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

Joseph C. D’Amico, DPM

   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.

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