Treating A Runner With Proximal Plantar Fasciitis, Hip Pain And A Limb Length Discrepancy
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.
Computer assisted gait analysis via the F-Scan system (Tekscan) revealed the following findings.
During barefoot walking, the patient had an increased impact of the right heel at contact, increased calcaneal stance duration that was 10 percent greater on the left side, active propulsion of 15 percent on the left and 24 percent on the right, and equalsingle support stance, swing and time.
Analysis of the patient in a New Balance sneaker with sport orthoses demonstrated reduced right calcaneal pressure in comparison to the patient being barefoot, increased calcaneal stance duration of 8 percent on the left side, active propulsion of 14 percent on the left side and 21 percent on the right, and equal single support, stance, swing and time.
Analysis of the patient in a New Balance sneaker with sport orthoses and a 1/4-inch lift on the right revealed a mild shift to the left with slightly greater midstance on the right and greater active propulsion on the left. However, the overall symmetry was notably better.
Gait analysis with the patient wearing lace rubber sole moccasin footwear with carbon-fiber devices revealed overall symmetry and normal weight distribution patterns.
Diagnostic ultrasound revealed a hypoechoic linear region of inflammation with its apex at the inferior, medial and middle segments of the calcaneal tuberosity extending distally approximately 27 mm. The plantar fascia was 5.6 mm at its widest point normal would be 3 mm). Dynamic examination through activation of the windlass mechanism revealed an intact functioning plantar fascia without evidence oftear or rupture.
Weightbearing radiographs of both feet revealed the presence of an inferior calcaneal spur bilaterally.
A Closer Look At This Patient’s Diagnosis
The diagnosis was chronic, subacute, proximal plantar fasciitis with spur formation exacerbated by running. The patient’s left hip pain was secondary to a right limb length discrepancy and restricted range of hip internal rotation bilaterally.
The patient had the following bilateral conditions: collapsed cavus, compensated rear and forefoot varus,compensated forefoot equinus, genu recurvatum and hallux extensis. He also had multiple digital contractures of the second through fifth digits bilaterally with extensor substitution.
Keys To Treatment
I prescribed hip internal rotation range of motion exercises for the patient as well as discontinuation of Achilles and plantar fascial stretches. Performing a local marcaine/dexamethasone PO4 ultrasound guided injection with recommended use of Campbell’s rest strap and bilateral heel raises for daily footwear did not produce definitive relief. A follow-up injection of 3 mg Celestone Soluspan did not resolve the heel condition well enough to withstand forces incurred while running. I encouraged the patient to wear his night splint and avoid barefoot walking.
The patient had a short course of naproxen 220 mg (Aleve, Bayer) ii BID. Since this individual has been suffering with this condition for several years, I utilized extracorporeal shockwave therapy (ESWT). The patient continued to use rest straps after each treatment. He discontinued nonsteroidal anti-inflammatory drugs (NSAIDs) one week prior to ESWT and for one month during treatment.
We resolved the left hip pain with appropriate implementation of a 1/4-inch lift on the right side in athletic footwear as well as improvements in hip internal ranges of motion. After the first ESWT treatment, the patient's comfort level was 90 percent and he hadsignificant reduction of heel pain upon arising from bed.
Pertinent Insights On Addressing Limb LengthDiscrepancy
The structural status of most individuals is not completely symmetrical and is usually characterized by one leg being longer than the other. This limb length discrepancy increases with age until ages 16 to 18. At this point, the limb length discrepancy is approximately 1.1 cm and patients usually easily compensate. When there are greater discrepancies than this, a host of debilitating problems may ensue. Most experts agree that limb length discrepancies of 2 cm or greater are enough to cause significant symptomatology. However, even minor discrepancies may result in major problems when the musculoskeletal system is subject to increased system demands such as those that occur during sports participation.
One can assess limb length discrepancy directly with supine or standing measurements. In my experience, standing radiographs are the most accurate as clinicians may assess either relative or absolute length of the limb. For indirect assessment of limb length, place lifts under the shorter limb until the patient achieves pelvic symmetry.
The problem is that neither of these methods assesses the pathomechanical impact of the discrepancy during ambulation. What’s more, both a level pelvis and equal limb length do not ensure symmetrical function. Some individuals with an imbalanced pelvis have symmetrical feet and limb function as do some individuals with uneven limb lengths. The underlying issue is the objective assessment of symmetry during function.
In my early years in practice, I would equalize limb length based on clinical and radiographic measurements as well as sacral leveling. The use of computer assisted gait analysis taught me that leveling the pelvis or equalizing limb length may in fact create pedal and limb imbalances that manifest by asymmetrical plantar pressures as well as temporal parameter gait disturbances. We cannot predict functional symmetry or asymmetry following the use of prescription foot orthoses. Therefore, one should not address this until several weeks after dispensing the orthotic.
Note whether asymmetry is present. See if the patient has an extended midstance phase, increased single support, increased stance, increased calcaneal duration and increased medial calcaneal pressure all with the longer limb. Also note the presence of an increased propulsive phase, decreased midstance, decreased calcaneal duration, and relative supinatory center of force all on the shorter limb. If all of the aforementioned signs are present, then equalization with lift therapy in 1/8-inch increments is indicated. In essence, the longer functioning limb pronates and the shorter limb supinates in an attempt by the patient to extend the length of the extremity.
In this case, the heel pain was being perpetuated by the continued need for further collapse of the left foot to shorten the longer limb. This was not a symptom producer for everyday walking but because of the increased demands placed on the foot during running — the theory that during running, forces on the foot are increased by three times that of body weight and are three times that for everyday walking — the limb length discrepancy recurrently precipitated the calcaneal symptomatology.
Dr. D’Amico is a Professor in the Division of Orthopedic Sciences at the New York College ofPodiatric Medicine. He is a Diplomate of the American Board of Podiatric Orthopedics. He is a Fellow of the American College of Foot and Ankle Orthopedics and the American Academy of Podiatric Sports Medicine. Dr. D’Amico is in private practice in New York City.