Let’s talk about Maria
The following case study highlights the principles of the assessment and management of someone with plantar heel pain.
Maria is a 53-year-old mother of 4 adult children. She immigrated to Australia from Malta when she was seven years old and her family was supported by other Maltese families. This community consisted of families from lower socioeconomic backgrounds, therefore she was required to work from a young age to support her family. As a result, Maria received minimal education and has limited English. Maria met her husband from the Maltese community, and had four daughters who are now either working or attending university. Unfortunately, when Maria’s daughters were teenagers, her husband passed away.
Maria has hypertension, diabetes mellitus and a BMI of 33 kg/m2 (a BMI > 30 categorises a person as obese). She works in a factory and stands for 12-hour shifts. Maria had experienced pain in her plantar heel for six months prior to seeing her general practitioner but she had maintained belief that her pain would eventually resolve. Over time, the pain had progressed to become more debilitating and was affecting her ability to work. She had taken time off work due to the severity of her pain. Because Maria has limited English, she relied on her daughters to advise her on matters she did not fully comprehend, to drive her to work and other appointments, and to help her navigate the healthcare system. After taking advice from her daughters, Maria saw her general practitioner who suggested calf stretches, cushioned footwear while at work, and oral non-steroidal anti-inflammatory medication. Maria followed this regime for three weeks with minimal change and was dependent on anti-inflammatories to complete her shifts at work. The general practitioner recommended that she see a Podiatrist for further advice.
Examination
Maria’s assessment is not complete but she was diagnosed with plantar heel pain based on pain localised to the bottom (plantar) surface of the heel that was reproduced on palpation of a specific spot on the heel (review the section on diagnosis of plantar heel pain). All other serious causes of plantar heel pain were ruled out by the general practitioner and podiatrist. There was no need for imaging to support the diagnosis. Maria’s history might suggest that psychological and social factors may be playing a role in the symptoms she described.
Treatment
The aim of treatment for Maria is to address any biological factors (i.e. tissues beneath the heel) and psychological factors (e.g. mood, beliefs and thoughts about her heel pain) and develop a support network around Maria.
Based on Maria’s presentation, the podiatrist and the patient worked together to develop an individualised treatment program that was consistent with her beliefs:
- Maria was provided with extensive education about the nature of the problem as she had a poor understanding of the diagnosis, causes and expectations for recovery. She was provided reassurance that there was no serious damage to the heel.
- Maria’s footwear was appropriate for work, although she was walking barefoot at home and on the weekend. Maria was encouraged to wear her supportive shoes after work and on the weekends.
- A simple taping technique was shown to Maria which was easily performed by her daughters. The tape was removed each night prior to going to bed to avoid the risk of skin irritation. Maria used tape for a period of four weeks (refer to the video which demonstrates how to tape the foot)
- Maria was prescribed a prefabricated foot orthosis which was modified to suit her foot posture and worn in her supportive shoes. The combination of taping and the orthosis was designed to reduce the load on her heels at work.
- Maria was advised to stretch her calf muscles and stretch her plantar fascia at her morning tea, lunch and afternoon breaks at work (refer to the video which demonstrates how to perform a plantar fascia and calf stretch)
- Maria spoke to supervisor at work who was supportive and arranged for Maria to alternate between sitting and standing postures to avoid long periods on the concrete floor.
- Maria’s level of activity after work was monitored closely to ensure she was not overloading the heel following long periods of standing at work.
- Maria’s psychological status was closely monitored for negative thoughts, distorted beliefs, unrealistic expectations but also her emotions (e.g. depressive symptoms such as hopelessness or low mood), particularly if they were associated with her heel pain.
- Maria was reviewed weekly over the first month to monitor her thought processes, level of pain, function, and ability to undertake self treatment.
- Maria’s daughters were encouraged to show awareness, provide support and reassurance.
Outcome
Maria’s symptoms beneath the heel gradually reduced over the following 12 months. She occasionally experiences pain beneath the heel but her ability to stand for long periods at work has great improved and she has begun to gradually increase her level of exercise outside of work.
Summary
This case highlighted the importance of treatment that targets biologocal factors (e.g. the tissues beneath her heel); psychological factors that might be associated with Maria’s pain (e.g. her beliefs and expectations) and the importance of family and workplace support.
Further research
Werner, R. A., Gell, N. , Hartigan, A. , Wiggerman, N. and Keyserling, W. M. (2010). Risk factors for plantar fasciitis among assembly plant workers. PM&R, 2: 110-116. doi:10.1016/j.pmrj.2009.11.012