Symptoms (client reported)
The right heel pain started a few months ago, out of nowhere. At least, I don’t remember doing anything out of the ordinary. I limp out of bed in the morning, or when I get up after sitting for a while at work. The pain eases after I move around a bit, but if I walk too much, I start limping again. I haven’t gone to the gym or biked to work in months. My stomach gets bigger, and I get a little more depressed each day, he exclaimed.
Observations (therapist observed)
In standing, the client leans to one side, putting most of his weight on one leg. His feet are flat (barely noticeable arch), the painful side flatter. He walks with minimal heel rise (push off). He sits with his knees turned in. He has tight calves, and weak inside ankle (tibialis posterior) and outside hip (gluteus medius) muscles, the painful side worse. On the painful side, his arch is tender, especially at the attachment to the base of the inside heel.
Right pronation (flat foot) syndrome, commonly referred to as plantar fasciitis.
Postural and movement recommendations:
In sitting, don’t let the knees turn in (knee cap faces inside of big toe), flattening the foot. Keep the knees in line with the hips and feet in line with the knees.
In standing, put equal weight on both legs. Don’t lean to one side, flattening the foot.
Walk with a rolling heel to toe pattern. Strike down with the heel, roll your weight to the toes, raising the heel as your trunk progresses forward.
If you change shoes for various activities, make sure they’re of relatively equal heel heights (even a small change in heel height could aggravate symptoms). Going from a shoe with a larger heel to a shoe with a smaller heel aggravates symptoms.
Don’t walk around barefoot. When you get out of bed in the morning, slip on a pair of shoes to reduce the morning pain and stress on the plantar fascia.
I evaluated his work and gym shoes, and educated him on shoe characteristics to provide stability for his feet.
I didn’t recommend an orthotic in this case as the client effectively corrected his movement impairments. Keep in mind an over the counter orthotic is as effective as a custom orthotic.
Stretch the calves, 5-8 times a day, holding each stretch for 30 seconds. Wear shoes with standing calf stretches, and make sure knee is in line with hip and foot (knee cap should not point inside of the big toe, flattening the foot).
Before getting out of bed in the morning, move your ankle back and forth a few times, and stretch the calf with a towel.
Strengthen the calf muscles (tibialis posterior and gastrocnemius) with an elastic band. Progress to functional strengthening with single leg stance (standing on one leg), and a focus on hip, ankle, and foot strategies to reduce flattening of the foot.
The client attended four physical therapy sessions over six weeks. At the end of six weeks, he had no pain, but still felt a sensation of “tightness” or “discomfort” in his right arch. He went back to the gym, and resumed biking to work. A few months later the client returned, right foot pain fully resolved, with a hamstring strain after falling off his bike rounding a corner.