Case studies Archives - Page 7 of 8

Case Study 8th Feb – Arch Pain

A 67-year-old male presented with arch pain and heel pain in his left foot left. He reported that the pain came on suddenly and has been present for over 2 months. He is retired, however he is a physically active person who plays golf 3 times a week, and also enjoys running and going to the gym where he regularly does bench presses and squats. He informs the podiatrist that he thinks he has Plantar Fasciitis.

He had tried a few remedies at home to relieve his heel pain, these included a few stretches that were incorrect, and were further aggravating his arch pain. He also performed some gentle passive stretches in the mornings, which were of no harm, and were quite beneficial to his heel pain.

He had also performed an ultrasound, which confirmed he had Plantar Fasciitis of the left foot.

He had firm orthotics which he used previously for different reasons, however he found them to be too firm and uncomfortable to wear with his newly developed heel pain. Furthermore, upon examination of the orthotics, it became apparent that they did not have adequate cushioning on top of the orthotics, or a plantar fascial groove, which is a ridge designed inside the orthotic to accommodate for the plantar fascia and unload it, allowing recovery to take place.

However, it was explained that once the inflammation of the plantar fascia is taken down and there is no more heel pain, he may be able to tolerate his old orthotics. Hence new orthotics were not prescribed for him at this stage.
It was explained to him that extra cushioning on top of the orthotics along with a plantar fascial groove can greatly help in reducing his heel pain, as well as correcting any biomechanical misalignments, and relieving the Arch Pain.

His footwear was also assessed. He commonly wore 3 sneakers, one of which was the best suited for his foot type. He was asked to wear the desired sneakers which provided maximum support to his feet and will hence help to
reduce his arch pain.

Arch Pain Examination

Upon physical examination, the left heel was very sore on the squeeze test, where the origin of the plantar fascia from the base of the heel was firmly palpated along with the body of the Plantar Fascia to its insertion at the base of the toes. The area closest to the inside of the heel elicited the most pain on palpation. There was also arch pain on palpation, but no swelling, redness or warmth was noted.

The patient was asked to perform a single leg heel raise on his right foot which he achieved without a problem. However, when asked to perform the same test on his left foot he underperformed and was limited by pain. This test adds stress to the Plantar Fascia and is a good indicator of Plantar Fasciitis. Most patient’s with Plantar Fasciitis at the base of the heel can perform the test, if there are not tears and the condition is not acute, but patient’s with Plantar Fasciitis that involves irritation through the arch of the foot too will struggle, and will report Arch Pain during the lift.

The cause of the heel pain was explained to the patient. The plantar fascia was being overly stretched away from its insertion to the heel bone, causing it to become inflamed. The patient had Plantar Fasciitis of the medial slip. The strain was sufficient to cause inflammation and irritation through the mid fibres of the Plantar Fascia also. This is not as common as the inflammation at the base of the heel.

Biomechanical Assessment for Arch Pain

A thorough biomechanical assessment was conducted to understand the causes and/or contributing factors of his heel and arch pain.
On gait analysis, he reported pain every time his heel hit the ground, and mild pronation at the subtalar joints was noted. There was early heel lift with both feet affected, and this is usually due to shortening of the calf muscles.

He had very tight gastroc muscles, which further increases the pull going through the plantar fascia, contributing to the pain. The correct way to stretch the calf muscles, without stretching the plantar fascia was demonstrated to the patient.

Furthermore, his arches were measured in a relaxed stance position and it was noted that they were higher than average. It was explained to him how his high arches were also contributing to the arch pain he gets, and ways this can be accommodated for.

Heel and Arch Pain Treatment

An immobilisation boot was placed on the left foot. The patient was asked to walk a short distance, and reported no to very minimal pain inside the boot.

He kept the boot on for a period of 4 weeks, and his heel pain was re-examined. Upon palpation of plantar fascia, he reported mild pain, but this was much less painful than the initial heel pain examination. He was asked to remove the boot after 4 weeks and monitor his progress.

The heel was also treated with 5 sessions of shockwave therapy at weekly intervals.

He reported further improvement after each treatment with shockwave therapy. After the 5th session a big improvement was noticed by the patient, and he reported that there was minimal pain when his heel hit the ground in the mornings. The lack of morning pain in the heel is always a good sign and it indicates that the inflammation is settling down. Physical examinations of this patient’s left foot also revealed that it was time to cease treatment. There was minimal heel pain and very mild Arch Pain on palpation of both areas.

He was advised to keep stretching and following the advice that was initially given at the start of the treatment, to prevent heel pain in the future. Furthermore, he was asked to contact the clinic if his condition returned.

Please note: The information in this case study is specific to one particular patient and should not be taken as general advice. There are several causes of Plantar Fasciitis and if you are having foot problems you should consult with a Podiatrist or suitable healthcare practitioner.

Written by Karl Lockett

February 16, 2017/by karl

Case studies

Case Study December 2016 – Plantar Fasciitis Following an Ankle Sprain Injury

Plantar Fasciitis

A 38 year old male presents to the clinic complaining of Plantar Fasciitis and heel pain in his left foot, of approximately 7 weeks. He describes a pulling and tightness through the arch of his foot, which creates mild Arch Pain but a sharp pain and a dull ache under the centre of his heel. The heel pain is extremely sore first thing in a morning when he rises from bed and is present throughout the day. The pain settles after his morning shower and after walking around the house for approximately 15 minutes. Although the pain eases it never goes away completely. Mid afternoon he reports a rise in pain levels due to being on his feet for longer periods. When he stands up from his office chair he feels a sharp heel pain which forces him to hobble.

This patient reports that 10 weeks ago, he sprained his ankle while playing football and was under the care of a physiotherapist. His ankle swelled significantly and the patient was forced to alter his gait. In particular, he was forced to walk on the outside edge of his left foot, and was weight bearing on his forefoot more than he normally would. It is not uncommon for patient’s to develop secondary Plantar Fasciitis or other types of heel pain after an ankle sprain, or other foot injury. The altered gait leads to an overload of stress on the other parts of the foot, in particular the Plantar Fascia. Walking on the forefoot also tightens the calf muscles and directly loads the Plantar Fascia. The tightness in the calves causes a pulling on the heel and this is a contributing factor in the development of the heel pain.

This patient informs the Sports Podiatrist that he has had many ankle sprains in the past and that he has a tendency to “go over” on his left ankle, more than his right. This patient’s physiotherapist instructed him to perform calf stretches to assist in the recovery of his ankle injury. He was dropping his heel off the back of a step and holding it for 30 seconds. There is a chance that he strained his Plantar Fascia whilst performing these stretches or that he did too many stretches for too long, and this strained the fascia, causing it to pull on the heel.

