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.
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.
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.
At 18 days post-op, the patient presented with left calf pain that began the previous night. A physical examination revealed pain, swelling and tightness in the left gastrocsoleus complex. I immediately referred the patient to a vascular specialist and he diagnosed deep venous thrombosis (DVT). The vascular specialist prescribed enoxaparin sodium (Lovenox, Sanofi Aventis) and his DVT completely resolved with no further sequelae. At three months postoperatively, the patient had returned to all activity including running with no pain or symptoms in the left foot and a one-year follow-up visit revealed no symptoms with pain-free activity.
The in-step fasciotomy has the advantage of avoiding the neurovascular bundle and allows excellent visualization of the fascia the surgeon is transecting.11 Not allowing weightbearing for three weeks postoperatively does increase the risk of a DVT and one should consider prophylaxis, especially in those patients who have any risk factors.
The treatment of plantar fasciosis is not always predictable but it is important to develop a protocol that is sensible and consistent to allow the practitioner to determine which treatment works best. Anecdotally, I have found that the sooner one initiates conservative treatment, the more successful one is in resolving the pain. As with most pathology, the treating physician must address the potential causes and not focus solely on treating the symptoms.
Dr. Fullem is in private practice in Tampa, Florida. He is board-certified in foot surgery by the American Board of Podiatric Surgery and board-certified in foot orthopedics by the American Board of Podiatric Orthopedics and Primary Care Medicine. Dr. Fullem is a Fellow of the American Academy of Podiatric Sports Medicine (AAPSM) and is currently organizing the AAPSM’s first stand-alone conference in almost 20 years. The conference will take place March 14-16, 2014 in Tampa, Fla. For more info, e-mail Dr. Fullem at firstname.lastname@example.org .
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