This gentle 63 year old was referred to me by an orthopedic surgeon in 2009. She’d had 9 months of worsening heel pain on the right. The pain began after she’d initiated physical therapy for right side hip arthritis, which was not severe enough for hip replacement surgery, but not well enough to ignore without treatment.
Amidst her treatment were three cortisone shots into her heel and two pairs of orthotics, one of which she was still using on a daily basis, and physical therapy, particularly calf stretches aimed, as the Internet uniformly but occasionally incorrectly advises, at relieving plantar fasciitis. None of these approaches relieved her symptoms.
There were only two problems with this approach. First, her right or involved-side calf was not tight. It was remarkably loose. Her uninvolved-side calf was quite tight. I have been teaching and employing a simple technique to measure calf flexibility internationally for nearly thirty years. But I cannot teach it to everybody. Her PT’s were having her stretch her tight left calf, fine, but also had her stretching her killer-loose already involved-side right calf. Not OK.
Secondly, she did not have plantar fasciitis. I am currently using and enjoying my ninth upgrade of diagnostic ultrasound machines. By 2009, I had already upgraded 4 times. Once one catches on, one will employ an ultrasound machine very frequently in a musculoskeletal microtrauma practice such as I have. One of the most used applications for me has been assessment of heel pain, particularly plantar fasciitis. She did not have plantar fasciitis. It was textbook normal as I scanned it in shape, size, lack of tearing, and lack of neovascularication (inflammation) on power doppler. What was abnormal was her fat pad. It was at once flattened, inflamed and sensitive to sonopalpation (discomfort when I gently pressed the flat ultrasound probe into the area of contused or flattened fat padding).
The calf stretches she was performing for an already overstretched calf were not helping. Calf tone protects the heel like a good bungee cord. She was stretching her calf tone away. Nor were her orthotics helping. Not surprising, as they were of a rigid carbon-fiber plastic. The prescriber had used a press-foam casting technique for these orthotics. This splats the fat wide under the heel during the casting. Thus, the lab has a wide cast at the heel to use to form the orthotic. The net result is a heel cup which cannot grab the heel bone from the sides (to retain the fat protectively under the heel at heel strike). The wide heel cup also prevents the heel counter of the shoe from adequately protecting the patient’s heel. There are other concerns using this casting technique, not the least of which is relying more on gravity than the prescriber’s judgement to create the shape of the orthotic. I prefer the messy wet-plaster off weight bearing casting technique. At least with this I can capture in plaster the shape I want for the orthotics. This patient’s orthotics also had a very shallow depth to the cup, reducing its effectiveness, and a ¼-inch pad under the involved-side or right-only heel.
So what could make a calf muscle extraordinarily tight on one side, and crazy loose on the other side? It was certainly loose enough to contribute to a heel bruise, as she undoubtedly had, and perhaps insidiously during her lifetime contribute to acquisition of excessive heel-strike impact leading to infra-operative degenerative joint disease in her hip.
So I checked for the gremlin I’ve consistently seen responsible for such asymmetry in calf tone since I first noticed it in 1980.
She had the gremlin (aka leg length difference). Her right leg when standing was about ¾” higher at the hip crest than her left. When one has such a difference, just as we have to do with other perturbations of our frame, we have to compensate to attain symmetry. We do this subconsciously, for both efficiency of energy consumption and for reduction of discomfort due to repetitive stresses and strains on one side or the other of our frame. Specifically, the short-side calf will tighten, to heel-off a bit earlier than the long side does when we stride, to try to keep the pelvis and spine even. Conversely, the long-side calf will loosen, due to heeling-off late in the stride, reducing time spent with the pelvis tilted higher, inauspiciously reducing time spent using the calf, thus weakening it. The calf acts like a bungee cord, reducing heel impact. If the bungee is too long, when we jump off the bridge, we go smashing into the water. If the calf is too long, when we stride, the heel goes smashing into the ground, inducing in this patient’s case a right heel bruise. Stretching her calf, as she was advised, worsened this effect. So standing before me was a patient, barefoot, with a right pelvic crest way higher than the left. When I asked her to stand on her orthotics, with that ¼” long-side only heel pad under them. her leg length asymmetry was even more exaggerated, again worsening the heel bruise.
So what’s a doc to do? Well, she didn’t have plantar fasciitis, and had no other foot complaints so maybe she didn’t need orthotics. She did have a heel bruise, so she needed a soft-soled, low profile, firm heel counter shoe which would accommodate her wide ball-narrow heel foot shape…perfect for a Saucony Pro Grid. She didn’t mind wearing sneakers, so I was lucky there. Then the kicker. I gave her a heel pad (actually a heel lift, ⅜” thick) for her left or uninvolved side, to be used instead of her orthotics. This was tough for her to accept, especially as I also instructed her to stop her calf stretches. Stop stretches, stop orthotics (with the wrong-side lift), and let me put the pad under the heel which doesn’t hurt. Need I say, “trust me?”
I also asked her to keep up with her Pilates and begin strengthening her involved-side calf. And to call me in 6 weeks. She did. Heel pain gone. Hip pain lessened. I love my job.