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Help with pain in the heel

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Bruce McLaggan, Feb 29, 2008.

  1. Bruce McLaggan

    Bruce McLaggan Active Member

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    I need some help.

    A client recently visited my surgery saying that she has plantar fasciitis. She mentioned that she had visited an osteopath and a physiotherapist, who both diagnosed her painful heel as plantar fasciitis. The Osteopath treated using acupuncture techniques and the Physio applied ultra sound treatment. Neither treatments were successful either reducing or resolving her pain. Thereafter, she visited an NHS clinic where orthotics were prescribed and these too have not resolved her problem.

    On my examining her foot today, I am of the opinion that she is not suffering from plantar fasciitis. The reason being is that when I dorsi-flexed the toes and palpated the plantar fascia along its length, I could not elicit any painful reaction from her. However, when I compressed the calcaneus on the medial and lateral side with my hands, she almost jumped out of the chair! The pain was on the lateral side on the calcaneus in the area where the foot strikes the ground at the beginning of the gait cycle.

    Can anyone suggest treatment protocols as she is desperate to resolve this problem as it has been painful for over 2 years and is getting her down.

  2. medisrch

    medisrch Active Member

    Hi Bruce

    Suspicion here it is a calcaneal spur. It needs an xray/scan to ascertain but in my experience ultrasound alone is not enough. Low to medium level laser is helpful in fasciitis.

    Hope it helps
  3. DaVinci

    DaVinci Well-Known Member

    I very much doubt it based on the symptoms described. Have you seen this?
    How? You just said it a bony spur. How does low level laser help that?
  4. DSP

    DSP Active Member

    Hi Bruce,

    Have you ruled out a calcaneal stress fx. I would suggest ordering x-rays. Were there any abnormal neurological findings?
  5. Atlas

    Atlas Well-Known Member

    How about fine-tuning the orthotics? Change the forces (Payne-ism)? Change the angles (non-Payne-ism)?

    My greatest frustration as a physio pre-pod, was that Podiatrists, like the failed coach of my football team, had plan-a only!

    My greatest frustration as a physio and podiatrist, is that physiotherapists are using ultrasound. Fair dinkum, like employing Einstein and paying him to do simple addition.

    Doesn't matter what the theory says, every clinician should have a plan a, b, c, d....

  6. Trent Baker

    Trent Baker Active Member

    How about a simple calcaneal fat pad inflammation? Pain on lateral compression of the fat pad, correction doesn't help and not a surprise that ultrasound or accupunture had little or no success.

    What activities is she involved in? Work, sports etc? What is her footwear like?

    I would try a simple 6mm PPT/Poron heel pad to cushion the area. Have a good look at her shoes and advise her on footwear that will cup and support the fat pad.

    Just a thought
  7. lcp

    lcp Active Member

    I agree, footwear, occupation, physical activities, all very important factors, and sometimes trying the more simpler methods (eg heel pad, change of footwear) are a better place to start. I, for one, am often guilty of trying to think of complex answers,when the solution is far more straightforward(and commonsense). Worst case.......it wont work, cross that option off the list. Like ATLAS said above, try going through possible dx and come up with treatment options a, b, c, d etc.
  8. adavies

    adavies Active Member


    differential diagnosis for heel pain - panniculitis - inflammation of subcutaneous and muscle tissue.

    hope it helps

  9. medisrch

    medisrch Active Member

    Read the post. It is suggested Bruce requests xrays or and a scan.

    Low to medium frequency will help as it reduces inflammation effectively whereas ultrasounc near to any bony structure can cause, at worst the periosteum to "boil".
  10. Scott

    Scott Member

    Since the heel pain doesn't seem to be responding to the modalities attempted thus far, I would suggest an MRI of the affected heel. It will show to what extent inflammation is playing in your patients problem and where that inflammation is. It will also show a stress fracture if one is present. If MRI is not an option consider CT to rule out the stress fracture. You may even consider diagnostic ultrasound if that is available.

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