Heel pain - plantar fasciitis (The case study)

Heel pain - plantar fasciitis (The case study)

What is Plantar Fasciitis?

Plantar fasciitis (PF) is the most common foot condition treated by health care providers. This painful condition can cause impairment of activity and disability. In the United States, about 2 million people are treated annually for this foot condition. Patients usually report pain after palpation of the proximal insertion of the plantar fascia and plantar medial heel, and the pain is most noticeable when patients begin walking after a period of inactivity. Clinicians have used many approaches for treating pain and improving the function.

Case Study of 44 year old patient with Planter heel pain

A 44-year-old patient reported heel pain for approximately 1 year before treatment. The patient reported plantar heel pain and tenderness at the calcaneal tuberosity. The pain was most noticeable in the morning but was reduced after a 30-minute walk. A diagnosis of plantar fasciitis was made at the initial assessment. 

Past interventions

He had gone to a doctor first who gave some anti-inflammatory and advised him to take rest, however; there was no difference in the pain after he had stopped taking the medicines. Afterwards he started with physiotherapy sessions which on questioning, had consisted of calf stretches and ultrasound over a 6-week period. He had also tried orthotics in her shoes provided by a podiatrist. But the intervention could not have long term success.

Findings on Examination

1. Flat and mobile feet but he could not roll in or out excessively.
2. Extremely long strides and at heel strike, his foot landed way in front of his centre of mass (hip/pelvis).
3. Heavy landing (could tell by sound)
4. Weak foot muscles – Tibialis Posterior and Flexor Hallucis Longus (muscles on the inside of the leg and of the big toe).
5. Excessively weak calves (unable to do more that x 3 standing single calf raises before he had to stop due to calf burn)
6. Weak gluteal muscles (unable to hold any resistance when lying on his side and was unable to hold a good single leg bridge)
7. Good Calf and big toe mobility

Analysis

In my opinion, the Planter fascia had been overloaded in the past with a number of contributing factors:

1. High BMI and standing for long periods at work.
2. Coupled with a sudden increase in walking distance and frequency in an effort to lose weight.
3. Walking over rough ground.
4. Heavy landing and over-striding.
5. Weak foot, calf and muscles around hip.

Treatment 

After analysing the contributing factors to Planter Fascia, it was concluded to aim initial treatments at reducing pain and off- loading the sore tissue.

• Taping – Taping is the method to maintain stable position of bones and muscles with application of tape directly to the skin. It reduces the pain and maintain stability.
• Hands on massage – The physiotherapy involving hands on massage helps calf muscles, planter facia and lateral structures of the hip to make soft tissue more pliable and able to adapt to stretch.

• Dry Needling- The process of dry needlingis also recommended to tight the structures in between the rehabilitation sessions. 

• The manual intervention consisted of passive joint mobilisation of the ankle and foot along with some bit of MWM on the affected hip to increase the hip internal rotation.

• Exercises – It is recommended to do exercises that strengthens the hip muscles (flexors, abductors, adductors, and extensors) included exercises with increasing resistance. The training consisted of 3 sets of 10 repetitions, with a 30-second rest between each set.

• Education  I suggested to sit down as much possible than standing once again to off-load the plantar fascia and to keep walking to a minimal amount.

I introduced a home exercise programme at this stage, which included no more than 3 key exercises.

1. Strengthening of the muscles on the inside of the foot
2. Strengthening of the muscles of the hip
3. Strengthening of the calf muscles but with the Plantar Fascia on stretch.   Double leg calf raises from the ground but with a towel folded under the toes to put the big toe on stretch. Rest of towel under the base of the foot to give cushioning.

We kept a record on a simple spread sheet. Over the course of the next 4 weeks, we re-assessed progress every 1 week. We were generally able to increase the load of the exercises at each session and very gradually increase the walking distance.

Outcome of Therapy

At the end of the 8th week period, his pain levels had reduced considerably-mostly 0/10 and occasionally 1/10 with one measure 2/10 after an unusually long day standing. He was delighted with the results. He was discharged but with a maintenance exercise programme to be continued x 5 per week. (The maintenance is important so that the changes we have achieved in strength gains etc. remain and continue beyond the time of discharge. 

Final Thoughts

A chronic problem necessitates time to be treated and on the part of physiotherapist, it requires hard work to implement the therapy.  I suggested to the patient that he should self-monitor the pain levels at 2 key points in the day using a VAS 1-10 scale; morning and at the end of the day, after sitting down. These would act as improvement indicators.   Pain levels should remain under VAS of 3 at the 2 points in time. If it would increase, he would just back off standing for a long time.

Conclusion

The combination of hip strengthening and manual therapy improved foot pain in a patient with a clinical diagnosis of plantar fasciitis.