Case Presentation: 55 year old female presents chronic pain to left posterior heel for the past 5 years
We are gonna be talking about a 55-year-old female, presents with chronic pain to the left posterior heel for the past five years. The patient has seen several orthopaedists, podiatrists and physical therapists, but the pain persists, causing a limitation in daily activities and exercise. Patient states that the pain is greatest in the morning, decreases slightly during the day and then increases again at the end of the day. There’s a sharp pain and it’s rated a six out of 10, no associated tingling or numbness. The patient does not recall an acute injury and it’s been a gradual increase over the past five years.
Jeff Frame quickly presents his thoughts on this case presentation.
Obviously with the information presented here, it almost appears to be like a classic case of possible plantar fasciitis, just based on the initial information gathered from the patient. Classic pain in the back of the heel, hurts most first thing in the morning, decreases a little bit through the day as the plantar fascia tissue loosens up, and then gets worse throughout the day as that person continues to walk on it. As we know, as humans, we can’t quit walking, that’s how we get from one place to the other. So if we never give that tissue a chance to heal or relax, it’s gonna consistently get irritated, and hence it goes on for a long period of time. And if not corrected, in this case, this person’s been dealing with it for five years.
Now that’s just what it looks like on face value. What I would begin looking at is just literally watching the person walk. Is there any type of abnormal gait normality? And specifically looking at just initial contact, not necessarily heel strike, but in this individual because of the pain, they could be striking the heel harder on one side versus the other. And so, when we see things like that, the first thought is, “Is there some type of a leg length discrepancy?” And when we talk about leg length discrepancies, it’s not always structural, it doesn’t mean that one leg is physically longer that the other, it could be something functional. And in my experience, I have always seen that a pes planovalgus foot, if one is more flat than the other, that’s sometimes a compensatory mechanism for that being the longer leg, ’cause that’s the body’s way of trying to self-level. And in doing so, you’re gonna change the loads.
So looking at uneven loading due to the foot and knee alignment, when we have this pes planovalgus, it’s gonna put more strain on the posterior tib and also on that plantar fascia tissue. You could also be causing some bruising to the calcaneus or even a bursa or bursitis, due to this uneven or blunt loading, depending on their gait strike. I would use some type of either a force plate to look at the ground reaction forces and determine if there is an uneven strike, or if the strike is harder than what we should see in normal gait based on someone’s body mass. We could also use some type of a gait mat, or a proto kinetics mat that’s gonna give us pressure data to see if there is any differences in the anterior posterior pressure loading, if there’s a timing difference between contact with the ground.
What I’ve also seen is, due to the fact that there is also a valgus knee, as we all know, all movement originates from our center of mass, okay? Well, what’s closest to the center of our mass working down? It’s the hip and pelvis. If there’s lack of stability there, as it continues to travel down the chain, our last line of defence for stability is the feet. And if the feet can’t be those mobile adaptors, then that means it has to flatten out more to maintain stability, then that’s again that’s our last line of defence. So it could be a compensatory mechanism for the fact that they don’t have good strength and stability up in their hip and pelvis, and that’s what’s causing that internal hip rotation which gives us that apparent valgus. And I don’t know if it was disclosed that the valgus is a true knee valgus, which in reality is very rare. But it could be more that apparent knee valgus, where it truly is more of that internal hip rotation. And so I would begin to kinda look at strengthening and working on the stability of the hip and pelvis to then help offset the demand on the feet.
Other things, obviously, to look at is insoles. It didn’t say that insoles or orthotics had been used. They’re not always the panacea for everything, but if there’s a way we can find something more of an accommodating insert that helps to give some biofeedback and proprioception to tell that posterior tib to maybe fire and stay up. You can go into more invasive, of having a posterior tib transfer to get it to be more effective. Making sure they’re in the right type of shoe, which is good and bad. A lot of times people think the shoe is the end-all correction, and what I’ve found is it’s usually a combination of shoe and insole to help correct with that. And then really going into correcting the leg length discrepancy. If it is a structural issue, then doing some type of modification to the shoe, doing some type of an insert or a lift inside the shoe, and not just the heel. I would actually unload the heel with a doughnut sort of lift, but make sure that the lift goes though the entire shoe, not just in the heel, because what that’s gonna do is, if they don’t have the strength and structure in the hip, what I’ve seen is it just kinda tips them forward and throws the hip even more forward. So I would do either a modification to the shoe, lifting it up depending on how much of a structural leg length discrepancy there is, or doing something inside the shoe.
If it’s a functional leg length discrepancy, again I’ve seen that as being one arch drops more than the other, so that causes the hip and pelvis to be uneven which again is gonna cause uneven striking on the ground and/or look at a functional leg length discrepancy due to some imbalance in either pelvic obliquity or pelvic rotation.
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Jeff Frame, MS, ACLS, EMT, USACF, CSCS, SICI, FMS
With an extensive research background, Jeff has obtained credentials from USA Cycling as an Expert Coach and SICI’s Advanced Bike Fit Specialist, Triathlon Fitting, and Custom Bike Fitting certifications. Jeff served as faculty for some of the largest Universities in America, and was instrumental in the development of 2 new biomechanics research labs. Jeff created BioVelo, LLC (a company focused on cycling) consisting of consulting, product development, professional advanced bike fitting, coaching/training, custom orthotics and speaking. During this time he was also recruited by IU Health to develop and implement a clinical gait lab and service line where he still serves as the Coordinator of Motion Analysis.