Help with Pt

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Hi I am having difficulties with a pt and wonder if anyone had any other ideas I could try??

32 year old male, with a 5year+ Hx of plantar fasciitis.
No noted injuries to feet prior to or during the time of pain, nor any new/ extended sports activities.
Normal weight for height.
No family Hx or previous Hx of any underlying medical problems.

Foot Ax:
STJ ROM and QOM WNL about 35deg motion but is quite medially deviated axis.
TCJ limited - throught very tight Soleus/ gastrocs comoplex.
MTJ joint WNL.
Huge plantarflexed 1st Ray.
RCSP - 5deg everted Bil
NCSP - 1deg invert.
Hyperextends about 5+ degress at knees.

Has seen a number of clinicians both in the UK and here in Aus, and has had a no. of different custom insoles made, including MASS and Blakes styles. He is so bad with this condition/ pain that he cant even walk to the local shops for fear of not being able to walk home.

Treatment:
I issued soleus/ gastrocs stretching, along with deep tissue massage and mycofascial releasing, and stretching of hamstrings and ITBs and glutes. Issued custom orthoses with med skive and reverse ext 2-5 for control of rearfoot and to equate for PF 1st and facilitate windlass, using the orthema cad/cam system. also issued a 4mm heel raise for hyperext.
At first 2-3 weeks got a huge improvement in pain levels, however now has resorted to only 30% relief.

I now dont know what else to try, has anyone got any other suggestions they could give me, would really appreciate the help with this one!!

Many thanks,

Col.

 

Col

Has he had an MRI, it seems that having seen many different people and it appears that the same diagnosis is made - maybe it´s not Plantar fasciitis/fasciosis but something else.

It will also give you a bit more confidence to say the patient we have a diagnosis now, the device I have issues is designed to reduce tension in the Plantar fascia - if this does not work then we made need to consider having a surgical release.

And if it not the Fascia you maybe able to alter the design of your device and treatment program. Always good to have the next steps planned in these harder cases makes the patient confidence in you increase.

Great that you got the big improvement with the program you started with - I would add to it ice 20-25 min at the end of the day or 25 min ice 60 min rest 25 min ice before he goes to sleep, Tennis ball massage 2* 5 min in the middle of the day and before he starts walking stretch the Plantar fascia. There is evidence for this one which I can´t find at the moment.

sit on the edge of the bed , cross the legs so the foot is resting on the other leg which is bent at 90 degrees with the foot on the floor.

Grab the heel with 1 hand and the toes with the other and dorsiflex the toes and forefoot on the rearfoot. I get my patient to do this 2 * 15 sec before they start walking in the mornings.

Hope that makes sense and helps.

 

I assume TCJ is talocrural and not talo calcaneal. Spelling out abbreviations helps if not everyone uses them. I often use AJ for ankle joint in charting.

The recruvatum, limited ankle motion is reeking of a quite severe equinous. I agree with the treatment you had so far and find it encouraging that it helped a lot at first and then decreased in effectiveness. It makes it sound like you were on the right track and then he either increased activity level or increased stride length and the stress returned. You might try more lift or have him stand on your devices and see how far he can move his tibia forward before heel lift occurs. That might help you figure out if more lift would help.

One of the things that I learned from John Weed was that in the presence of a severe equinous you should (as John Weed said) take a pronated cast. (My interpretation is that you should have a lower arched device.) I would predict that the MASS device for this case would not be tolerated. What happened with it?
Good Luck.

 

Hi Michael and Eric, many thanks for your responses. Michael I have now sent him for an MRI as you say we will definately have a Dx.
Eric sorry for the abbreviation yes it was ankle joint. I did have a look at him on the insoles and even with the 4mm lift the tibia was not allowed to pass over the foot before heel lift so I have used a higher lift and will wait to see how that goes.
Cheers again guys, much appreciated.

Col.

 

any contra-indications to putting him in a POP immob. cast for 4-6 weeks? that often setlles it down

 

I agree with Peter, POP immobilisation may be an option at this late stage. Also steroid injection?

I recently had a lady who was referred for chronic long term plantar fasciitis. I referred for an ultrasound which showed a big fibroma within the fascia, which wasn't obvious visually.

However my biased opinion at this late stage would be for a surgical opinion for both the plantar fasciitis and the equinus.

George

 

in 14 years of practice, I have never sent a pt with plantar fasciitis for a surgical opinion. Could this be some sort of record?
Why am I seemingly lucky?

 

In my opinion you are not lucky, just very good with conservative care!

In cases like this, I personally use Local Anaesthetic injection with peppering technique, and find that this resolves the remaining symptoms that the patients are experiencing.

