Case Study March 2017 – Sports Podiatrist Working With Physiotherapy
History With Sports Podiatrist
A 47 year old lady presents to our sports podiatrist, at the Randwick clinic, complaining of acute foot and ankle pain in both legs of more than 2 years. She is unable to pin point a specific part of her foot that hurts but describes the pain to be “all over”. She has been to see a podiatrist for this problem and received no diagnosis or treatment as such. The podiatrist that she saw simply recommended she purchase a specific pair of running shoes. The patient purchased Asics Gel Kayano and wears them all day every day to no avail. She has found no improvement in her foot and ankle pain since changing her shoes and is frustrated. She informs the podiatrist that she has a busy job where she is running around on a day to day basis, using her feet daily.
The patient informs the sports podiatrist she is approximately 10k heavier than she would like to be but does not suffer with diabetes or any other condition. She takes no medication.
The patient explains that she used to work in the corporate arena and wore high heels for many years, but has not worn such shoes for some time. She admits that her job was stressful and that she endured a long period of nervous tension. (Stress and nervous tension can create tightening of the glutes, hamstrings and calf muscles, which can affect bio mechanics and cause foot problems).
She informs the sports podiatrist her preferred form of exercise is long walks, up to an hour each time. She refuses to stop exercising despite the extreme foot and ankle pain.
Physical Assessment by the Sports Podiatrist
This patient had already described to the sports podiatrist that her symptoms were vague, and she was sore all over. After a thorough assessment it was apparent that she had pain in some very specific areas of her feet and ankles and she was diagnosed with several conditions.
- Plantar fasciitis
- Achilles tendonitis
- Peroneal tendonitis
- Insertional Achilles tendonitis
She also had pain on palpation of the anterior aspect of the ankle, the ball of the forefoot and the 1st toe joint – but without bunion formation.
The sports podiatrist carried out a series of measurements and range of motion tests at the key joints of the foot.
The most apparent finding was severe tightness in the calf muscles. This patient’s range of motion at the ankle was approximately 50% of normal. The sports sports podiatrist explained that the years of wearing high heeled shoes, and possibly the long period of stress and nervous tension would have caused this problem. The patient agreed and confirmed, when asked, that she did in fact feel better when she returned to the use of footwear with a considerable heel height. Her calf range was so restricted that her heel was unable to sit in a flat shoe, without the calf muscles pulling strongly on the back of the heel. Relief from foot and heel pain is commonly found in patient’s with tight calf muscles, when they defer to a shoe with heel height.
When standing in a relaxed position the patient demonstrated an average medial arch height. Her foot posture index was deemed appropriate. There was mild external rotation at the right hip which caused mild abduction of the right foot.
Bio Mechanical Assessment By Sports Podiatrist
This patient was observed, bare foot, walking on a treadmill while the sports podiatrist recorded her gait using digital software. Markers were drawn on the foot and lower leg prior so that pronation / supination could be measured. Tibial torsion during gait was measured.
There was mild abduction of the right foot during gait. The patient pronated mildly and her foot did not collapse under load, to the point that would alarm or concern the podiatrist. There was, as to be expected, early heel lift of both feet, which is a common finding in patient’s with tight calf muscles. Knee alignment was normal, the right knee demonstrating a mild externally rotated position.
The Sports Refers To The Physiotherapist
This patient was relieved to know that she did not over pronate and hence did not need to be fitted with prescription orthotics at this stage. It was explained again to the patient that the source of her problems was her tight calf muscles, and to this end all her treatment should be initially directed here. The patient was referred to the in-house physiotherapist who specialises in dry needling, with the use of acupuncture needles. In cases such as this one, the patient benefits tremendously from soft tissue release, deep tissue massage and the dry needling techniques offered by the physio. In addition to this, the patient is then asked to perform calf stretches several times a day. The physiotherapist and the sports podiatrist demonstrate the stretching techniques and instruct the patient accordingly. Stretching is performed by the patient in the clinic under the guidance of the practitioner and is carefully adjusted where necessary.
This lady was referred for an ultra sound scan of her feet so that the extent of her tendonitis and plantar fasciitis could be measured. She would see the physiotherapist twice a week for 4 weeks, before dropping her sessions back to once a week. The treating sports podiatrist was able to step in to the physiotherapy room to discuss improvements and assess pain levels.
Calf range improved gradually over the 8 week period. It did not demonstrate the normal range that one could expect in a person with average calf muscle function. This was to be expected in this patient who had worn high heels for an extended period of her life and with such a severely limited range. She was advised to continue treatment for another 2 months, and stretching as part of her daily routine indefinitely. She was also advised to limit the use of flat shoes and thongs, and to favour footwear with a small heel. At least 2 to 4 cm would be needed.
Foot pain improved and reduced over the 8 week period but was slow in the first 2 weeks. To this end, the sports podiatrist and physio decided to apply rigid sports tape to both feet to offer support. This would reduce the strain on the affected muscle tendons and plantar fascia.
The patient was asked to apply ice packs to all affected areas and this helped to accelerate the healing progress. The report from the ultra sound scan confirmed all the above conditions and also detected retro calcaneal bursitis. Consideration of injection therapy was discussed with the patient if the latter of these conditions did not improve sufficiently.
At the 8 week period the patient reported an overall improvement of approximately 50%. She was satisfied with the rate of improvement and was committed to continue working on her calf range.
This patient returned to see the sports podiatrist after 16 weeks and reported further improvement. There was pain on palpation of the affected areas although minimal pain on a day to day basis when walking. She was booked in for a short course of shock wave therapy to stimulate further healing.
Patient outcomes are often better with treatment from more than one practitioner/modaility. If you have foot or ankle pain you should consult with a suitably qualified sports podiatrist, as the information in this case study is not general advice.