Plantar Fasciitis Remedies

This gentleman decided to roll his foot on a frozen coke can each afternoon and before bed. He reports temporary relief at the time but an increase in symptoms later that day and the next morning. He would take a beach towel and throw it around his forefoot and then lie back and pull the towel, to stretch his Plantar Fascia and calf muscles. Once again, temporary relief was the experience and no long term benefit after stretching daily for 2 weeks. His heel pain persisted and was present every day.

A work colleague informs him that he has the symptoms of Plantar Fasciitis and he then seeks the help of a Sports Podiatrist.

Assessment of Plantar Fasciitis and Heel Pain Diagnosis

There was a typical jump response with the Plantar Fascia squeeze test. Pain was prominent on the medial aspect of the heel and also the central portion of the base of heel. There was also arch pain in the left foot as mild pressure was applied the sole. Patient was able to perform a single leg heel raise with only mild heel pain.

Heel Pain – Bio Mechanical Assessment

This gentleman was able to walk bare foot on the treadmill while we recorded his gait with the iPad digital software. He experienced pain on heel strike and mild heel pain during heel lift. His tight calf muscles were noted, causing an early heel lift. Mild pronation was noted at the right rear foot – less in the left foot due to ankle injury and stiffness.

Treatment for Plantar Fasciitis with Ankle Sprain

This patient was suffering with Plantar Fasciitis as well as lateral ankle pain from the football injury. He was still unable to walk normally, due to the heel pain, without limping. To this end it was important to unload the whole foot and ankle via the use of an immobilisation boot. Full height boot with rocker sole and air pump for extra security. He was advised that he would be using the boot as much as possible for at least 3 weeks and that he could come out of the boot once he felt comfortable and able to do so.

This patient also commenced a course of Shock Wave Therapy, whereby 2000 reps were applied to the bae of the heel and the Plantar Fascia at a rate of 5 HZ and at 1.3 bars of pressure. He was informed that we would carry out 1 session per week with a minimum of 5 days and a maximum of 7 days in between each session.

He was instructed to apply ice packs to the injured ankle and the heel pain area at least once a day and preferably 3 times a day for 30 minutes. Patient’s with Plantar Fasciitis must not apply heat to the affected area, even if it gives short term relief.

Specific calf stretches were demonstrated so that the patient could gain an increase in ankle joint movement, without straining the Plantar Fascia during the stretch. Stretching was to be done in the morning before applying the boot and in the evening before bed, when the boot was removed.

Follow up of this Patient’s Plantar Fasciitis and Ankle Pain

After 4 weeks and 4 sessions of Shock Wave Therapy this patient was able to remove the immobilisation boot and transition into firm, supportive trainers. His heel pain although still present was very mild. The swelling and stiffness in his ankle had subsided and he had approximately 90% normal range at the joint. Continued support for the left foot was required, in particular for the Plantar Fascia. Cases of Plantar Fasciitis settle much quicker when the Plantar Fascia is unloaded. The patient was informed that we would now use rigid sports tape to support the fascia and that this would resolve his heel pain completely over the next 3-4 weeks. The strapping would be re-applied each week and the Shock Wave Therapy would continue for 2 more weeks. He was advised to continue applying ice packs to the heel and wear his trainers as much as possible.

At the 6 week follow up appointment the heel pain had subsided completely and the Plantar Fasciitis had healed.

NB: Please do not take this case study as general advice. Treatment for Plantar Fasciitis and other foot conditions is tailored specifically to different patient’s.

Written by Karl Lockett

February 2, 2017/by karl

Case studies

Case Study – 10th November 2016 Plantar Fasciitis in a Builder

History

A 42-year-old man, a builder, has been suffering with Plantar Fasciitis for approximately 4 months. He reports pain under the ball of his heel and has a hard time walking when he gets out of bed in a morning. His Heel Pain is only in one foot and he has never had Plantar Fasciitis before. He enjoys good health and is taking no medications. He is carrying approximately 5kg’s more than he would like to but is unable to exercise properly due to the Plantar Fasciitis.

This gentleman’s Heel Pain came out of the blue and came on very suddenly. He woke up one morning and the Plantar Fasciitis was so bad that he could not walk properly. There was a throbbing sensation and a stabbing pain under the ball of his heel and he had to take the day off work. He lay down and rested his foot all day and applied an ice pack. The following day he went to his GP who mentioned a heel spur and Plantar Fasciitis. The doctor arranged an X ray and gave him a prescription for some anti inflammatorie’s. The Heel Pain did settle down slightly but he reports a pain level of 7 out of 10 every day. His Plantar Fasciitis persists and is constant.

Out of frustration, he purchased some gel cushions for his shoes but after using these for 3 weeks they did not change the Heel Pain. If anything, they made his feet wobble a bit more inside the shoe and so his Plantar Fasciitis felt worse on some days.

This gentleman usually enjoys a game of squash, once or twice a week, but he has given up on this for now as the Heel Pain and Arch Pain are too much to cope with the following day. He would return from squash and within an hour or so he would feel throbbing and shooting pains which would render him idle. He would again lie down and elevate his foot, applying an ice pack.

Plantar Fasciitis / Heel Pain / Arch Pain and Footwear

This patient’s squash shoes are typical of this sport in that they are without a heel drop, and so are flat and flexible which means they do not offer much support. His work boots although appear to have a thick and robust sole, are actually constructed from a low density rubber and hence are also flexible, offering minimal support. They are also over 12 months old and have become very soft underneath. This extreme wear on such a work boot in a patient who has such a physical job is a problem. Not only is he on his feet for long periods, but he is carrying heavy loads and is up and down ladders throughout the day, which adds a lot of strain to his Plantar Fascia and feet in general. Heel Pain and Arch Pain are common symptoms in this situation and Plantar Fasciitis is also common.

Physical Examination – Plantar Fasciitis

Direct finger pressure was applied to the central aspect of the plantar heel and the patient reported pain, immediately. Along the medial aspect of the calcaneus was also tender, and this is typical of Plantar Fasciitis. Ankle joint range of motion was limited due to tightness in the calf muscles. In particular Gastrocnemius but also soleus muscles. Again, this is extremely common in patient’s with Plantar Fasciitis. It is rare that we see a patient with Plantar Fasciitis or Achilles Tendonitis who does not have tight calf muscles. The muscles pull hard on the back of the heel bone and this in turn puts strain on the Plantar Fascia which is attached to the base of the heel. This patient also had some soreness along the tibialis posterior muscle and its tendon, and as sports podiatrist’s we see this commonly. The tibialis posterior muscle becomes over active as it fires too soon in the gait cycle due to that early heel lift.

