Clinic Case Report

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Chief complaint (CC): 25 y/o, white male, plantar fascia pain since 2011, metatarsal pain since 2015, hip pain since 1 year. He progressively quitted almost every physical activity gaining no pain relief. The pain has now become unbearable even when walking for a very short time (5-10 mins).

History of present illness (HPI): plantar fascia pain first occurred when the dancing portorican salsa wearing unconfortable shoes. In that period the patient had a very active life practicing running, football and dancing.
In 2011 the treatments with 10 tecar, 10 ultrasounds, ice and FANS brought no relief. The same happened practicing postural gym with Mezieres method to enlongate the instep.
In 2012 treatment with FANS, Platelet Rich Plasma (PRP) infiltration (2 for each foot) have been of no relief, but a new plantar orthosis led to bland parcial relief.
In 2013 treatments with ostheopatic manipulations, depomedrol (cortisone) infiltrations (2 for each foot) have been of no relief.
In 2014 metatarsal pain occurred when standing or walking probabily because of the compensation produced by the forward shift of the body weight, due to persistent pain in orthostatis .
Treatments with ESWT (10 for each foot), assumption of FANS where alternated, constantely without any improvement of the symptomps. Bland improvements have been obtained with the use of soft shock absorber foot orthosis. The pain reduction was of the 20-30%). Surprisingly the pain reduced even when wearing very soft slipper without any foot orthosis.
In 2015 intermitting bilateral hip pain appeared too.
In 2016 the treatment with a functional foot orthoses (Medial Heel Skyve 3 degrees bilaterally) reduced significatively hip pain but had no effect on metatarsal and plantar fascia pain.
By now, metatarsal pain got worse and worse and became continuous. There are severe difficulties in walking even for very short distances. Pain reducs (till complete disappearance) when the patient is not standing (es. during night).
Hip pain is transient and discontinuous but doesn’t disappear.

Phisical Examination (PE):
Reumathological:
In 2015 PE resulted negative for rheumatologic diseases.
Tissue typing: HLA-B Class I: 35.
In 2016 PE resulted negative for rheumatologic diseases but, because of the persistence of the pain, Dott. Numo (Reumathologist, Bari, Italy) suggested to try with Metotrexate (Reumaflex vials). (This treatment has been refused by the patent).

Orthopedical:
(March 2013, Dott, Manzo, Orthopedic, Rome)
Calcanear extra rotation and mandibular angle too open.
(Feb, 2017, Dott. Morisi, Orthopedic, Milano, Italy)
Negative to Lasegue test, abnormal pronation of subtalar joint on both feet
R.C.S.P. 2° eversion bilaterally.
Supinated forefoot 6° bilaterally.
Tibio tarsal dorsiflexion -14° bilaterally, both with extended or flected knee.
Abduced hallux bilaterally.
Hallux dorsiflexion 30°(SX) 40°(DX).

Tests:
ECG (April 2011, Dott. Canzoni, Reumathologist, St. Andrea Hospital, Rome): Mild insertional thickening of plantar aponeurosis both on left and right foot.
RM Scan (July 2012): Nodular thickening of plantar aponeurosis close to the insertion point, of 6,55mm in the right foot and 4mm in the left foot respectively.
RM Scan (Sept 2015): Right foot: Tenosyvitis of tendon sheath of long and short and long peroneal muscles
Left foot: Mild tenosyvitis of tendon sheath of long and short and long peroneal muscles.

Diagnosis:
Dic 2011, (Dott. Morico, Phisiatrist, Umberto I Hospital, Rome)
Plantar fascitis in fore claw foot, tibio tarsal laxity, retraction of hamstring muscles, lumbar hyperlordosis.
March 2012 (dr. De Carli, Orthopedic , St. Andrea Hospital Rome)
Confirmed diagnosis of plantar fascitis for both left and right foot with more pain for the left foot.

Actual treatment plan (without pain relief):
Continue using the functional orthoses, shock absorbing shoe, heel or wedge to achieve an high difference between forefoot and rearfoot of 3 cm.
Stretching of sural triceps having the foot in mild supination.
If there is no pain reduction, it could be necessary to make an RX of standing foot or, eventually, a TAC.

 

I'd really need your opinion of experienced clinicians: which treatment would you suggest for reliefing such a compromising pain in a young man?

 

It is really hard to comment with the information provided. Chief complaint of metatarsal pain and no physical exam findings in the metatarsal region? Can you reproduce the pain that the patient is having during the physical exam?

 

Which informations can I add to improve the anamnesys?
During physical exam I can reproduce in the patient the pain he complains about by palpating the metatarsal area.
The patient told me he had an ECG of both left and right foot attesting a joint effusion in the metatarsal area but there is no report avaliable of this ECG.

 

Which metatarsal? Plantar or dorsal? Metarsal head, neck, shaft, or base? Attempted ray motion? Impression in sock liner of shoes? Calluses?

 

All the five metatarsal heads, in the plantar area. No impression in socks, no calluses. Normal ray motion.