This topic contains 4 replies, has 2 voices, and was last updated by 
William Brady, DC March 29, 2018 at 1:36 pm.
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Andrew Wengert
53 year old female. Pain located at the proximal medial attachment of the plantar fascia. Patient rates pain an 8/10. Worse with first movement after rest, gets better, then gets bad after being on feet for 3 hours. Not being on feet is palliative.
Patient’s works 35 hours a week, standing for almost all of it. Patient is looking into modifying schedule so she can have a couple days off each week. Patient is also overweight.
Dorsiflexion was 3.5 inches.
PK Test was negative.
Lockout failed with 2 feet.
Adhesion found in FHL and FDL and Plantar foot.
We are six visits in with no symptomatic improvement. Dorsiflexion is up to 4.75 inches. I just sent a cast for orthotics, despite a lack of tibial torsion. My thought process being, she is in a high load environment, the orthotic is a load management tool that can help restore the load/capacity balance.
Questions:
Did I order the orthotic too soon/ too late?
Should I implement strength exercise even though symptoms have not improved?
Scott Glidden
The goal is to get her functioning and feeling better, and the functioning part seems to be coming along nicely. For someone who works on their feet all day I think you made the right call for them, as long as you continue to stress the importance of reducing adhesion for lasting results.
Adam Holen D.C.
Several points make me suspicious of something bigger than only adhesion going on: 8/10, local symptom, worst in morning-better-then sucks again, years of standing for work (assuming), 53, and overweight. So my initial thought is tendinopathy and adhesion. With functional improvement yet no symptomatic improvement, another tendinopathy point (or at least something else besides adhesion). So I’d be more curious about seeing this on imaging to grade severity and confirm. Could help with her request for hours off. High load (hours standing/weight) may be beneficial to have orthotics at this stage, but my concern would be putting a (still) dysfunctional foot into a good orthotic.
Keith Puri, DC
I agree with Adam… First order hx data points towards additional pathology; namely plantar fasciopathy. If the patient has reduced load to the local tissues and you have treated the relevant adhesions in the plantar foot, ankle and lower leg, I suggest treating the degenerative fascia directly with IAR at it’s insertion onto the medical aspect of the calcaneal tuberosity if you haven’t done so already. As with all degenative tendinopathies the only reliable treatment is to load the crap out of it with exercise to strengthen the tissue. Micheal Rathleff has proposed a ‘new’ exercise for PF which involves unilateral heel raises with a towel under the toes to further load the fascia. I’ve been using this exercise with my PF cases with favorable results.
That said, you can clear out all her relevant adhesions and she can progressively load the PF with exercise but she needs to reduce the amount of time she stands. If standing for greater than 3 hours provokes her pain she has to sit and rest before that time lapes. An anti-fatigue mat could help if she does not move much while standing. if you haven’t had the dreaded conversation about her weight I would do so.
Lastly, if she fails to improve despite reducing her load, treating her adhesions/degenerative tissue and adding progressive exercise I would rule out a Baxter’s neuropathy.
Plantar fasciitis – important new research by Michael Rathleff
William Brady, DC
Degeneration may be so severe that the tissue is torn. Imaging is the next step. If severely torn and she is not healing, immobilization or surgery may be necessary.
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