As George has said a drop of steroid in the right place also has a very good chance of reducing the symptoms.

Regards David

 

Peter okay i admit, i very rarely see plantar fascia release procedures. However if the patient has a severe equinus which isn't reducing with conservative therapy, i think a TAL, recession or whatever may be appropriate, should be considered.

Whilst in the USA I observed and did a couple of TOPAZ procedures for chronic plantar fasciitis which did seem to work quite well. However i have to admit i wasn't there long enough to see long term follow up.

George

 

That is a severe equinous if he can't keep his heel on the orthotic, with a lift, when his tibia is vertical. An equinous that severe will probably strain the fascia immediately after he gets out of his cast. Well, maybe not that fast, but I would bet that the heel pain would come back soon unless something else is done. Before you send him to a surgeon try and explain to him the difference between bony and soft tissue equinous so he can make an informed decision about the surgery. If it were my foot, I might consider a life in high heels before I'd get a lengthening if I did not see an increase in ROM of the ankle with knee flexion.

Eric

 

Hi

What is the cause of the equinus?

If it was me I'd be looking for tp's in gastroc proximally, soleus distally and with regard to the recurvatum perhaps have a look for tp in plantaris too

Also check for tp's in abductor hallucis and quadratus plantae

Mobilise ankle joint and release work on the medial band of plantar aponeurosis.

Med skive will likely increase compressive force at med tubercle, so probably not the best idea. Remember plantar fasciitis is not always induced by excessive tractional force in the medial band of the plantar aponeurosis, can be compressive at origin too.Up the heel raise too if you can.night splint?

All the best

Scott

 

My only concerns with POP is he already has a tight calf complex, and hyperextends at knee, so immob this complex even more for this period may increase tightness.

col.

 

Hi Scott, and others following this thread, many thanks for the responses.

The equinus is soft tissue in nature, very tight posterior muscles, flexion of knee does increase ROM at AJ. I have found large TPs in gastrocs and soleus and also in ABDH and QP, and have been releasing these weekly.

I have only used a small amount to skive, and the Pt feels this was the reason for the big improvement at the start, as the previous insoles had not used a skive, and so for this reason am reluctant to reduce it.

Eric and others, we have already had a discussion re-surgery, and my Pt feels this is not really an option just yet, he feels at present he can still live life and just needs to be conservative with the amount of walking/ standing he does.

we are waiting for MRI result to come back and I am due to see him in a couple of days so will see how increase of heel raise goes, and may even consider injecting to help with acute nature.

cheers guys I will keep you updated.

col.

 

Hi col.

Regarding the medial skive. In theory it will likely increase the external supinatory effect at the subtalar joint by transferring orf medially. This may well reduce the mla drop and corresponding increased traction in the medial slip of the plantar aponeurosis. That's probably why initially he felt much better. Why then did his symptoms re-appear? Have you thought about removing the orthotic? The guy has been in orthotics for ages and isn't any better. My guess is the may be interfering with your tp therapy. Why don't you try soleus tp release, stretch and spray with moist heat applied after. Supportive footwear with heel lift. Ask yourself why are these trigger points re appearing??

Good luck col

 

Have you measured for The Inclines POsture (TIP) and considered either B/L heel lifts or a unilateral heel lift if the affected side lives on the short side?

Not a cure, just ancillary care.

Dr Sha

 

To all who were following this thread..
Eric you were in fact correct, the recurvatum was limiting A.J flexion causing stress, since increasing the heel raise the pain in his heel has decreased and seems to be improving evey day. cheers for all the comments.

Col

 

The medial heel skive will shift pressure more medially when there is contact between the foot and heel cup of the orthosis. It appears that this guys heel lifts off of the orthotic very early in stance phase. So, it would help with initial pronation at heel contact, but not after heel lift.

Eric

 

The bias of The Arena shows yet once more.

What did I suggest.

Heel lifts.

So on this site, I'm chopped liver!!


The very thing you guys spent an entire post telling me you rarely use!!! mand that I should not usde so frequerntly!
Do you remember?

Furthermore, my posting on this thread said the lifts were ancillary in this (and most other cases), they are temporarily eliminating the tissue stress at the area of the chief complaint (McPoils and Kevins and Craigs and your unbelievable work) this patient needs muscle engine conversion of posterior tibial and probably anterior tibial to eliminate the need for compensatory work of t. achilles causing the current issue.

You are offering medial skives and waiting for the next weak MCF on the totem pole to rear its ulgy head and cause TISsSUE STRESSsss (purposeful missspelling).

