A 35 year old presented with complaints of pain in the left and right foot around the:
- Achilles
- Plantar fascia
- Along the medial arch of the foot extending into the great toe.
The pain had been present for the last 4 years. They had tried multiple interventions including more supportive shoes, physiotherapy, laser acupunture and orthotics which were very high arch supports. All of which were unsuccessful.
They had previously been told they had Plantar fasciits and Achilles tendinopathy. The presentation was different from normal Plantar fascia and Achilles pain as the pain was worse at night than during the day.
There was also reports of a tingling sensation in the foot with electrical shooting pain which kept them awake at night.
Performing an ultrasound of the Achilles and plantar fascia indicated that these structures were completely normal and so plantar fasciitis and achilles tendinopathy were excluded.
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There was pain with percussion of the tibial nerve (tinel’s sign). Tapping the nerve replicated the symptoms in the foot and heel.
An ultrasound of the tibial nerve also indicated that the nerve was thicker as it coursed around the tibia.
They stood with a pes planus foot posture (flat foot).
The aim of treatment is to reduce the irritation of the tibial nerve, this is achieved by minimising the activity of the invertor muscles and tendons, and reducing the damage to the nerve. This can be achieve with:
- Orthotics with a rearfoot post –There are a number of different orthotic designs available for flat feet. Most orthotic designs are simply arch supports.
These are not ideal for the flat foot, often only irritating the arch of the foot. - Shockwave therapy
- Surgery