A 47 year old female presents to the clinic complaining of pain on the bottom of the left heel. She states the condition has existed for at least 3 months, started gradually and has worsened over time. She also states no recollection of injury or specific incident related to the onset of the pain. The pain was initially only present for a short period when first weight bearing after rest and has gradually progressed to being constantly painful during standing and walking. She states that she is moderately active, walking for exercise but has had to discontinue due to the condition and has subsequently gained unwanted weight. Her occupation is retail clerk in a grocery store and is afraid she may have to go on disability due to the heel pain. She states she has tried OTC remedies such as Ibuprofen, ice packs and stretching exercise, has changed shoe gear, but nothing seems to be providing relief. The patient denies having any systemic disease, takes no prescription medication and relates no known allergy to medication.
Physical examination findings include a female, 5’6” height, 175 lbs. weight. Dermatological findings include normal skin tone and temperature both lower extremities, hair and nail growth within normal limits, negative for remarkable skin lesions however there is hyperkeratotic callus formation around the rim of the heels with xerosis and fissuring bilateral. Vascular findings include intact dorsalis pedis and posterior tibial pulses bilateral, superficial venous plexus filling time under 3 seconds all digits, mild non pitting edema in the left lateral ankle, within normal limits right ankle, no varicosities bilaterally. Bilateral Achilles and Patellar reflexes are normal, sharp/dull discrimination is present in all areas, there is negative Tinel sign in the tarsal tunnel area bilateral. Range of motion of the ankle, subtalar, midtarsal and metatarsal phalangeal joints are all within normal limits, no crepitus noted. Muscle strength of dorsiflexors, plantar flexors, inverters and evertors of both feet are within normal limits. Exquisite tenderness is elicited upon palpation of the proximal plantar fascia near the insertion into the Calcaneus. Tenderness is also elicited upon medial-lateral compression of the Calcaneus and the sinus tarsi of the left subtalar joint. The plantar fascia is noted to be taught when dorsiflexing the ankle and 1st MTPJ with some thickening palpable. The plantar fat pad is adequate. Minimal edema is present with absent erythema, ecchymosis, calor noted in the area of the chief complaint. Gait is markedly antalgic on the left side, with reluctance to heel contact and significant lateralization of the left foot. Mild pronation is noted during midstance and propulsive phase on the contralateral foot Limb length appears symmetrical, and mild genu valgum is noted bilateral.
Weight bearing radiographs of both feet reveals well formed plantar Calcaneal exostosis present bilaterally without apparent fracture. Posterior spurring of the Calcaneus is absent, no signs of arthritic changes are present. There is slight reduction of the Calcaneal inclination angle, and anteriorly broken cyma line and slight elevation of the first ray with respect to the second ray on the lateral view.
Preliminary diagnosis of plantar fasciitis/fasciosis/fasciopathy, left foot is made. The patient is counseled on the likely etiology of the condition and possible treatment options that are available. Subsequently an MRI was ordered which revealed bone marrow edema in the Calcaneal tuberosity as well as thickening and mucoid degeneration of the proximal plantar fascia. Conservative treatment consisting of combined physical therapy, and immobilization was performed with 90% resolution of the symptoms at approximately 3 months following initial exam. At that time gait analysis revealed moderate pronation of both feet and a recommendation for functional orthotic devices was made.
Next week’s post will discuss the process of determining which type of orthotic device to use, and why, in order to successfully treat this all too common condition.
