Case Studies In Treating Chronic Plantar Fasciitis

Brian Fullem, DPM

   I referred the patient to a neurologist to test for tarsal tunnel syndrome and rule out radiculopathy. The neurologist ruled out tarsal tunnel syndrome through nerve conduction velocity/electromyography (NCV/EMG) examination and a subsequent MRI revealed that a thickened plantar fascia was the only abnormal finding. Twelve weeks after shockwave treatment, the patient did not note any improvement at all and she requested surgical intervention.

   I performed an in-step fasciotomy on the right heel 11 months after the initial presentation. The post-op course was uneventful and at six weeks post-op, the patient began increasing her activity level and the pain recurred at the same level as before the surgery.

   I referred the patient to another podiatrist for a second opinion. He referred her to a different neurologist and nerve testing found evidence of entrapment of the lateral plantar nerve. The neurologist placed the patient on gabapentin and she felt significant relief in her pain. The medication dosage was titrated up but then the patient began experiencing some negative side effects.

   Three months later, the patient requested a second tarsal tunnel release. After undergoing this procedure in November 2012, the patient experienced complete relief of pain. At her last visit six months post-op, the patient was pain-free the majority of the time and was able to resume running and martial arts at her desired level.

When An Avid Marathon Participant Has Seven Months Of Heel Pain

The second patient is a 57-year-old female who presented in March 2011 with heel pain that she had for the preceding seven months. The patient is a running coach and avid marathoner and ultramarathoner. Her pain was consistent with plantar fasciitis as she had more pain with her first steps in the morning and after sitting during the day. Taping, icing, a night splint and OTC orthotic inserts all failed to alleviate her pain prior to this office visit. The patient refused the use of custom orthotic devices and cortisone injections.

   The patient’s past medical history was non-contributory. She was not taking any medications and there were no known drug allergies. The physical examination revealed pain upon palpation of the plantar medial calcaneal tubercle. The patient had a cavus foot type and was an under-pronator. Ankle dorsiflexion was approximately 5 degrees with the knee extended and 10 degrees with the knee flexed. Radiographs were negative for any signs of fracture or spurring. Diagnostic ultrasound revealed thickening of the plantar fascia.

   The patient elected to have shockwave therapy. She had three treatments in weekly intervals via the D-Actor 200 utilizing 2,000 shocks at 4.0 bar and 12 Hz. Six weeks after shockwave treatment, the patient was still experiencing pain. However, over the following six weeks, the pain gradually receded and at 12 weeks post-shockwave therapy, the patient was able to resume running at her previous level completely pain-free. Recent follow-up for a different injury revealed that her heel was still completely pain-free more than one year after shockwave treatment.

   The medical literature has shown that extracorporeal shockwave therapy is very effective for plantar fasciopathy with success rates exceeding 60 percent.10 In our office, we often offer extracorporeal shockwave treatment as a first-line treatment for those suffering from plantar fasciitis longer than three months and in those who have had prior treatment. Our initial protocol in acute cases typically involves stretching, icing, taping and good supportive shoes. I often utilize a Powerstep insert if the patient has not used prior custom inserts. A corticosteroid injection may also be part of the treatment but if one injection does not help, I usually do not perform further injections.

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.

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