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Hi guys,

I have a 60 yr old female pt with heel pain which she describes as a dull ache that gets worse with weight bearing. The x-ray came back with nothing (i thought she may have had a fractured heel spur). theres no history of trauma and she doesnt do much exercise.

i also got an ultrasound which came back with a fairly large hypo-echoic area and the report said plantar fasciitis. (I am positive its not plantar fasciitis as she has no post static dyskinesia and the pain doesn't warm up as she walks)

I tried low dye taping (as her foot posture is quite flat and she is over-pronating at the midfoot a lot during gait) which she says provided a little relief, and i have given her an icing regime and voltaren cream, no bare foot walking, plantar fascia stretching, appropriate footwear etc..

Im just not sure where to go from here- she is coming back next week (i know the taping didn't do wonders as I rang her to see how she was going)

my plan was to give her orthotics to redistribute more weight to her arch if the taping helped but ive just read the thread on here that says taping is not a good indicator of success of orthotics. should i be trying some padding instead? im not really sure what else i can do for her or if i should be getting more imaging? if someone has a stress fracture in their heel do you also get soft tissue swelling associated with that??

any thoughts??

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Hi Erin
Be a little careful here- an atypical presentation of a common pathology is more likely an an atypical pathology...
You have 2 parts to the problem-
What is the actual diagnosis, and what is the cause.
Sometimes with PF it can be hypersensitive and irritable so that nothing short of complete offloading will allow it to settle. In this case you may end up putting her in a walking boot or similar.

I would be interested in knowing how she responded to your other management such as the stretching and footwear change.

Some more information with respect to the history may help- did it start initially with morning pain and has progressed since that time (many do not seek treatment until it has progressed)?
How was the original onset? Sudden? After a long day on her feet? etc etc...

My suspicion from your information would be that she needs to have the pain settled somewhat before you could reasonably assess and address biomechanics.

Consider other things such as trigger points and calcaneal oedema...

I hope these quick thoughts help.

__________________
Craig Tanner
Podiatrist
ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR
http://www.aspetar.com/

i also got an ultrasound which came back with a fairly large hypo-echoic area

this is important.. you might need to work backwards from this, but the area of echogenicity indicates pathology in that specific area. Unfortunately from your posting, we do not know exactly where the hypoechoic area is.

I agree with toomoon, if the hypoechoicity is at the PF origin on the calcaneus, typical plantar fasciitis is likely present. However the hypoechoic region is sometimes in the midportion, and typical of a partial tear of the plantar fascia, and which is often treated differently.

__________________
“Body: A thing of shreds and patches, borrowed unequally from good and bad ancestors and a misfit from the start”

Ralph Waldo Emerson

thanks guys! the hypo echoic area was around the medial calc tubercle.

CraigT- the onset was gradual, shes only had the pain for a few weeks before she saw me so i presumed that the pattern of pain hadn't changed however thats a really good point and ill ask her when she comes in this week.

ill let you know how it went when i see her!

she couldnt remember if the pattern of pain had changed or not but did say that she had had it for a lot longer than she initially told me so i think you guys might be right.

When she came back she said the taping had helped a little, she wasn't interested in completely offloading her foot and she didnt seem like she was in as much pain so I taped her up again (low dye and campbell's rest) and put a D filler in her shoe which provided her relief until it flattened so ive decided to go down the orthotic path.

thanks for the help!