Heel Pain – Plantar fasciitis
The Plantar facia consists of layers of tough connective tissue that spans the underside of the foot from the toes to the heel and blends with the tendons on the underside of the foot. It contributes to supporting the arch of the foot where it undergoes tension when the foot bears weight. It inserts into a bony tubercle on the front edge of the heel and it is generally here that it gets sore. When troublesome, it can appear quite thickened on ultrasound. It acts a bit like a spring when we walk, storing energy when it is lengthened and released on push off helping to propel us forward when we walk.
Presenting condition and history
It had been troubling her for over 3 years and had recently got worse after a long cross country walk and now she was struggling to walk normally due to the severe pain she was getting on the inside edge of her heel which she described it as “like walking on broken glass”. She was unable to walk her dog for more than a quarter of a mile without severe pain (9/10 VAS). It was particularly bad first thing in the morning after inactivity.
My client in the past had tried physiotherapy previously, which on questioning, had consisted of calf stretches and ultrasound over a 6-week period. She had also tried orthotics in her shoes provided by a podiatrist. Neither intervention had long term success.
Findings on Examination
- Flat and mobile feet but she did not roll in or out excessively.
- Greater than 2 stone overweight.
- Extremely long strides and at heel strike her foot landed way in front of her centre of mass (hip/pelvis).
- Heavy landing (could tell by sound)
- Weak foot muscles – Tibialis Posterior and Flexor Hallucis Longus (muscles on the inside of the leg and of the big toe).
- Excessively weak calves (unable to do more that x 3 standing single calf raises before she had to stop due to calf burn)
- Weak gluteal muscles (unable to hold any resistance when lying on her side and was unable to hold a good single leg bridge)
- Good Calf and big toe mobility.
In my opinion, the PF had been overloaded in the past with a number of contributing factors:
- High BMI and standing for long periods at work.
- Coupled with a sudden increase in walking distance and frequency in an effort to lose weight.
- Walking over rough ground.
- Heavy landing and over-striding.
- Weak foot, calf and muscles around hip.
Initially treatments were aimed at reducing pain and off- loading the sore tissue.
- Taping – to help support and off load it to reduce the pain.
- Hands on massage – to make soft tissue more pliable and able to adapt to stretch.
- Education – discussed the long term plan for treatment. I suggested that if possible to sit down for as much as possible during teaching rather than standing once again to off-load the plantar fascia. Keep walking to a minimal amount. We then discussed the long term plan for treatment.
- Treadmill Analysis – Once the pain was manageable not above the 3/10 level, with the aid of the treadmill and camera, we were then able to consider some of the walking issues.
By asking my client to try to naturally up the cadence when walking (by taking more frequent steps this naturally reduced the over-striding which then with the aid of the camera and slow motion playback we were able to see an improved position on heel strike (more directly under the hip and pelvis). The other cue that was useful was to try to make less noise (walk quietly). I think this reduces the force of the landing. I suggested to try to implement these strategies into everyday walking.
I introduced a home exercise programme at this stage which included no more than 3 key exercises.
- Strengthening of the muscles on the inside of the foot
- Strengthening of the muscles of the hip
- 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 16 weeks we re-assessed progress every 2 – 3 weeks. We were generally able to increase the load of the exercises at each session and very gradually increase the walking distance.
Outcome – At the end of the 16 week period her pain levels had reduced considerably mostly 0/10 and ocassionally 1/10 with one measure 2/10 after an unusually long day standing. She was delighted with the results. She was discharged but with a maintenance exercise programme to be continued x 2 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.
Thoughts – Often changes to a chronic problem can take time and hard work to implement and it is worthwhile working hard to achieve this. I suggested that she self-monitored 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 increased she would just back off from the dog walking a little.