case study

pain management certificate

Plantar fasciitis

-Dr Harith Shahiran-

 Case study
• A 43 year old malay female came in with a chieft
complaint of right heel pain for the past 4 months.
She described the pain is pricking in nature and
felt worse especially at morning time and subsides
throughtout the day. She gives a pain score of 8/10
at morning time. Pain localises only at her heel
area with no referred pain that can be appreciated.
Over the past 4 months, she had been visited
several clinic for treatment, completed several
sessions of physiothery however she felt very little
improvement.
Physical examination
• o/e
• -Alert, full GCS, normal vital signs

• right foot examiantion

- no deformity seen
- able to dorseiflex/ plantarflex
- minimal pain felt during deep palpation at heel area
- moulder sign negative
ultrasound image

• hypoehcoic thickening (5.4mm)

of proximal plantar fascia
• no effusion noted

imaging : courtesy of google

management
• proceeded with plantar fasciits injetion
• 1mls trimiconolone + 4mls marcaine to increase the volume
• prior to injection, posterior tibial nerve block was done with5mls
lignocaine.
posterior tibial nerve block
1. solution: 5mls lignocaine
2. Spread the LA around the
posterior tibial nerve,
3. Wait around 5-10 minutes, test
if patient felt any pain, if no
then proceed with injection
injection technique

• I prefer short axis view for injection

• Two approaches for injection
• 1) Superficial injection to the
plantar fascia
• 2) Injection under fascia
- needle tip located in the
undersurface of the plantar fascia
insertional area
Short axis view
Follow up weeks
• patient symptoms improved a lot
• Pain score 0/10
• plantar fascia thickness reduce from 0.54mm to 0.24mm
Plantar fasciitis
• Degeneration of plantar fascia
leading to inflammatory reaction
• occur mostly due to the
biomechanical stress on plantar
fascia.
How to diagnose plantar fasciitis?
• diagnosis is based on patient history, risk factor and physcial
examination findings
• patient have heel pain and tightness after standing up from bad in the
morning or after they have been seated for a prolonged time
• heel pain would improve with ambulation but could intensify by days
end if the patient continues to walk or stand for a long time
does imaging help?
• ultrasound findings- proximal plantar fascia thickness greater than
4mm and area of hypoehcogenecity
• MRI is useful to access recalcitrant heel pain
• Subcalcaneal spur on lateral foot radiography does not support the
diagnosis of plantar fasciitis
differential diagnosis
Treatment and guideline