Case Studies In Treating Chronic Plantar Fasciitis

Start Page: 46
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Author(s): 
Brian Fullem, DPM

When MRI Is Beneficial In Isolating Partial Tears In The Plantar Fascia

The next patient is a 24-year-old elite female track runner who presented eight weeks after the initial onset of heel pain. She began experiencing pain in her heel during her track season and was extremely successful despite her injury. The patient does not recall any specific incident that instigated her pain but it became progressively worse. After setting personal best times in her last two races, she ended her season and took a break from running.

   The patient’s past medical history was non-contributory. She denied taking any medications and has no known drug allergies. The physical examination reveals ankle dorsiflexion beyond 90 degrees and a neutral foot type with pain on palpation just distal to the medial calcaneal tubercle. There was not a palpable defect in the fascia and the patient exhibited excellent tension in the central and medial bands. The patient was able to walk on her toes and heels without any difficulty.

   A subsequent MRI revealed a partial tear of the central band of the plantar fascia with the unique finding of an incomplete tear occurring dorsal to plantar. It is also interesting to note that the patient did not experience any bruising or swelling but was symptomatic in the area corresponding with the increased signal on MRI.

   Researchers have shown that athletes will typically return to activity in less than three months after a plantar fascia tear without the need for any injection therapy.7 There are no high-level studies that prove the effectiveness of PRP and one recent study did not show any difference in plantar fasciosis treatment between PRP and corticosteroid injections.8

Emphasizing The Importance Of Considering DVT Risk After An In-Step Plantar Fasciotomy

The final patient for this review is a 53-year-old male who had a complaint of left plantar heel pain for over a year. The pain was worse with his first steps in the morning and after sitting during the day. The patient is on active duty in the military and in addition to his physical fitness activities for his job, he enjoys running up to five miles four to five times a week.

   Previous treatment had consisted of physical therapy, custom orthotic devices, a night splint, icing and stretching. The custom orthotic devices were semi-rigid sport type devices that were comfortable and in good condition. The past medical history was non-contributory. The patient denied taking any medications and had no known drug allergies.

   The physical examination revealed significant overpronation with a flexible pes planus foot type. The patient had pain at the plantar medial calcaneal tubercle area that was consistent with plantar fasciitis.

   I initiated extracorporeal shockwave therapy with the Storz D-Actor 200 at the first visit with 2,000 shocks at 4.0 bar and 12 Hz, and performed weekly treatments for four weeks. One typically sees maximum improvement between 12 to 20 weeks. At six and 12 weeks post-shockwave treatment, the patient noted that his symptoms had worsened and he was unable to run or work out on a regular desired basis. At this point, the patient elected to undergo surgical correction and I performed an in-step plantar fasciotomy approximately six months after initiating treatment in our office.

   I instructed the patient to remain non-weightbearing on the operative foot for a period of three weeks. This allows the skin incision to heal and minimizes the possibility of painful scar formation. I removed the sutures at 12 days postoperatively and the patient was healing well and uneventfully.

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