Plantar Fascial Fat Pad Inflammation with tear in Plantar Fascia

Age: 29
Sex: F
Sx Loc: 1) Left Plantar Fascia at insertion on calcaneus (fat pad), 2) Right Achilles
Sx Q: Aching, Throbbing, Burning, Stretching
Sx I: W: 8 out 10, at rest: 0 out of 10
P+:
Primary: Standing on left heel= 9 out of 10 pain, Exercise- running 1 minute, elliptical – 5 minutes, Stretching- 30 minutes/cooking dinner
1st thing in morning: 10 mins, limps daily
Secondary: Muay Thai (skipping rope), running (immediate), standing (mild), warming up with execise
P-: hot water (bucket), massage, stretching

Onset: Foot: April 2019- gradual, Achilles: September 2018 (on and off)
Course: worsening
Rec: 6 days/week exercise
Occ: Public Relations

Secondary:
Bilateral Anterior Hip pain for 2 years, sometimes cannot get out of bed – 3 to 4 mornings per week
Q: Ache
I: 10 out of 10 (can feel like they’re smay give out)
P+: biking, Muay Thai, running 3 miles (feels that night or next day, can linger for 3 days)
P-: rest

MRI 9/18/2019
Severe active plantar fasciitis w/ approx. 0.8 x 0.5 cm intrasubstance/interstitial tear
Moderate stress edema in adjacent calcaneus
Mild strain of muscle fibers of flexor digitorum brevis
Mild Achilles tendinosis (no tear of Achilles)
Moderate to Severe insertional tendinosis of Posterior Tibialis tendon

Exam

PKF
R: Full
L: Full
KFHE
R: Full, mild pull distal quad
L: Full, mild pull distal quad
SLR
R: 90 deg (100%), mild pull post thigh, DF: No change
L: 80 deg (88%), moderate pull posterior-medial thigh, DF: No change
Dorsiflexion
R: 5.25” (88%), mild pulling medial calf, Selective Tension: 1st toe
L: 5.25” (88%), mild pull anterior ankle, Selective Tension: 1st toe
PK
Full bilaterally, no symptoms
Lunge
R: Heel fault, mild knee adduction (no sx)
L: Heel fault, moderate knee adduction (no sx)
Lockout
R: single- 5.25” (95%), no sx
L: single- 5.25” (95%), mild pain left fat pad

*For Hips
SHF
R: 1 finger (92%), mild pain anterior lateral hip
L: ¼ finger (95%), mild pain anterior lateral hip
KHE
R: 14”, slight left anterior hip pain
L: 12” (100%), mild pain right anterior hip

Palpation
Bilateral FHL: significant
Left PF: Mod-Sig
Left P Zone: Sig
Left M Zone: Sig
Left A Zone: Mild-Mod
Left Lat. Zone: Mod

Relevant findings:
Right Achilles – 20% thicker than Left Achilles
19 deg Scoliosis
Standing Posture
Bilateral Femoral Torsion
Right Toe out

Dx
Severe plantar fasciitis with tear and stress edema at insertion
Left Adhesion (50-75%): Calf, Left Hamstring, Bilateral Hip
Mild Left Achilles tendinosis
Moderate to severe tendinosis of Left Tibialis Posterior
Overload

Tx:
After 29 treatments (3 of which are maintenance) percent improvement was reported at 35-40%, with VRS at 6 out of 10. This was a worsening of symptoms from visit 28 at which she was 70% improved overall, with a VRS at 3 out of 10. She has been at 70% improvement since visit 26.

Visit 29 (two weeks after visit 28):
Lx: Left plantar fascia (fat pad)
P+: Constant
LD: bag work 20 mins, bike 20 mins, ab workout, etc. 3 times per week

Pre-Test
Left: 5.75”, moderate tightness in calf
Post-Test
Did not re-test
Tx
Moderate adhesion over left plantar fascia fat pad
Medial Zone, Posterior Zone, 1st MTP joint capsule were mild

Based on the size of the tear in the patients left Plantar Fascia, is this something that could reasonably be expected to heal on its own with proper load management?

Any other input is welcomed/appreciated.

Thank you in advance!