This topic contains 3 replies, has 2 voices, and was last updated by Christopher Stepien July 26, 2016 at 10:54 am.
July 20, 2016 at 5:30 am #2096
45 year old male. Recently started a house painting business. Spends a lot of time on ladders. He came for bilateral foot pain. 1st movement after rest is provocative then gets better as he loads it more. Data point tendinosis. The location is what is confusing me. Initially the complaint was deep to the fat pad, in the flexor digitorum brevis attachment region on the distal calcaneus. After two IAR treatments that symptom has reduced and now he has pain on the medial, posterior, and lateral side of the calcaneus.
Dorsiflexion is 6.5 bilaterally. Mild calf “stretch”. PK test reveals full range of motion with no symptom. Patient passes lockout test on both and single leg. Visualization of patient when standing reveals a fallen arch bilaterally. Second toe does not line up with shaft of tibia. I have mentioned the possibility of the need for an orthotic.
My question is about the current location of his pain. Could this be a superficial nerve entrapment?July 20, 2016 at 6:56 am #1947
How did you get “tendinosis” from “bilateral foot pain”? Was it at the plantar fascia insertion point? I assume yes. That’s possible, but Bill always says “Nothing degenerates alone”. And your DF + PK Tests are passing with flying colors.
45 years is starting to get into OA age. OA can also improve with activity like tendinosis or fasciosis. It sounds like he’s grossly overloading his feet in a way that was quick/abrupt when he started this business. The possibility of bilateral superficial nerve entrapment is not very likely. “Bilateralness” often indicates a common denominator – the spine, or excessive load.
I imagine the plan moving forward would be to continue to palpate and treat adhesion (since you’ve already helped him improve), load management with orthotics and potentially standing on different parts of the foot (heel vs. mid-foot), and strengthening with the lock-out test.
Someone else check my conclusions please. Good stuff Andy!July 21, 2016 at 12:21 pm #2121
I left out palpatory findings.
When the Plantar Fascia was tensioned. There were minimal symptoms with the instrument and my hands. When slackened, his symptom was more intense. This made me believe it was more of a tendinosis of one of the deeper structures vs. a fasciosis.
I am in agreement with you that the load is likely too much too soon and I have instructed him to try to load a different part of the foot when on ladders.
Thanks for the feedback Dr. ChrisJuly 26, 2016 at 10:54 am #2122
Your selective tensioning makes sense to me Andy.
Sounds like you have a good plan.
THe soft tissue degeneration should continue to get better with treatment.
To the extent you plateau, the data would likely point to bony degeneration and hitting your ceiling. Keep strengthening and treating, then report back?
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