A 41 year old lady presents to the Sydney Heel Pain Clinic, Miranda, complaining of pain from a heel spur. She reports to the podiatrist, Rami Ghorra, that she feels pain first thing in the morning when she gets out of bed. She has been feeling pain in the heel for approximately 6 months but prior to this has never complained of a heel spur. There is a noticeable pain following long periods of being seated and at the end of the day after being on her feet at work. This lady works in the retail space and has had a physical job for the past 12 years. She describes a sharp stabbing pain under the base of her heel which is typical in patients who have a heel spur. She also reports the feeling of a stone bruise or a pebble in the shoe. A colleague that she works with informed her that she may have a heel spur as she herself experienced the same condition recently. After being in pain for three months this patient went to see her local doctor who arranged a foot x-ray.  After careful examination of the X-ray Rami the podiatrist was unable to clearly see a heel spur. The patient was informed that the pain that she was experiencing was not coming from a heel spur, but likely from something else such as plantar fasciitis. This is a common misunderstanding amongst patients who suffer from pain in the base of the heel. For many years the heel Spur has been the focus and has been incorrectly assumed to be the cause of heel pain. More often than not, patients who complain of a heel Spur actually have plantar fasciitis. During the appointment, Rami carried out an assessment of the patient’s footwear only to find that she was wearing shoes that offer minimal support. This patient was using flat and flexible shoes that were very soft and comfortable but lacked support. Patients complaining of pain from a heel spur often lean towards soft shoes as they feel that they need more cushioning under the heel. However, this is counter to treatment as a softer shoes collapses under load allowing the foot to work harder. This patient also reported calf tightness and a feeling of cramping in the calf muscles towards the end of the day. She explained to the podiatrist that sometimes she wakes in the middle of the night with cramps in both of her lower legs. She has tried to use magnesium powder to counter this problem but has found only slight relief. This patient has been rolling her foot on a frozen water bottle on a daily basis and reports that she feels very little relief. She has also been to see her local massage therapists who has applied deep tissue massage to the sole of the foot under the base of the heel around the heel spur. Following six sessions with the massage therapist this patient decided to stop treatment as her condition was feeling a little worse. Feeling frustrated she decided to do some online research and found some foot stretches on YouTube. The foot stretches involved hanging her heel off the back of a step and she reported immediate but very temporary relief. Due to the temporary relief she continued to carry out these stretches several times a day. However, after 5 days of foot stretches her condition began to get much worse. It should be noted that patients who complain of a heel spur often aggravate the condition by carrying out home rehabilitation. Some of the common exercises do provide immediate pain relief that is very short lived but that aggravate the condition overall. Naturally, this patient stopped these exercises and decided to seek treatment from a qualified sports podiatrist. Prior to feeling pain from the heel spur, this lady enjoyed going for morning walks each day. Since the heel pain, she has stopped exercising and reports a slight increase in body weight.

Physical Assessment For Heel Spur

Firm pressure was applied to the base of the heel in the area where a heel Spur can develop. The patient reported pain as the podiatrist palpated the tender area. The area of concern correlated with the attachment of the plantar fascia onto the base of the heel. Pain was experienced centrally and also quite medially which is common in patients with plantar fasciitis. Rami reported to the patient that the pain she was experiencing was not from the heel spur, but that she was suffering from a very common condition known as plantar fasciitis. The type of pain that she felt as pressure was applied was identical to the pain that she experienced on a day to day basis. The patient was asked to stand and raise up onto her tiptoes which she did without reporting pain. She was then asked to perform the same exercise on a single leg. The patient reported mild pain during this exercise which was normal for a patient complaining of a heel spur. Once again the patient was informed that the pain she was experiencing during this exercise was coming from the plantar fascia and not the heel spur.

Treatment: For Plantar Fasciitis Not Heel Spur

After assessing this patients biomechanics the podiatrist decided to treat this condition with some footwear changes, calf stretches, rigid sports tape, and shockwave therapy.  The patient was given a list of shoes that she could buy which suited her foot type and architecture. The biomechanics of her feet did not suit the footwear that she was currently using. Patients complaining of pain from a heel Spur benefit from more rigid and supportive shoes as opposed to soft comfortable and cushioning shoes. The more rigid and supportive shoes support the plantar fascia and this helps the conditions to normalise. The patient was treated with 2000 reps of Shockwave therapy at 5HZ and 1.4 bars of pressure. The treatment was well tolerated. Rigid sports tape was applied to the foot and the patient was asked to return to the clinic in 5 days so that this strapping could be replaced and further shockwave therapy treatment applied. The patient was advised not to worry about a heel spur but to be more mindful of the stress and strain on the plantar fascia which attaches to the base of the heel, and runs through the sole of the foot. She was assured that her condition would settle in approximately 6 weeks. If there was insufficient Improvement with this patients’ condition then other treatment options would be considered such as orthotic therapy, dry needling or the use of an immobilisation boot. She was also advised that patients complaining of a heel Spur recover quicker if they apply ice packs to the affected area on a daily basis for approximately 30 minutes.

6 Weeks Follow Up

Following patient education, this lady understood that the heel Spur was not her problem and hence she focused on the plantar fascia. The weekly sessions of shock wave therapy, strapping and the use of ice packs provided significant relief.  The patient reported that her pain has subsided sufficiently. She did report to the podiatrist that on occasions she would feel some pain and stiffness first thing in the morning, but this was short lived and rare. She was comfortable in her new shoes that Rami recommended. This lady was advised to return to the clinic if her pain returned or deteriorated. She understood that the heel spur was not a problem but rather the plantar fascia, and to this and she should continue to support the foot with appropriate shoes and remove stress from the plantar fascia with regular calf stretching. Please note: The information in this case study is specific to one individual and should not be taken as general advice. If you have a heel spur or plantar fasciitis you should seek medical advice.

 
Written by Karl Lockett