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Plantar Fascial Fat Pad Inflammation with tear in Plantar Fascia

Exit forum ID Forum Discussion Plantar Fascial Fat Pad Inflammation with tear in Plantar Fascia

This topic contains 8 replies, has 4 voices, and was last updated by   drjeff@barefootrehab.com February 17, 2020 at 6:56 pm.

Viewing 9 posts - 1 through 9 (of 9 total)
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  • #9029

    drjeff@barefootrehab.com

      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!

      #9030

      Seth Schultz, DC
      Participant

        Can you post her FastMap score please?

        The MRI from September, I’m assuming all of those findings are Left sided?

        #9034

        drjeff@barefootrehab.com

          I do not have a FastMap score for her.

          Yes, the MRI from September was for her left side.

          #9035

          Seth Schultz, DC
          Participant

            Given the significant findings on her MRI coupled with her tests all being close or above 90% on initial exam how would that shift the functional/structural and load management conversations for you?

            #9037

            Adam Holen D.C.

              At 70% overall improvement, mild adhesion left, did she increase her load since visit 28?
              She’s active 6 days/week which doesn’t leave much room for a healing environment. Any time she’s even standing the structures with reduced capacity are under load.
              If she continues to decline (increase symptoms/reduced overall progress) address load because she has 2 main options: dials WAY back on activity for the *chance* of tissue healing with continued treatment, or she entertains the idea of a surgical option.
              I’m not sure of the parameters for PF surgery (how much of a tear needs to be present), but with visits 30-40, the further along you go the more likely she’s reached MMI, as her functional runway gets smaller.
              As Seth alluded to, at any point have you asked about or has she mentioned any potential metabolic factors or psychosocial issues?

              #9039

              Andrew Wengert
              Participant

                To directly answer your question I do not know if that will heal on its own , but I am pretty sure it will not in its current load environment. With function this good, assuming the fast map comes back pointing toward structure and function, this is largely a load management case due to all the structural pathology.
                I would have a serious convo with the patient explaining that this is already really bad and can get even worse.
                Also because of the huge load management component, have you considered sole supports for her?
                Definitely get the fast map to determine if there is anything else that could be affecting her healing/symptoms as well.

                #9050

                drjeff@barefootrehab.com

                  I apologize for the delay gents!

                  a) Seth
                  – The conversation I’ve been having with her, particularly over latter portion of her case has been educating her on the shift from an adhesion removal issue to a load management one. I’ve been transparent with her that load management is essential in reducing strain on the Plantar Fascia and enabling the tissue to heal. I informed her that based on the severity of the tear, that the tissue could take a bit of time to heal. Especially since she has to load the foot with routine daily activities.

                  b) Adam
                  – Yes, at visit 29 she informed my assistant that she had increased her loading. She reported adding in bag work for 20 minutes, 20 minutes of exercise bike, abdominal exercises, and along with other exercises. She had been working out roughly 3 times per week. I again, educated her on how essential load management was in enabling the tissue to heal. I discussed with her how her change in percent improved and increase in symptoms was her body telling her that she was doing too much, too soon, and that the tissue was being aggravated as a result. She understood and has reduced her activity, which I am helping her to monitor. I have discussed the potential of the tissue not being able to fully heal on its own and the potential need for surgical intervention. She reported having moderate mental stress levels on her initial in-take form, but has not mentioned any psychological issues. She does have “upset stomach” issues that she has been addressing with dietary modifications. To the best of my recollection she has eliminated diary products and gluten.

                  c) Andrew
                  – Yes I agree with you and have had that conversation with her. It went about as positively as one could hope it would. To answer your other question, yes she was casted for orthotics by Dr. Chris at her third visit and has been using them since Dr. Chris transferred her case to me at her 12th visit. I will check FastMap as you and Seth recommended.

                  #9051

                  Seth Schultz, DC
                  Participant

                    Aside from any metabolic and psychological issues, her function is great but her structure is poor. For example, her FastMap after consult could have been 75 function/structure, 10 met, 15 psych. After the exam and seeing her tests come back close to 90% that would shift the 75 in the function/structure category to almost all structure. So something like 95 structure 5 function. With that data from the start, load management could be implemented very early in the case.

                    I also don’t want to take away from the fact that there are other issues in her foot besides the plantar fascia tear. She has mod-sev tendinopathy in the tib post which is an important stabilizer for the foot and ankle. It’s on the brink of ripping. She also has bone bruising of the calcaneus and tendinopathy of the achilles. With all of that in the picture what would be the next best steps for her? Surgery? Immobilization?

                    #9052

                    drjeff@barefootrehab.com

                      With all of that in the picture the next most logical step would be for her to consider a surgical consultation. Although she has experienced improvement under conservative care, her fairly quick regression in symptoms under that level increase in load is indicative that her tissue capacity is quite low. How you phrased the additional MRI findings in conjunction with the severity of her Plantar Fascia tear also illustrates her need for additional care.

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