This topic contains 8 replies, has 4 voices, and was last updated by email@example.com February 17, 2020 at 6:56 pm.
February 10, 2020 at 3:29 pm #9029
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
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)
Rec: 6 days/week exercise
Occ: Public Relations
Bilateral Anterior Hip pain for 2 years, sometimes cannot get out of bed – 3 to 4 mornings per week
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)
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
R: Full, mild pull distal quad
L: Full, mild pull distal quad
R: 90 deg (100%), mild pull post thigh, DF: No change
L: 80 deg (88%), moderate pull posterior-medial thigh, DF: No change
R: 5.25” (88%), mild pulling medial calf, Selective Tension: 1st toe
L: 5.25” (88%), mild pull anterior ankle, Selective Tension: 1st toe
Full bilaterally, no symptoms
R: Heel fault, mild knee adduction (no sx)
L: Heel fault, moderate knee adduction (no sx)
R: single- 5.25” (95%), no sx
L: single- 5.25” (95%), mild pain left fat pad
R: 1 finger (92%), mild pain anterior lateral hip
L: ¼ finger (95%), mild pain anterior lateral hip
R: 14”, slight left anterior hip pain
L: 12” (100%), mild pain right anterior hip
Bilateral FHL: significant
Left PF: Mod-Sig
Left P Zone: Sig
Left M Zone: Sig
Left A Zone: Mild-Mod
Left Lat. Zone: Mod
Right Achilles – 20% thicker than Left Achilles
19 deg Scoliosis
Bilateral Femoral Torsion
Right Toe out
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
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)
LD: bag work 20 mins, bike 20 mins, ab workout, etc. 3 times per week
Left: 5.75”, moderate tightness in calf
Did not re-test
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!February 10, 2020 at 5:10 pm #9030
Seth Schultz, DCParticipant
Can you post her FastMap score please?
The MRI from September, I’m assuming all of those findings are Left sided?February 11, 2020 at 11:43 am #9034
I do not have a FastMap score for her.
Yes, the MRI from September was for her left side.February 11, 2020 at 12:07 pm #9035
Seth Schultz, DCParticipant
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?February 11, 2020 at 4:27 pm #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?February 12, 2020 at 12:17 pm #9039
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.February 17, 2020 at 1:14 pm #9050
I apologize for the delay gents!
– 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.
– 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.
– 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.February 17, 2020 at 3:20 pm #9051
Seth Schultz, DCParticipant
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?February 17, 2020 at 6:56 pm #9052
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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