Case of the Week 7-2-12: Plantarfasci-"itis"

A former patient of mine came back when I started taking her insurance (self-referral) for foot pain.

History: The patient reports at least 1 year duration of severe right foot pain along the medial arch. She saw me twice this past winter, but was taken out of physical therapy for some traditional medicine by her new DPM. Since then, he has tried cortisone injections, steroid packs, which relieved the pain for 1 day only, custom orthotics, and that ridiculous boot they use for treatment at night. The patient is only better in the morning, but has Sx that are worse as the day progresses and getting up from sitting. She had a prescription from the DPM for iontophoresis, the only thing he apparently thinks PTs can do. I told her to keep that script and treated her under direct access as I do not have any modalities as my clinic other than heat/ice.

Key: F = functional (WNL), D=Dysfunctional, N = non-painful, P=Painful
ROM

Lumbar
flexion FN
extension DN, sev loss
sidegliding Left FN Right DN, mild loss
repeated extension in standing improves ROM, no change in R foot pain as a result

Ankle
Dorsiflexion Left FN Right DN, mild
Plantarflexion Left FN Right DN, mild

Myofascia: moderate restrictions in R gastroc/soleus, plantarfascia, R lumbar paraspinals, QL, psoas

Special tests: lower limb neurodynamic test positive and limited on R with sciatic, saphenous nerve bias


Treatment: 


Day 1: Psoas and QL release, IASTM to gastroc/soleus, bony contours of talus and calcaneus, neurodynamic tensioners for saphenous nerve. She was instructed on repeated extension in standing for HEP and saphenous tensioners in sitting.


Day 2: After a longer weekend, she reported 3 out of the 4 days were completely pain free. We reviewed HEP, and she was only performing the neurodynamics. She was reinstructed on lumbar extension in standing (already using a lumbar roll from previous PT, but not doing lumbar repeated motions). Tx as previous, but added IASTM to lumbar paraspinals to prep and P/A to TL and LS junctional zones. Repeated extension in standing improved to mod loss. Ankle mobility was also now FN.


Day 3: Pain free for 4 days until this morning when she got into her car. However, that was transient and is currently pain free.  Lumbar repeated extension in standing still has a mod loss. She was instructed on rising and sitting with sternum elevated and to hip hinge. Tx as previous two visits, reinstructed on neurodynamics for saphenous nerve.


Day 4: Completely pain free, will follow up in 1 week. Lumbar EIS is now normal.


Discussion: It seems after several cortisone injections, steroid packs, anti-inflammatories, ice, and a time-frame of 1 year, that perhaps this is not a simple inflammatory condition in the patient's plantarfascia. It was really a lumbar derangement with some neural container issues affecting the saphenous nerve, which chicken/egg mimic plantarfasciitis. Peripheral nerve involvement is also more likely to be involved after the inflammatory soup has ran it's course. Suspect neurodynamic dysfunction in chronic cases.