Treatment for Plantar Fasciitis – Sports Podiatrist Recommendation

This gentleman had not seen a sports podiatrist before and so it was explained to him that he had a very common condition known as Plantar Fasciitis and this was causing his Heel Pain and Arch Pain. It was explained to him that his footwear was a big part of his problem and had probably caused his condition. His work boots needed to be changed as did his squash shoes.

Specific shoes were recommended to this gentleman and he was informed which stores he could purchase these shoes that had been matched to his foot type. New squash shoes, new work boots and a pair of every day walking shoes that he should get around in while his foot made a full recovery. He was informed that it would be ok for him to wear whatever shoes he wanted to once his foot had recovered and that he could lead a normal Australian lifestyle, so to speak, and wear bare feet and thongs from time to time. However, he should always keep a close eye on the state of his work boots as he spends most of his time in these shoes and it is here that he needs lots of support.

A very specific set of calf stretching techniques was demonstrated to this patient. He was given an instruction sheet which guided him through the techniques and reminded him how often they should be done. In cases of Plantar Fasciitis, if the technique is not adhered to then it can actually strain the Plantar Fascia and prolong the condition, increasing the symptoms and preventing healing.

The patient was advised that he would make a full recovery and that Plantar Fasciitis is not a life long condition such as arthritis. His Arch Pain and heel pain would subside completely as long as he is compliant with the advice of the sports Podiatrist. To help him along his road to recovery, rigid sports tape was applied to the affected foot and the patient was shown how to reapply the tape once it was due. He could continue to apply the strapping for several weeks until the Plantar Fasciitis had healed. He was also informed that he should continue applying ice packs every night before bed, until the heel pain had gone.

In cases of Plantar Fasciitis the morning pain is the metaphorical measuring stick. Once the morning pain has gone, the condition has likely healed.

The above information should not be taken as general advice as it is specific to one patient who had been diagnosed with Plantar Fasciitis.

Written by Karl Lockett

January 19, 2017/by karl

Case studies

Case Study – November 2016 Plantar Fasciitis Causing Arch Pain

History

A 56-year-old retiree has been suffering with Arch Pain due to Plantar Fasciitis for approximately 6 months. She is going through menopause and reports several of the typical symptoms such as facial flushing. While the exact etiology is unknown, it is not uncommon to find patient’s who are going through this change who develop acute Arch Pain.

This lady describes burning and a tearing pain through the arches of both feet and she is forced to hobble when weight bearing. She confirms that the Arch Pain is unbearable in the mornings when she walks from her bed, and is also very sore after periods of being seated. She has never had Plantar Fasciitis before and has always had good foot function, without any significant foot problems.

In order to make life a little easier, and to reduce the Arch Pain, she has been given prescription anti-inflammatories, which she takes in conjunction with her hormone replacement therapy medication. Her regular GP did not mention the correlation between Plantar Fasciitis and menopause but her endocrinologist was open to the possibility that they were connected.

This patient usually enjoys a morning walk of approximately 3 km’s and the occasional game of tennis, but she has had to refrain from all types of physical activity because of this Plantar Fasciitis. She applies ice packs to each foot every night before bed and also at lunch time when at home. The ice packs reduce the pain but only temporarily. Her GP also asked her to role her feet on a tennis ball but she finds that this irritates the fascia and increases the pain.

Arch Pain and Footwear

This lady has been wearing her tennis shoes as much as possible as she finds they give her more support and she feels a little less pain. When she wears ballet flats or soft summer sandals her Arch Pain increases. Walking bare foot is also a problem and she reports that this seems to exacerbate her Plantar Fasciitis.

Arch Pain – Physical Examination

As pressure was applied to the mid arch of the patient’s foot, distal to the heel, she reported extreme pain and retracted her foot away from the Podiatrist. An area of approximately 5cm x 3cm was symptomatic throughout both arches. The area of pain correlates with Plantar Fasciitis and there was also some pain more proximally at the attachment of the Plantar Fascia, at both heels. Typically with Plantar Fasciitis the pain is in one foot and is usually more prominent at the heel. In cases like this where the patient has menopause or some other underlying chronic illness the pain is often in both feet and can be more prominent in the arch as opposed to the heel. Heel pain can still be present but the main symptom is usually Arch Pain.

Plantar Fasciitis Treatment

This patient had not been receiving treatment for her Plantar Fasciitis from her GP or any other allied health practitioner. It was explained to her that her condition had likely come about due to the hormonal changes within her body and that this was a rare cause of Plantar Fasciitis. She was advised that she should consult with her endocrinologist with a view to changing or modifying her medications. It was also explained to this patient that in usual circumstances we often use orthotics to unload the Plantar Fascia but in her case the orthotics would probably cause pain. The pressure and support from the orthotics against the sole of the foot would be too much for her to tolerate, as her Plantar Fasciitis was acute. Other treatment’s such as immobilisation boots were not an option as they are designed to treat one foot only and not both simultaneously. Shock wave therapy was deemed inappropriate as both feet seemed hot and red and hence circulation was not an issue. To this end it was decided to offer some pain relief via the use of acupuncture needles, and some support with rigid sports tape.

Dry needling is a western version of traditional Chinese acupuncture whereby needles are inserted into trigger points along a muscle. This refers chemical and circulatory changes along the referral pattern line, to other parts of the body. In this case, the needles were inserted in to the calf muscles and the sole of the foot, and this provided relief from the Arch Pain. Dry needling is very good for pain relief from Plantar Fasciitis and it also softens and loosens the calf muscles which helps with bio mechanics. In turn, this helps to unload the Plantar Fascia.

Rigid sports tape was applied to both feet using a technique that would reduce the spread of the bones in the feet and hence help to unload the plantar fascia, but without applying pressure to the fascia itself – which would induce Arch Pain. The patient was advised that the strapping should remain in place for as long as possible, usually 5 days, and that it should be reapplied at home once it comes off. Strapping the feet continually for at least 3 weeks would become part of an ongoing treatment plan. In addition to the strapping, the patient was instructed to apply ice packs as frequently as possible while elevating her feet, at least twice a day for 30 minutes. She was asked to continue using her tennis shoes and to avoid soft, flat shoes and walking bare foot. She was advised not to role her feet on a tennis ball as this could irritate the Plantar Fascia and increase the Arch Pain.