So lost.

I will not offer advice on The Arena again.

Your bias has finally reached down to your students.

and you all missssssssssssssspelll you jerks.

Dr Sha


PS:

nice job Eric.

 

Hi Eric yes sorry it was the same patient, here is the new posts followed on this thread.

1.Hi just a thought!!

is it possible to strain the quadratus plantae or abductor digiti minimi, by inverting/ supinating the foot??

Friend has 5 year Hx of heel pain had several orthoses, on an earlier thread here I was advised to try and increase the heel raise for recurvatum, and this seemed to help for a period, but now back to original pain.

When I examined him at the weekend his pain was no longer at medial tubercle of calc as it was a year ago rather more central and lateral.
Only thing is he has had an MRI which showed nothing at all other than possibly early fasciitis!!! Very strange. he assures me it is not in his head lol, I had to ask the question.... any suggestions would be greatly welcomed!!! Michael, Eric, Dr Sha
Thanks

Col.

2. FootDoctor. - Obviously fell on deaf ears col ......trigger points

scott

3. eFuller. Is this the same guy? If it is, you should ask the question in that thread.

I don't see how you would strain quad. plantae by supinating foot. I think it would be highly unlikely that you would strain the other muscle, but it's theoretically possible if you rolled onto lateral boarder of foot and the patient choose to try and plantar flex 5th toe to spread load off of met head.

On the other hand the plantar fascia has 3 bands and if someone avoids medial slip pain by choosing to supinate their foot they may increase load in the central or lateral slip of the fascia.

Eric.

Sorry again for the confusion about starting a new thread. Anyways, Scott didn't fall on deaf ears, I have been releasing TPs over the last two weeks and still he says when he stands still for any length of time its excruciating pain.
This is what im thinking Eric it feels more like med and lat slips, but I guess I was fishing. Any Ideas as to how I progress with therapy, I'm stumped now!!!
MRI has thrown a spanner in the works. :craig::craig:

col.

 

Col, do you have tried a plantar fascia groove ?

Maybe it's compression from the device when standing still and tension from walking causing the symptoms.

Maybe an idea to add some felt to the patients foot medial and lateral to the fascia, get him to stand up see how it feels.

 

Sorry, but I had to interject to make a point.

The Arena experts rendered an opinion that this doctor accepted and followed as to how to design an orthotic for this patient.

It provided temporary relief (NY Times article and other research) and now the symptoms are back.

So lets try surgery or some other ORF that we have no idea will help, like a groove, because we cannot admit our inability to provide this patient relief with our device.

Does that kind of sum it up?
What does this young doctor say about her champions and their BioPhizzics?

Perhaps she may consider a functional foot typing, a Foot Centring, forefoot contact training and the advice of others?

Dr Sha

 

Col.

What t.p release points have you been doing? and is your patient still using orthotic devices as well as you doing regular release work.

Everyone seems hell bent on orthotics therapy here despite the fact the guy has tried a whole heap of orthotics and orthotic mods to limited success.

The orthotics may well now be the source of the problem!! Needle quadratus plantae and proximal 1/3 of gastroc (TrP1) (if triggers are found obviously)

Gastoc and soleus stretching daily and heel raise for the recurvatum, ankle equinus and its influence of p/f tensile load.

Scott

 

5 year Hx of plantar Fasciitis?
Conservative Tx not helping?
Your patient needs a plantar fasciotomy.

Steve

 

Hey Scott, cheers for the advice, I have been releasing TPs proximal to achilles and distal to popliteal, I have also tried to release TPs on the plantar surface distal to calc insertions, I had used needles but this was some time ago so maybe I need to go back to this one.

He is using heel raises for the recurvatum, and I have got him to stop using the insoles and go to a basic sorbothane shock attenuating insoles to see if this does help. will keep you posted.

cheers

col.

 

Hi Michael, he did have a PF groove on his last insole which didnt sem to help, so I have not added onto this latest device, but maybe I should try your technique!!

col.

 

We have had this discussion, however, he is not keen on surgery at this point in time.

col.

 

"We have had this discussion, however, he is not keen on surgery at this point in time."

Not many patient's are.

Conservative Tx does not always work. We all get to a point where you either fix it or have the patient live with it and change their lifestyle.

Pretty Black and White.

As a surgeon I'm, of course, more inclined to suggest surgery. Some non surgical practitioners are intimidated a bit by surgical procedures and their attitude, which is often transmitted to their patient either directly or indirectly, reinforces the patient's hesitation to follow through with a surgery.

Fasciotomy is very successful and very quick healing. No need for your patient to suffer with this.

Steve