Case Studies In Treating Chronic Plantar Fasciitis

Brian Fullem, DPM

Given the common presentation of plantar fasciitis, the variety of etiologies and at times concurrent conditions, this author reviews four illuminating patient cases, emphasizing pertinent diagnostic pointers and keys to effective treatment.

Plantar fasciitis, aka plantar fasciopathy, is one of the most common lower extremity complaints. It is estimated that 20 percent of the general population will experience some type of plantar heel pain at some point in their lives and 2 million are treated annually for plantar fasciitis in the United States alone.1-6

   Plantar fasciitis is one of the most common complaints in runners. Classic symptoms include pain with the first steps in the morning and after rest (poststatic dyskinesia). The pain usually dissipates with activity. Chronic plantar fasciitis/fasciosis can be debilitating. Reports suggest that over 90 percent of these types of cases resolve by 12 months. However, this is difficult to accurately report due to the fact that patients may seek treatment from many providers.1,3,5,6 Unless follow-up assessments occur at 12 or more months after onset by the same provider, this may only be conjecture. Most studies on non-operative treatments for plantar fasciitis only evaluate patients for symptoms up to one year or less, and do not report on the activity level (or the need for cessation).

   In addition to “classic” plantar fasciitis, other conditions such as calcaneal stress fractures and periostitis, plantar fascia and muscle ruptures, and local nerve entrapment can occur.

   Accordingly, let us take a closer look at four unique cases of plantar fasciopathy that I have encountered in my office in the last three years.

When Conservative Care, Shockwave Therapy And An In-Step Plantar Fasciotomy Fail To Get Results

The first patient is a 45-year-old female who presented in 2011 with heel pain bilaterally but much worse pain in the right foot. The patient noted the pain was worse with her first steps in the morning and she was unable to perform her normal physical activities including martial arts and running without pain.

   In 2004, the patient underwent tarsal tunnel releases and plantar fasciotomies bilaterally. These procedures were extremely successful and she remained pain-free until 2010. Other than those procedures, her past medical history was non-contributory. She was not taking any medications and had no known drug allergies. The patient had rigid custom orthotic devices, which she found uncomfortable partly due to the fact that the devices put pressure on the surgical scars.

   The physical examination revealed a flexible pes planus foot type and 0 degrees of ankle dorsiflexion. The patient had pain with palpation of the plantar medial calcaneal tubercle of the right foot. The Tinel’s sign was negative bilaterally.

   Over the first six months of treatment, the patient had two cortisone injections, received new, more flexible custom orthotic devices and diligently emphasized stretching, icing and utilization of a night splint with no success. At this point, I turned to shockwave therapy and performed three treatments with the D-Actor 200 (Storz Medical) at 12.0 Hz with 2,000 shocks ranging between 3.0-3.4 bar. Six weeks after shockwave therapy, the patient did not note any improvement.

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