Once again, it was important for this patient to revisit her endocrinologist as the cause of her Plantar Fasciitis did not seem to be physical but more so hormonal. While the treatment’s suggested here were important to help with the Arch Pain, they would not remove the cause of the condition. Changes to HRT usually take some time to take affect and so it was expected that any improvement would be 2 to 3 months away. As yet, there has been no follow up appointment with this patient so we have not been able to monitor her Arch Pain or Plantar Fasciitis.

Please note that this is a case study of one individual and the information here should not be taken as general advice.

Written by Karl Lockett

January 12, 2017/by karl

Case studies

Case Study – October 2016 – Arch Pain and Plantar Fasciitis

A 44 year old male has been seeing his Podiatrist for what he thinks is Plantar Fasciitis as the cause of his Arch Pain. He is a keen martial arts student and has been practicing Shotokan karate for 12 years, which he performs in his bare feet. He attends 3 times a week and each class is an hour long. His Arch Pain came on gradually over a period of 3 weeks and he reports that he strained his calf muscle in the same leg approximately 2 months prior to the pain developing. His physiotherapist was massaging his calf muscles and encouraging calf stretches following the strain and he sat out of karate for 6 weeks. When he returned to training, his leg did not feel 100% but he was able to complete the class with only slight pain. Stiffness in the muscles did persist and a reduced range of motion was apparent during training and walking. He had not made a connection between the calf problem and the Arch Pain but at this stage he is advised that they may be related.

He is otherwise a healthy individual with no other medical complaints and the only other foot problem he reports is a stress fracture to the 4th metatarsal of his other foot, 5 years ago.

This patient describes a sharp Arch Pain in the sole of his right foot, towards the right / outer edge. The area that he describes is along a line from the mid arch towards the cuboid bone, on the outer side of the foot. His Arch Pain is noticeable throughout his karate class and his podiatrist informed him that this is typical of Plantar Fasciitis. He does not feel much Arch pain in the mornings when he gets out of bed and the pain is very mild throughout the day when he is wearing his business shoes. When he wears his running shoes in the evenings and at weekends he does not feel any Arch Pain or Plantar Fasciitis pain at all. After his class has finished the patient drives home and struggles to walk from his car. He limps as his Arch Pain is quite severe and he believes that this is typical of Plantar Fasciitis. He finds relief from the pain when he applies an ice pack to his foot and he does this after each training session for approximately 30 minutes. He reports that the pain is present daily and he is becoming frustrated. He has a karate competition in 12 weeks and is anxious to partake.

Arch Pain Examination for Plantar Fasciitis

With the patient lying face up on the treatment table visual observation reveals swelling along the lateral edge of the foot, close to the cuboid bone. Firm pressure is applied to the arch of the foot from the heel, towards the toes, along the Plantar Fascia. There is pain when pressure is applied along the mid arch, approximately 3cm distal to the heel. The pain is not central as one would expect with Plantar Fasciitis but is more lateral towards the outer side of the foot, following the line of the long Peroneal tendon. Further pressure is applied to the tendon around the cuboid bone and this elicits a small jump response from the patient and he reports pain. The patient is asked if he ever feels pain along this outer side of his foot in addition to the Arch Pain and he confirms that this is definitely the case. He is under the impression that the pain on this side of his foot has been a result of compensation for the Arch Pain. He has been walking on the outer side of the foot to take load off the arch area. The patient is informed that the cause of his Arch Pain is not due to Plantar Fasciitis but more likely a result of tendonitis of the peroneus longus muscle. Peroneus longus is a muscle that runs down the outer side of the lower leg (fibula) and passes around the outer ankle into the sole of the foot. There is a short and a long tendon but they both pass the cuboid bone.

Arch Pain Treatment

The previous Podiatrist had been applying Shock Wave Therapy to the Plantar Fascia along the mid arch of the foot but this had not helped to reduce the patient’s Arch Pain. He had also arranged prefabricated, off the shelf, arch supports for the patient to use in his work shoes and trainers. Again, these had not helped the condition improve. The previous Podiatrist had also recommended heat packs be applied to the foot and although this was soothing, the long-term benefits were absent.

It was explained to the patient that because the cause of his Arch Pain was due to a peroneal tendonitis and not Plantar Fasciitis, it was important to unload the Peroneal tendon. He now understood why the Shock Wave Therapy had not helped. The probe had been used along the Plantar Fascia and not the Peroneal tendon. He was advised to stop applying heat packs but instead continue with ice, to reduce the inflammation within the tendon sheath.

To reduce the load on the Peroneal tendon, rigid sports tape was applied to the foot using a technique that lifts the cuboid bone, and creates a favourable arch on the lateral border of the foot. The patient is advised to leave the strapping in place for as long as possible and to expect it to remain for approximately 5 days.

Medium density padding is applied to the patients existing arch supports along the lateral border of the device in the area that will lift and support the cuboid bone, unloading the Peroneal tendon. The patient is advised that the tendon may take 4-8 weeks to heal completely.

Calf Stretches for Arch Pain

The patient is informed that his Arch Pain condition is likely to have been caused by his initial calf strain and hence he must restore normal range. He is instructed to perform the following calf stretches daily.

Shock Wave Therapy for Arch Pain

A discussion surrounding the benefits of Shock Wave Therapy for Arch Pain takes place and the patient is advised to wait and return in one week to have his progress monitored. If there has been a significant improvement from the strapping, stretching and arch support modification, then Shock Wave Therapy will not be necessary.

The patient was reviewed at weekly intervals for 5 weeks and his strapping was replaced at each visit. He was compliant with the application of ice packs and stretching and hence he responded well to the treatment programme. No Shock Wave Therapy was needed and he was able to continue martial arts. His Arch Pain had gone completely by the 6th week and no further treatment was required.

Please be aware that the treatment for this patient should not be taken as general advice and if you are suffering with Arch Pain, Plantar Fasciitis or any other type of foot pain you may benefit from consulting a sports Podiatrist.

Written by Karl Lockett

December 29, 2016/by karl

Case studies

CASE STUDY – NOVEMBER 2016 ARCH PAIN AFTER WALKING

A 48-year-old lady presents to the clinic complaining of Arch Pain of approximately 12 weeks following a period of being idle. She reports that she has not exercised for a number of years and has consequently gained weight. She is 12 kilos over her desired weight and hence decided to get fit again by walking. Her Arch Pain came on within a week of walking and she reports that she went from no walks to six mornings a week, without a gradual return to activity.

