Case Presentation: 55 year old female presents chronic pain to left posterior heel for the past 5 years
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.
Stephen King presents his thoughts on this case presentation.
Like Jeff said, it does seem to be sort of a classic case of plantar fascia pain syndrome. Obviously, you’d wanna confirm from a case study, the exact sort of location of the pain. So whether it is more inferior aspect to the calcaneus or whether it is more that posterosuperior aspect, given on the MRI findings there’s some degenerative changes in the Achilles tendon as well. But tentatively, this lady is 55 so that often makes you think more of those load, and more degenerative tendon-type issues tend to be more common in that age group in females sort of four to one. Whereas before 40, it tends to be more in your males. Often maybe that’s because the estrogen has got a bit of protective effect, they suggest. Given it’s been going on for five years, we’ve also gotta consider potentially there’s some central pain changes there as well that maybe continue to drive this, irrespective of the tissue and the nociception in the area. Also note the medication with Lisinopril, I think there is some links in the literature that I’ve seen between that and between these type of complaints as well. So we don’t know much else from the history sort of about the aggravating, relieving factors, what her current load tolerance is like and the current fitness level and activity level. We don’t also know what the other therapists have tried, so that would be all useful information that would help us as well.
Looking at this subjectively, I’d use an assessment very similar to Jeff. I think he sort of nailed it there. Collect as much of objective data as you can. Particularly having a look at that gait analysis and maybe using the force plate to collect some on that peak force and ground contact times and the loading profile with the gait in particular, but also with other functional movements. You might look at some squats and some lunges in sort of multiple directions in of all three planes to try and get a bit more indication of how her whole lower limb is functioning and how efficient she is in her movements. So especially with these type of cases, it’s often that sort of efficiency and that sort of springiness in movement can give you a bit of information to see how well she’s able to transfer the gravity in ground reaction forces and transfer her mass and momentum to meaningful movement. Noting the examination does say that it’s five out of five strength on manual muscle testing, but I’d also have a look at mass calf raises or have a look at eight to 10 repetition maximum of all the muscles in the lower limb to get an idea of what’s happening through there. But also have a look at some balance and proprioception.
I’d use our movement assessment tool, using the star excursion balance test as well as maybe some upper limb reaches to try and again gather some more objective data that we can use as a baseline to gauge her functional improvement going forward with our mat treatment and management plan. So management-wise, I’d look again very similar to Jeff. I’d probably go after those hips if we found some issues there on strength testing and assessment of those functional movements. It maybe you might offload with some orthotics or some footwear changes could potentially be beneficial, then try and modify her activity level and try to remove some of those aggravating factors if there is. Might also benefit from some isometric-type exercises, some general strength training and then starting to build some more variety and exposing it a lot to different movements. So maybe just making sure initially you’re not too much or too little. The Goldilocks effect is just right.
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Stephen King B.SC, M.H.SC, MPT
Steve has a unique skill set being qualified as a Physiotherapist, Osteopath, personal trainer and strength and conditioning coach. He is currently a director of the Functional Movement Group and co-creator of The M.A.T (Movement Assessment Tool). He has a keen interest in functional performance testing and using objective data, technology and analytics in his practice. Steve is also a current SMA-Victoria board member and performing research with both the University of Queensland and Victoria University in Australia.