The immobilisation boot would hold the ankle at 90 degrees and prevent the foot from moving. The patient was not over the moon about such treatment but agreed that he had to do something to fix his plantar fasciitis. The patient gave consent to be fitted with an immobilisation boot.

The patient was informed that the blood flow to the plantar fascia was quite poor, and to this end healing of the plantar fasciitis would take some time. The patient was made aware that he would be using the boot for a minimum of 4 weeks and possibly 6 to 8 weeks. Prior to the boot being fitted the podiatrist applied rigid sports tape to the foot. This would hold the joints of the foot together and prevent elongation or displacement of the foot. Patients with plantar fasciitis tend to heal quicker with the use of rigid sports tape inside the boot.

As is typical with plantar fasciitis, this patient was informed that the application of cold packs to the base of his heel on a daily basis would be highly recommended. Because plantar fasciitis is an inflammatory heel condition, the patient was informed that he should not apply heat. Patients with plantar fasciitis or other foot conditions that require the use of an immobilisation boot, will usually develop tightness in both calf muscles, after using the boot for sometime. Due to this unavoidable tightening, the patient was instructed to perform calf stretches on a daily basis.

To summarise, the treatment for this patient’s plantar fasciitis would comprise rigid sports tape, immobilisation boot, calf stretches, and the application of ice packs. He was booked in for a follow up that would take place in 3 weeks. He was also informed that after 3 weeks of using the immobilisation boot, we would consider commencing a course of shockwave therapy.

Ultra sound results: Small instar-substance tear in the plantar fascia measuring 7mm X 4mm and Achilles Tendonitis in the right leg.

Please note: This case study is not general advice for plantar fasciitis. If you have heel pain you should consult with a podiatrist or other medical practitioner.

 

Written by Karl Lockett