She was wearing Asics gel Kayano trainers which were approximately a year old and were showing signs of wear and tear. The mid sole had softened and was not resistant to manipulation by hand when tested. It was more pliable than it was as new, and too flexible to offer sufficient support for her body weight.

This lady was also type 2 diabetic and was using metformin to control blood sugar levels which were stable. She did not suffer from any complex medical conditions and reported that she did not usually suffer from inflammation in her joints or tendons.

The Arch Pain that she was feeling was in her left foot only and her right foot was asymptomatic. She informs the Podiatrist that she feels the pain as she starts her walk each morning but that after a kilometre or so the pain reduces to a level that allows her to walk relatively comfortably. The Arch Pain that she feels returns when she gets home and sits down. Within 5 minutes there is a throbbing sensation in the sole of her foot, between the heel and ball of foot, centrally. The Arch Pain persists throughout the day and fluctuates between being bearable and almost excruciating. If she sits down for more than a few minutes then the Arch Pain becomes apparent and then will increase as she stands up from her seat, causing her to limp. She would limp for approximately a minute or so until the foot warmed up.

In the evenings, the Arch Pain would feel worse due to the number of steps taken throughout the day, regardless of the type of shoes that the patient had been using. This patient had alternated between arch based thongs and her Asics trainers but could not find relief. She resorted to over the counter anti-inflammatories which reduced her Arch Pain slightly but did not rid her of the pain completely. Her GP was not particularly competent with Arch Pain treatments or foot health in general so had referred her to our clinic to see a sports Podiatrist.

Arch Pain Examination

This patient hobbled to the treatment table as she stood up from the chair in the consultation room, as her Arch Pain was so bad after being seated. She lay supine on the bed as pressure was applied to the sole of the foot. Pressure was applied at the heel first and then at 1cm intervals until the toes were reached. There was no heel pain reported but there was significant Arch Pain felt when finger pressure was applied to the Plantar Fascia approximately 2cm distal to the heel. The patient was informed that she had Plantar Fasciitis in the sole of her foot and that this was a common cause of Arch Pain. It was explained to the patient that she had strained her Plantar Fascia because she had increased her level of activity too quickly and had been wearing shoes that did not offer sufficient support.

Bio-Mechanical Assessment for Arch Pain

Bisection lines were drawn on the patient’s feet and legs and she was asked to walk on a treadmill so that her gait could be recorded. Joint and muscle testing was performed to look for issues that could have allowed the Arch Pain to develop. Hip position and hip rotation were assessed. Her knee joint and position was looked at and her ankle joint was also measured. Sub talar joint movement and forefoot examination was also carried out.

It was noted that this patient had an internally rotated tibia on the left leg which was leading to compensatory external hip rotation on the left side and subsequent limited internal rotation at the hip – due to tight gluteal and piriformis muscles. The end result was an externally positioned left foot (out-toed) which received a greater pronatory force. This had led to an increase in load on the Plantar Fascia of the left foot and subsequent Arch Pain.

Arch Pain Treatment

It was explained to the patient that in order to reduce her Arch Pain we had to unload the Plantar Fascia. This would be achieved by the Podiatrist applying rigid sports tape to the foot which would stay on for approximately 5 days. The patient would return to the clinic to the have the tape removed and replaced. She was instructed to purchase new walking shoes that would provide more support. This patient required a firm neutral shoe and was asked to buy a pair of Brooks Dyad. These would suit her foot function and body weight.

The patient was asked to apply soft ice packs to the sole of her foot every night for approximately 30 minutes. She was encouraged to avoid walking in thongs or without shoes at all.

At the follow up appointment 5 days later the strapping was removed and the patient was treated with 1000 reps of Shock Wave Therapy, at 5 hz and 1.2 Bar. The treatment was well tolerated and the normal pain relieving response was noted following the session. It was explained to the patient that this treatment would stimulate blood flow and increase the rate of recovery. Strapping was again applied to the foot which provided the support needed to unload the Plantar Fascia. The patient reported no Arch Pain once she was weight bearing with the strapping on the left foot.

At the 3rd appointment the patient reported that her Arch Pain was improving gradually and that she felt better with the strapping on her foot. She did feel some occasional throbbing the day after the Shock Wave Therapy treatment, as can be expected, but this was short lived. The 4 days that followed were almost pain free but it was explained to the patient that this did not mean that she had healed. This was a normal response to Shock Wave Therapy.

“Zapping and strapping” continued for 5 weeks until the patient reported minimal pain in general.

Arch Pain Re-Examination

At 5 weeks, the sole of the foot was re-examined and pressure was applied to the Plantar Fascia. Approximately 2cm distal to the heel the patient reported very mild Arch Pain but not enough to cause concern. She was advised to gradually start exercising again, but to avoid hills and inclines. If her Arch Pain returned she should come back to the clinic immediately to see the Podiatrist.

Please note that the information in this case study relates to one particular patient and if you have Arch Pain or any type of foot problem you should consult with a Sports Podiatrist.

Written by Karl Lockett

December 22, 2016/by karl

Case studies

Case Study November 2016 – Arch Pain

A 45 year-old female presents to the clinic complaining of arch pain in her left foot. She reports that the pain came on after an intense session of tennis, just before returning to work as a hairdresser, after having an extended period of time off work. A thorough medical history reveals that she has had plantar fasciitis before, which was successfully treated with custom made prescription orthotics to control her poor biomechanical foot function, and reduce the strain on the plantar fascia. However, any further damage to the plantar fascia as a result of overuse injury, or over activity, can cause repeated inflammation in the arch and base of the heel, and hence can be the source of the arch pain she is experiencing now. However, arch pain is also a common symptom of Tibialis Posterior tendonitis and Peroneal tendonitis. She is otherwise healthy with no other significant medical history.

She has been experiencing this arch pain over 4 weeks now. She describes the pain as a constant sharp pain, with mild infrequent throbbing, especially at night times. When the pain first suddenly came on, she bought a new pair of sneakers and put her orthotics inside, hoping the pain will gradually go away. However, she reports that the arch pain has been getting progressively worse since. She has been advised to take some over the counter anti-inflammatories to reduce the pain in the arch of her foot, and has found this to be helpful. However, after a long day of work and being on her feet all day, the pain comes back, and the only way to relieve it is by resting and elevating her feet. However, due to the nature of her work, she is unable to rest her feet, and has to continue work through the pain.

