Case Study March 2017 – Sports Podiatrist Treats Runner For Heel Pain

History – Taken By Sports Podiatrist

A 42-year-old male presents to the sports podiatrist complaining of heel pain in his right foot of approximately 12 weeks.  He is a dedicated runner who exercises 5 days a week each morning before work.  He informs the sports podiatrist that he has always boasted good foot health and has never experienced pain in the heel of his foot before. This patient is 6 foot 2 inches and weighs approximately 115 kilos. He is a type 2 diabetic but takes no medication.  He reports to the podiatrist that the pain in his heel is extremely apparent first thing in the morning when he puts his foot to the ground.  After 10 minutes of walking and taking a hot shower the pain in his heel is a lot more bearable and he’s able to walk without limping.  He informs the sports podiatrist that the application of a cold pack reduces his pain.  He also rolls his foot on a tennis ball throughout the day while seated in his office chair. While this provides short-term relief, his condition persists and he does not seem to be improving overall. This gentleman reports to the sports podiatrist that he regularly sees an osteopath for skeletal alignment and general help with his posture, and that he asked his osteopath to work on his foot.  The osteopath carried out some manipulation and mobilisation techniques to his foot and ankle and also recommended that he carry out calf scratches on a daily basis.  Once again, while there was short term relief following treatment, the pain would return quite quickly. This patient informs the podiatrist that he has not stopped his daily routine of running each morning and that once he is warmed up he is able to complete his 5 km run.  However, the two to three hours that follow his run are noticeably worse and he feels and mild throbbing in the right heel.  On occasions, he has taken anti-inflammatory medication and has also applied Voltaren gel to the affected area. This patient paid a visit to his regular GP who requested an X-ray of the right foot.  The X-ray revealed a small spur on the base of the patient’s heel measuring approximately 3 mm.  Following this his GP did not offer any specific treatment but suggested but his condition would heal naturally in approximately 18 months. To this end, the patient continued to do some research and a work colleague recommended that he visit a sports podiatrist.

Physical Assessment By Sport Podiatrist

The podiatrist carried out a thorough physical assessment of both feet, ankles and lower legs.  This included muscle testing and range of motion tests at the key joints of the foot and ankle. Pressure was applied to the base of the heel along the medial slip of the plantar fascia and during this examination the patient confirmed severe pain. The sports podiatrist informed the patient that his heel spur was not the cause of his pain but rather the plantar fasciitis. Note, it is a common misconception amongst patients and some practitioners that a heel spur in the base of the foot can be the cause of such pain. In most cases the inflammation within the plantar fascia is the source of discomfort. The sports podiatrist also noted some tightness in the calf muscle of the right leg and a limited range of motion in the first toe joint. The patient confirmed that recently he had experienced some cramping in the calf muscle of his right leg and that on occasions he feels discomfort in the big toe joint of his right foot, particularly when running up hills. The sports podiatrist revisited the patient’s foot x-rays and found some arthritic change within this painful toe. This arthritis would be the source of discomfort and would reduce the range of motion, negatively affecting the biomechanics of the right foot.  It is not uncommon to find big toe joint dysfunction in association with plantar fasciitis, and moreover the condition is seen commonly in patients with reduced calf muscle range. The sports podiatrist informed the patient that his treatment would be multifactorial but would definitely include treatment to the calf muscles of the right leg. In addition to diligent calf stretching the patient was advised that he may benefit from using a foam roller to soften the muscle and increase the range.

Biomechanical Assessment By Sports Podiatrist

The patient was asked to walk and run on a treadmill while the sports podiatrist observed and recorded his gate using digital software on an iPad. The podiatrist also took measurements and recorded angles of the patient’s foot architecture. It was noted that this patient’s foot architecture and shape was asymmetrical. The arch of the right foot measured 32mm and the arch of the left foot only 24mm. The left heel demonstrated a significant amount of rear foot eversion. During gait, the sports podiatrist noted severe over pronation of the left foot and minimal pronation in the right foot. It is not uncommon to find plantar fasciitis in the foot with a reduced amount of pronation. Over pronation is responsible for a variety of foot conditions while plantar fasciitis can be seen in the stable foot as well as the weaker one. Once again, the podiatrist advised the patient that his condition was probably due to dysfunction of the big toe joint and tightness of the calf muscles in the right leg.

Treatment Plan By Sports Podiatrist

This patient was advised by the sports podiatrist to perform regular calf stretches on a daily basis. He was shown how to perform these stretches in a very specific manner and was advised to refrain from other stretches around the lower leg, as these may strain the plantar fascia and prolong his condition. The sports podiatrist was quite happy with the patient’s running shoes. He was using Brooks adrenaline and the wear pattern was fine. However, due to that differing architecture of this patient’s feet it was recommended that we remove the liner from these running shoes and replace them with prescription orthotics. The podiatrist captured digital foot scans of both feet and requested the patient return in two weeks with his running shoes, to have the orthotics fitted. These orthotics would remove the strain from the plantar fascia of the right foot and allow it to heal naturally without injections or medication. The orthotics would be made from carbon fibre which is extremely strong and lightweight, and fits easily into the running shoes. They would be covered with slow-release poron to provide cushioning and comfort. The sports podiatrist recommended a course of shockwave therapy to stimulate blood flow and accelerate healing. The patient was advised to continue applying cold packs to the heel each night before bed for approximately 30 minutes. The sports podiatrist advised the patient to continue his daily running routine but to bear in mind that he may need to stop exercising if there was insufficient improvement within the six-week treatment period.

Follow Up Appointment With The Sports Podiatrist

After 8 weeks, the patient returned to the sports podiatrist for an assessment of his plantar fasciitis. He reported that his condition had improved significantly and that he was happy with progress. He was able to continue running without having to stop exercising.  He reported to the sports podiatrist that on occasion he would feel some mild pain and infrequent stiffness in the heel but that these symptoms were short-lived and mild.  He was informed that no further treatment was required and that there would be continued healing over the next number of weeks as the Shock Wave therapy continued to be effective. He was informed to return to the clinic if his symptoms came back.

Please note that the information in this case study is specific to one particular patient and it should not be taken as general advice for foot pain or plantar fasciitis. If you have heel pain or any type of foot problem you should consult with your doctor or a suitably qualified sports podiatrist.