Treating A Runner With Proximal Plantar Fasciitis, Hip Pain And A Limb Length Discrepancy

Joseph C. D’Amico, DPM

This author discusses the treatment of a 63-year-old runner who presents with recurring pain in the left heel and hip.

A 63-year-old, physically fit, active 5’10” male runner and longtime patient recently presented with a recurrent concern of left hip and heel pain. He has had this condition intermittently for two years with gradual pain onset and the pain varies with the type, amount and intensity of activity.

   The patient says the heel discomfort is most pronounced upon arising from bed. His current comfort level is 75 percent with the heel when he is not participating in fitness activities. The patient denies knee or back symptomatology and does not suffer from foot or limb cramping.

   He has been wearing footorthoses for many years. This was prompted by right heel pain in 1986. The patient currently uses high-density polyethylene orthoses with extended forefoot varus posts to the sulcus for running and carbon fiber devices with rearfoot and metatarsal forefoot varus posts for daily use. All the deviceshave 3/4-inch deep heel seat and he received them in 2012.

   The patient does not walk barefoot to any appreciable degree. All footwear is current and appropriatewith rigid counters and flexible forefoot regions. Based on a 2012 post-orthotic dispensing computer assisted gait analysis and his primary concern at that time of left hip pain, I added a 1/4-inch lift under the orthotic so it is removable if necessary on the right side. In an attempt to remedy his current concerns, the patient has increased the right orthotic lift to 1/2 inch. He does not wear a night splint.

What The Diagnostic Workup Revealed

The physical examination revealed the patient’s vascular and neurologic parameters to be well within normal limits and commensurate withthat of a younger individual. The results of the biomechanical examination were notable for a significantly restricted internal range of hip rotation bilaterally. This finding was not present in his 2011 examination.

   The patient has a collapsible cavus foot with digital proximal interphalangeal joint contractures. I observed a compensated rearfoot and significant forefoot varus as well as forefoot equinus and genu recurvatum bilaterally. The right pelvic brim was noticeably lower when the patient was standing. I took measurements of the anterior superior iliac spine to the medial malleolus, which revealed a 3/4-inch discrepancy with the right side noticeably shorter. The first metatarsophalangeal joint (MPJ) dorsiflexion off-weightbearing was 85 degrees on the right and 73 degrees on the left with good quality. The patient had a hallux extensis bilaterally.

   A physical examination of the area of chief concern revealed an absence of visible inflammation. There was mild tenderness plus 5/10 (on a maximum scale of 10) on the left inferior calcaneus. No tenderness was reproducible at the left hip, iliotibial band or along the course of the plantar fascia distally.

   Observational gait analysis revealed extensor substitution during the swing phase of gait, an abductorytwist at lift off, increased impact at heel contact and a relatively apropulsive gait.

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