After some research on the internet, she found some remedies to treat her arch pain at home. These included rolling her feet on a frozen bottle and pulling her toes back in an attempt to stretch the tight plantar fascia. She had also read online that putting heat packs on the arch can also be helpful. After trying these treatments at home for 2 weeks, she found the arch pain had gotten worse and decided to see a podiatrist.

Arch Pain Examination

A thorough physical assessment was conducted, where the origin of the plantar fascia from the base of the heel, through to its attachment to the base of the toes were firmly palpated to elicit any pain. The patient did not report pain on pressure to the plantar fascia.

Hence, the tendons which can also cause arch pain were assessed, and the patient reported pain when firm pressure was applied to the tibialis posterior tendon, along its attachment to the navicular and medial cuneiform bones of the foot. No swelling or redness was noted.

In order to understand the cause of her arch pain, the action of this tendon was explained to the patient, which is to hold up the arch and support the foot when walking. Hence, any injury to the tendon can cause it to become inflamed, or torn, consequently reducing its ability to provide stability and support for the arch – leading to arch pain as the inflammation in the tendon progressively increases.

The patient had a mild case of Posterior Tibial Tendon Dysfunction (PTTD).

Biomechanical Assessment for Arch Pain

The patient was asked to stand in her relaxed position. It became apparent that the left arch height was slightly lower than the right. This was confirmed when her arch heights were measured at 22mm for the left foot, and 26mm for the right foot. It was explained to the patient that once the tendon becomes inflamed or torn, the arch can slowly fall (collapse over time).

A few other examinations were conducted to confirm that the arch pain was a result of PTTD. These included the following:

Single Leg Raises: Patient was asked to stand on her left foot on her tiptoes, and was unable to elevate her heel without pain.
Limited range of motion of the ankle: This is tied to the tightness of the calf muscles – which further increase the pull going through the heel – exacerbating the arch pain.
Over pronation due to muscle and tendon weakness.

The patient was also sent for an ultrasound, which confirmed that her arch pain was due to inflammation in the tibialis posterior tendon.

Arch Pain Treatment

In the short term, the patient’s foot was strapped with sports tape and she was fitted with an immobilisation boot to reduce her arch pain. This completely immobilises the foot and allows the inflamed tendon to heal, as she did not have the option of resting her feet due to work. Hence, she was still able to resume work as normal without experiencing any arch pain inside the boot. She was also advised to stop heat packs, and only apply ice packs to the area of the arch which was painful.

In the long term, she was instructed to do specific calf stretches which aimed to increase the range of motion at the ankle. She was also advised to do strengthening exercises of the tendon once her arch pain was completely gone.

Follow Up

At 6 weeks, she was reviewed and reported no pain in the mornings and when without the boot in general. She was also able to work a weekend without the boot, with no pain or discomfort. Firm pressure was applied to the mid-arch, where she initially experienced the arch pain, and no pain was reported.

As her previous orthotics were still firm and functional, they were still successfully able to control her foot function. Hence, she was asked to remove the boot and wear the orthotics in her new sneakers, which were also suitable for her foot type and function, at all times. This is to reduce the likelihood of a flare-up in the tendon, re-initiating her arch pain in the future.

An increase in the range of motion at the ankle was also noted, as she was consistent with her calf stretches. Light strengthening exercises of the tibialis posterior tendon were demonstrated and asked to be initiated, since her arch pain was now completely gone.

Please note: The information in this case study is specific to one particular patient and should not be taken as general advice. There are several cause of arch pain and if you are having foot problems you should consult with a Podiatrist or suitable healthcare practitioner.

Written by Karl Lockett

December 15, 2016/by karl

Case studies

Case Study June 2016 – Arch Pain Following a European Holiday

Arch Pain

A 52 year old lady presents to the clinic complaining of arch pain in one foot of approximately 2 months. The pain in the arch of her foot came on while on a 3 week holiday in Europe, where she describes lots of walking and sight seeing with her husband. She has never had foot problems in the past and has always been a keen walker, and so it came as a surprise to her when the pain in the arch of foot developed and didn’t subside. She is otherwise healthy and takes no medications apart from the occasional anti-histamine for seasonal allergies. The arch pain that she describes is constant and can only be relieved by rest and sitting down with the foot elevated. She describes some throbbing in the arch at times, but this is usually after a big day on her feet. She is currently working in an office based environment so is still able to work as she sits at her desk daily. However, she feels arch pain when walking to and from the office and train station. She describes a tightness and a pulling sensation while walking, and almost a tearing sensation too. She reports that her holiday was spent in Italy and France, and involved lots of walking on cobbled streets and hard footpaths. She was wearing summer style shoes in Europe due to the hot weather and these offered less support than her regular footwear.

When the arch pain came on she initially ignored it and proceeded to walk the streets as planned. However, within 3 days she was unable to ignore it and she decided to buy some arch supports from the chemist. The Pharmacist advised that she may have Plantar Fasciitis and was happy to supply the arch supports to the patient and these gave some mild relief for a short period of time.

Note: Arch pain can be a result of Plantar Fasciitis but is commonly found in Peroneal Tendonitis and Tibialis Posterior tendonitis.

This lady also found some temporary relief from her arch pain when she applied ice packs to the sole of her foot. She also used her trainers for the remainder of the holiday and this helped a little too. However, she was still sore every day and the pain continued after she returned to Sydney.

Arch Pain Examination

When finger pressure was applied to the sole of the foot this would elicit pain in the arch. The pain was distal to the heel towards the toes and was most intense around the mid arch area. The arch pain felt like the same sort of pain that the patient would feel when walking. The affected area of the foot seemed to be the medial band of the plantar fascia. The patient was informed that she was likely suffering with Plantar Fasciitis.

Bio Mechanical Assessment for Arch Pain

With the patient standing on a pedestal in a relaxed position foot measurements were taken and recorded. The high arches observed in this patient stood out markedly and were re measured. Left arch height 32mm and right arch height 34mm. The extreme height of this patient’s arches results in an overload of pressure under the heel and forefoot and a problematic lack of support through the arch / sole of the foot. The lack of support from the summer shoes like ballet flats and sandals which have very little arch contour inside the shoe, causes problems in patients with very high arches. There is minimal contact from the shoe liner and this results in stretch and strain through the arch. This is a common problem in patients with arch pain. If the strain is prolonged and sufficient then the plantar fascia can become irritated and inflamed. Sometimes heel pain can develop too, as the plantar fascia pulls on the base of the heel bone.

