Plantar fasciitis, aka plantar fasciopathy, is one of the most common lower extremity complaints in

runners. Classic symptoms include pain with the first steps in the morning and after rest (poststatic
dyskinesia). The pain usually dissipates with activity. Chronic plantar fasciitis/fasciosis can be
debilitating. Reports suggest that over 90 percent of these types of cases resolve by 12 months.
However, this is difficult to accurately report due to the fact that patients may seek treatment from
many providers.

   In addition to “classic” plantar fasciitis, other conditions such as calcaneal stress fractures and
periostitis, plantar fascia and muscle ruptures, and local nerve entrapment can occur.

Case study

The patient is a 45-year-old female who presented in 2011 with heel pain bilaterally but much worse
pain in the right foot. The patient noted the pain was worse with her first steps in the morning and she
was unable to perform her normal physical activities including martial arts and running without pain.

   In 2004, the patient underwent tarsal tunnel releases and plantar fasciotomies bilaterally. These
procedures were extremely successful and she remained pain-free until 2010. Other than those
procedures, her past medical history was non-contributory. She was not taking any medications and
had no known drug allergies. The patient had rigid custom orthotic devices, which she found
uncomfortable partly due to the fact that the devices put pressure on the surgical scars.

   The physical examination revealed a flexible pes planus foot type and 0 degrees of ankle dorsiflexion.
The patient had pain with palpation of the plantar medial calcaneal tubercle of the right foot. The
Tinel’s sign was negative bilaterally.

   Over the first six months of treatment, the patient had two cortisone injections, received new, more
flexible custom orthotic devices and diligently emphasized stretching, icing and utilization of a night
splint with no success. At this point, shockwave therapy was administrated and three treatments with
the D-Actor 200 (Storz Medical) performed at 12.0 Hz with 2,000 shocks ranging between 3.0-3.4 bar.
Six weeks after shockwave therapy, the patient did not note any improvement.

  the patient was referred to a neurologist to test for tarsal tunnel syndrome and rule out
radiculopathy. The neurologist ruled out tarsal tunnel syndrome through nerve conduction
velocity/electromyography (NCV/EMG) examination and a subsequent MRI revealed that a thickened
plantar fascia was the only abnormal finding. Twelve weeks after shockwave treatment, the patient did
not note any improvement at all and she requested surgical intervention.

    an in-step fasciotomy was performed on the right heel 11 months after the initial presentation. The
post-op course was uneventful and at six weeks post-op, the patient began increasing her activity level
and the pain recurred at the same level as before the surgery.

   the patient was referred to another podiatrist for a second opinion. He referred her to a different
neurologist and nerve testing found evidence of entrapment of the lateral plantar nerve. The
neurologist placed the patient on gabapentin and she felt significant relief in her pain. The medication
dosage was titrated up(adjusted) but then the patient began experiencing some negative side effects.

   Three months later, the patient requested a second tarsal tunnel release. After undergoing this
procedure in November 2012, the patient experienced complete relief of pain. At her last visit six
months post-op, the patient was pain-free the majority of the time and was able to resume running
and martial arts at her desired level.