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Single Heel Raise

Discussion in 'General Issues and Discussion Forum' started by Snapdragon, Mar 23, 2015.

  1. Snapdragon

    Snapdragon Member

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    I have a client who has a long term problem, starting with arch pain and now cannot perform a single heel raise! I am in the process of collecting history of problem. What should I be looking for?
  2. Griff

    Griff Moderator

  3. Heather J Bassett

    Heather J Bassett Well-Known Member

    Welcome, how long have you been a Podiatrist? :) Great to have you on board. Searching tags on Podiatry arena will bring forth a multitude of heel cases. These can vary from soft tissue, skeletal, nuerovascular to foreign bodies. The history should help in the direction that you need to proceed. please keep us informed of your progress.

    Kind regards
  4. Snapdragon

    Snapdragon Member

    Hi Heather,

    I have been a podiatrist four years and this is the first time I have come across this problem.

    Patient is doing exercises to maintain muscle tone, has no pain but walks with a limp and cannot climb stairs. She is becoming more dependent on the other side.

    She has had a scan on her lower back which has been a long term problem but has not had a scan or x-ray on lower limb or foot.
  5. efuller

    efuller MVP

    What is interesting about the single heel raise test is that textbooks will list this as a positive finding for posterior tibial dysfunction and the posterior tibial muscle is not a plantar flexor of the ankle.

    A good question to ask the patient is why can't they do the heel raise. Is it pain or weakness?

  6. Snapdragon

    Snapdragon Member


    No pain at now. There was pain when problem occurred which is more than 12 months ago when out walking. Definitely weakness and the whole leg feels like a wooden leg now.
  7. Heather J Bassett

    Heather J Bassett Well-Known Member

    "wooden" feeling, is usually associated with "nerve" involvement? Add the weakness and this is of major concern. Detailed history is really important. What was the original pain problem?
    what happened 12 months ago? What anatomy was involved? What was the cause of the initial symptoms? 12 months later, there are compensatory changes to function. Were there any other injuries or symptoms in the past?
    What is the foot posture? biomechanics? Asymmetry? So many questions to ask :) Are you liaising with the practitioner looking after the "back"? If not definitely touch base. Please keep us posted. An interesting case.
    Kind regards
  8. Snapdragon

    Snapdragon Member


    I just put together the history and lost the lot before sending
  9. Snapdragon

    Snapdragon Member

    I saw patient March 2014. Problem started summer holiday 2013. Walking on the sand problem with left heel/arch. When wearing heels, pain in arch/heel with weakness in forefoot and feeling unstable.
    Dec 2013 realised she was limping so contacted GP who did muscle strength test which was OK

    my assessment showed slight weakness in L with little ankle rotation and no single heel raise. Patient mentioned that weakness felt like it was travelling from ankle to groin.
    Twitching started after limp - Dec time. Twitching in calf/thigh/buttock. odd chronic pain behind knee before discomfort/weakness got to hip. Twitching/jangling also above knee anteromedial aspect. Pain first thing in morning with heel and Achilles tendon when weight bearing.
    When trying to walk at speed, Achilles/soleus/gatroc insertion hurts.

    Sept 2014 saw Nhs podiatrist who thought it was lower back and referred for MRI. In the meantime, stretching exercises, trainers and insoles.

    Oct 2014 MRI showed : History: twitching of left leg L3/L5 lower back pain. Findings: T10 vertebral body for report. Normal alignment normal face joints, no spinal stenosis.
    multilevel disc prolapse - no root nerve compression. T12/L1 moderate - posterior central disc prolapse - no significant nerve root damage. L3/L4 annular disc bulge with prominent right para central disc prolapse - significant narrowing of right lateral recess. Narrowing of left lateral recess with impingement on left L4 nerve root. L4/L5 level - loss of disc height with annular disc bulge - narrowing of both lateral recesses minimal impingement of left L5 nerve root in lateral recess.
    Result L4,5,S1 - left side compression.

    Still limping and left foot colder than right. Still doing stretching exercises and insoles help.

    Patient frustrated and seeking private referral to foot/ankle specialist.
  10. Greg Fyfe

    Greg Fyfe Active Member


    "wooden leg" reminds me of how my leg was after a spinal anaesthetic.

    I'm suspecting something neurological.

    I've attached a lower limb neuro exam checklist you may find handy?

    I don't know much about spinal scans/ mri. If you get the opportunity I think it would be interesting to see how the lower limb exam correlated to the scan findings.



    Attached Files:

    Last edited: Jul 15, 2015
  11. andrewong

    andrewong Welcome New Poster

    normally when doing the single heel raise test, there is such ankle inversion of the foot. you could ask if he or she has the history of posterior tibial tendon rupture. Other symptoms could be palpitation or weakness of the inversion. Hope this help you solve the problem. :eek:
  12. efuller

    efuller MVP

    That history is screaming posterior tibial muscle weakness. The PT muscle slows pronation with each step. If the pronation is not slowed, the anatomical structure that eventually stops pronation will start to hurt. You will often see arch (plantar fascia) pain and sinus tarsi pain with PT dysfunction. With that history (instability, wooden calf and others) I'm really surprised there is no weakness.

    Calf circumference L vs. R? Did you do a really thorough sensory testing? Sitting here on my couch, it seems the question is, is the tendon weak because of rupture or attenuation or is weak because of neurological involvement. Of course that could be all wrong if the muscle twitches are fasciculations which are a sign of upper motor neuron problems.


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