This patient had vertical heels and minimal pronation. She had very slight out –toe but nothing more than the usual. Her leg length appeared equal and pelvic rotation was not noted. It was also noted that this patient had a reduced range of ankle joint dorsiflexion due to tight calf muscles. Tightness in the calf is common in patients with very high arches (Pes Cavus foot type) and is one of the common causes of arch pain.

Arch Pain Treatment

It was essential to support this patients arches with prescription orthotics, in order to remove the strain on the plantar fascia and hence reduce the arch pain. Generic shoe liners and off the shelf arch supports were not high enough to make sufficient contact with the arch of the patient’s foot, and therefore would not aid healing. Furthermore, one arch was higher than the other and so the orthotics had to be made to reflect this asymmetry.

Digital foot scans were taken in order to prepare the orthotics and sports tape was applied to the affected foot, to reduce the arch pain until the orthotics were ready to be fitted.

Calf stretches were demonstrated and instructed and the patient was asked to continue using sports shoes or walking shoes as much as possible. She was asked to avoid walking barefoot and in thongs or ballet flats until her arch pain had subsided.

Follow Up

This patient was fitted with her orthotics and then reviewed at 4 weeks. She reported that her arch pain had gone completely and that she was able to walk without any discomfort. She had been using her orthotics daily and was wearing her sports shoes more than any other type of shoe. She would wear her trainers and orthotics to and from the office and would then change into her court shoes once at work. Her seated job made this acceptable.
She had occasionally walked barefoot and in thongs for short periods of time without feeling any pain in the arch of foot. She had been diligent with calf stretching and reported an increase in the range of ankle joint dorsiflexion. Due to her pes cavus foot type she would always need to be mindful of her calf range.

Written by Karl Lockett

December 1, 2016/by karl

Case studies

Case Study 20 November 2016 – Plantar Fasciitis and the Use of Thongs

A 61-year-old lady presents to the clinic complaining of Plantar Fasciitis. She describes heel pain under the ball of her heel of approximately 3 weeks, and informs the Podiatrist that her pain is bad in the mornings when her foot hits the floor. Her heel pain has been getting worse since the warmer weather came about and coincides with an increase in the use of thongs / summer shoes. She admits that she had started to feel some “tight pulling” through the arch of her foot and describes the sort of arch pain that is common in Plantar Fasciitis. She has not seen her doctor nor any medical / allied health practitioner but has self-diagnosed her condition, via on line research. It is not uncommon for patients to experience arch pain, before the onset of aggressive heel pain. The arch pain can sometimes subside within a short time frame, but the heel pain becomes chronic as inflammation within the plantar fascia sets in.

This lady reports the use of thongs, ballet flats and soft summer sandals that offer minimal support, for the last 4 to 5 weeks. During this time she felt general foot fatigue and also developed cramps and stiffness in the calf muscles and shin area. The transition into summer shoes from colder weather footwear, which offered more support, was too quick. She was using these summer shoes to and from the office as well as around the house and was also walking in the thongs at weekends. This chain of events is extremely common in patients who develop heel pain, in particular Plantar Fasciitis.

Home Remedies for Plantar Fasciitis

This lady had been applying Voltaren Gel to her heel and arch pain on a daily basis. She had been rolling her foot on a frozen water bottle each evening before bed and described temporary relief, but an increase in pain afterwards. To this end, and because her heel pain was getting worse, she stopped using the frozen water bottle but continued applying the Voltaren Gel. Her husband had very kindly offered to massage this patients sore foot but she reported that this was too painful for her to tolerate, particularly in the arch area. The arch pain was too intense as his fingers moved from the heel, towards the toes. This lady had also soaked her feet in warm water with Epsom salts to no avail.

Restriction of Exercise for Heel Pain and Plantar Fasciitis

This lady usually enjoyed walker her dog each morning before work but her heel pain was too much to cope with. She reports that she was able to walk a little easier after the first 5 minutes, but that she was hobbling through the start. Upon her return from the walk, and after she would sit down to breakfast, she would limp as she got up from the dining chair to walk from the dining table. Her heel pain was so bad that she would need to hold on to the back of the chair for a minute or two. To this end, she decided to stop her morning walks. She was able to swim without pain due to this being a non-weight bearing activity. This is the preferred form of exercise for patients with Plantar Fasciitis.

Treatment for this Patients Heel Pain and Plantar Fasciitis

This lady had come for treatment of her heel pain within a relatively short period of time since its commencement. Seeking treatment for Plantar Fasciitis within the first few weeks usually brings about quicker and more reliable results when it comes to treatment. Patients who leave their condition for more than a month or two usually take a little longer to heal and sometimes require more intervention. Plantar Fasciitis treatment can range from strapping and stretching through to orthotic therapy and footwear changes.

This lady was treated with sports tape, to strap and hold the affected foot, and to take strain off the Plantar Fascia. She felt immediate relief as she walked around the room and reported some reduction in heel pain. Her foot was still sore but felt a little easier.

Footwear Changes for the Heel Pain

It was explained to this patient that she needed to change her footwear in order to get on top of her heel pain. The shoes that she was wearing were too flat, too flimsy and not rigid enough to support the foot. Plantar Fasciitis will not recover quickly, if at all, if the footwear being used is unsupportive. Even if the footwear change is a temporary one, it is crucial to healing. This is not to say that the shoes that are recommended at the time of consultation need to be worn for ever. Patients can still revert back to the less supportive shoes such as thongs and ballet flats in future, but should be careful not to overuse them. At the first sign of heel pain or Plantar Fasciitis they should consider their choice of shoes around the time leading up to the heel pain symptoms, and then make changes accordingly. This lady was given a list of footwear brands and places where she can purchase appropriate shoes. It was explained to the patient what she should look for in a shoe.

Home Remedies for Plantar Fasciitis and Heel Pain for this Patient

This patient was asked to stop all of her home remedies, even if they provided short term relief. It is not uncommon for patients with Plantar Fasciitis to find short term relief from certain home treatments, only to find that there is long term irritation that prolongs the heel pain. This patient was asked to apply a soft ice pack to the affected heel and arch pain area, and to then strap the cold compress to the foot for approximately 30 minutes, as she lay down with her foot elevated.

She was also shown how to do safe and effective calf stretches.

1 WEEK FOLLOW UP

This patient was reviewed after one week and reported approximately 30% improvement. Strapping was reapplied at follow up and there was no skin irritation from the sports tape. Patient was compliant and had been applying ice and performing calf stretches daily.

2 AND 3 WEEK FOLLOW UPS

As above

4 WEEK FOLLOW UP

Patient reported no heel pain in the mornings nor at any other time of day. There was no pain on palpation of the heel as the patient was examined.

She was informed that she should start walking the dog in the mornings again but to stop and return to the clinic if the pain returned. She was also advised to be mindful of calf tightness and to maintain good calf range at all times.

Written by Karl Lockett

November 24, 2016/by karl

Case studies

Case Study 10 August 2016 : Achilles Tendonitis Causing Heel Pain

A 50-year-old male presents to the clinic complaining of posterior heel pain of more than 2 years. He is a keen golfer and plays 18 holes twice a week. His heel pain is bad in the mornings and hurts him after he has been sitting down for more than 30 minutes, particularly after a game of golf. He also describes pain in the Achilles Tendon in the same left foot. He has been playing golf for many years and never uses a cart, preferring to walk as part of the game and part of his exercise. He is slightly overweight and understands that this puts more pressure on his knees and feet.

This patient went to visit his doctor who examined the foot and informed the patient that he has Achilles Tendonitis, and subsequently arranged an X ray. The X ray report did in fact describe a posterior Heel Spur at the insertion of the Achilles Tendon.

Heel pain from Achilles Tendonitis is very common and is usually seen in patients who walk a lot but do not stretch. A limited range of motion occurs at the ankle joint due to stiffness in the Calf muscles and this in turn causes pulling through the Achilles Tendon. The Achilles Tendon usually becomes irritated if the pulling persist for long enough and then becomes inflamed. This inflammation in the Achilles Tendon sheath is commonly known as Achilles Tendonitis.

The over use of the Achilles Tendon also results in the formation of the Heel Spur – the constant pulling on the back of the heel bone results in the growth of the spur in the direction of pull.

However, the pain at the back of the heel is usually caused by a degeneration of the Achilles Tendon, at the site of the attachment to the heel bone itself. This condition is known as Achilles Tendinosis or Achilles Tendinopathy.

In summary, posterior heel pain can be caused by the Achilles Tendinosis / Tendinopathy and the pain in the Achilles Tendon is a result of the Achilles Tendonitis.

It is important to ensure that the pain is not being caused by retro calcaneal bursitis, and this can be determined by physical examination and ultra sound scan.

PHYSICAL EXAMINATION FOR ACHILLES TENDONITIS

There is visible thickening and redness of this patients left Achilles Tendon. It is hot to touch and overall looks larger than his healthy Achilles Tendon on the right foot. There is a jump response and pain reported with mild finger pressure – laterally. The patient reports extreme pain when the tendon is squeezed.

Lower down the leg, at the back of the heel bone and the site of the patient’s Heel Spur there is pain when pressure is applied into the heel.

The patient is informed that he does in fact have 2 conditions that are causing pain – Achilles Tendonitis and Achilles Tendinosis. The latter of these 2 is also known as an enthesopathy – which describes a disorder of a tendon attachment.

It is still unclear as to the cause of an enthesopathy although in the Achilles Tendon it seems to be related to the ageing foot. This suggests that circulation and blood flow plays a part as can general health and some medications.

ACHILLES TENDONITIS TREATMENT

This patient has a very big jump response and reports extreme pain on palpation of the tendon. He also reports hobbling and gait compensation, particularly later in the day. To this end, he was fitted with an immobilisation boot to unload the tendon and to allow it to settle. He was advised that he would probably be wearing the boot for 4 to 6 weeks. A 9mm heel wedge was inserted into the boot to elevate the heel and further unload the Achilles Tendon. The patient was asked to walk around the clinic for 5 minutes, which he did without heel pain. In addition to healing of the Achilles Tendon, the boot provides immediate pain relief and hence emotional relief too. When the foot hurts for more than 2 to 3 months on a day to day basis, patients become very frustrated and emotional, and need a psychological break from the pain. This patient felt that emotional relief and was quite overwhelmed. This is common.

ACHILLES TENDINOSIS TREATMENT

This patient was advised that by increasing blood flow to the back of the heel, the tendon attachment would have more chance of recovery. He agreed to receive treatment with the shock wave therapy unit and this was performed immediately during this initial consultation.

SHOCK WAVE THERAPY FOR ACHILLES TENDONITIS / TENDINOSIS

The probe was applied to the shaft of the Achilles Tendon at a frequency of 6 HZ and 1.8 Bar of pressure. 2000 reps were applied and were well tolerated. The tendon felt free and loose after the treatment and the pain was reduced during sitting and walking.

The probe was then applied to the back of the heel and the pressure dropped to 1.0 Bar and a frequency of 5 HZ. 2000 reps were applied to the Heel Spur area around the back of the heel bone.

STRETCHING FOR ACHILLES TENDONITIS / TENDINOSIS

This patient had tight calf muscles due to lack of stretching and a lot of walking during golf. The tightness in the Gastroc and Soleus muscles puts strain on the Achilles Tendon and delays healing.

The following stretches were demonstrated, explained and instructed.

FOOTWEAR CHANGES FOR ACHILLES TENDONITIS / ACHILLES TENDINOSIS

This patient brought several pairs of shoes to the appointment including golf shoes. It was found that his footwear did not suit his foot type, nor did it provide the correct type of support for the rehabilitation of his conditions. The patient was asked to walk on a treadmill in bare feet and a digital video was captured. This was replayed to the patient so the he could see how his feet functioned. He was then able to understand which type of shoes were more appropriate for him and his foot type.

FOLLOW UP

This patient was asked to return for weekly visits of shock wave therapy. After the 3rd treatment his heel pain had improved and there was a reduction in the Achilles Tendonitis. The Achilles tendon was “looser” and more “pliable” and was not as hot or as red as before.

The pain and stiffness that he experienced first thing in the morning was still present but was less. Pain after golf was also better.

Treatment continued for 6 weeks but the boot was removed after 4. Improvement was typical in that each week the heel pain was less and the symptoms in the Achilles Tendon had reduced. The patient was asked to continue stretching as part of his daily routine, especially when playing golf. He was advised to return to the clinic if his symptoms worsened.

Note: The symptomatic Achilles Tendon was still a little thicker and still tender to squeeze at the end of treatment. This is often the case and healing usually continues during the weeks that follow. Blood flow to the Achilles Tendon is poor and so healing can take several months.

More info:
How we treat heel pain
Plantar Fasciitis

Written by Karl Lockett

November 17, 2016/by karl