This author discusses the need for additional imaging when a 55-year-old patient complained of worsening pain after getting extracorporeal shockwave therapy (ESWT) for plantar fasciitis and flexor hallucis longus tendonitis. 

A 55-year-old female presented with a complaint of left heel pain for the past nine months. The patient likes to dance but is unable to do so without significant pain. She had sought care from other podiatrists prior to her first visit with me. Past treatment included three cortisone injections, a controlled ankle motion (CAM) walker for two weeks, a night splint, over-the-counter and custom orthotic devices, physical therapy and different shoes. All the prior treatments were ineffective but she felt best during the two weeks she was immobile.

The patient has a non-contributory past medical history. She is not currently taking any medications and denies any past relevant surgical or social history. She has more pain at first steps but the pain also increases as the day and activities progress. The physical exam reveals a normal neurovascular status. There is pain with palpation of the medial plantar calcaneal tubercle area and she also has pain along the flexor hallucis longus tendon in the arch. There is palpable thickening of the fascia near the attachment but no palpable defect. The calcaneal squeeze test is negative for a possible stress fracture. A gait exam reveals an antalgic gait with a rectus foot type. Radiographs do not reveal any signs of a fracture or calcaneal spur.

At the initial visit, I diagnosed the patient with plantar fasciitis and flexor hallucis longus tendonitis. I performed focused extracorporeal shockwave therapy (ESWT) using the Duolith device (Storz Medical) with 2,000 shocks delivered to the medial plantar calcaneal tubercle area at 0.25 MJ/mm². She received radial ESWT with 3,000 shocks using the D-Actor 200 (Storz Medical) at 4.0 Bar and 10 Hz. The patient had three treatments spaced two weeks apart.

Shockwave is an effective treatment for plantar fasciitis and the review article by Schmitz and colleagues provides an excellent overview of how the treatment works.¹ More specifically, a recent randomized multicenter study found that nearly 70 percent of patients who received three treatments with the aforementioned Duolith device had a significant reduction of heel pain according to the VAS scale in comparison to 34.5 percent of those in the placebo group at one-year follow-up.

Partial Tears Of The Plantar Fascia: What You Should Know

The patient was immobile in a CAM walker boot but continued to experience pain. According to the literature, the maximum effectiveness of ESWT may not be apparent until 12 to 20 weeks after treatment.¹ While it is not unusual to see a lack of significant improvement during the treatment phase with ESWT, the patient felt her foot was getting worse at the third visit. At this time, magnetic resonance imaging (MRI) revealed a partial tear of the plantar fascia.

I was co-author of a paper on plantar fascia tears with Saxena.³ In our study, we found it took an average of nine weeks to return to activity after a fascial tear and we also found partial tears take longer to heal than complete tears. The two athletes in our study who took the longest to return to activity (up to a year) had partial tears while one athlete was back to full activity three weeks after a complete rupture. The treatment protocol we outlined in the paper includes immobilization in a boot with offloading if walking in the boot is painful. The offloading period is typically one to three weeks. Patients use the boot for another one to three weeks with subsequent strengthening and other treatments including OTC or custom orthotic devices along with ESWT.

The aforementioned patient progressed to being out of the CAM walker and recently began physical therapy aimed at foot strengthening and improving range of motion and proprioception. I add proprioceptive exercises and foot strengthening to almost all my patients’ treatment plans. In regard to patient education, explain to patients that a simple way for them to add proprioceptive training is to balance on one foot when they brush their teeth twice a day. When it becomes easier for patients, have them close their eyes to add more a challenge. Additionally, I recommend ice, the wall stretch, arch stretch and taping if they improve the symptoms. I advised holding the wall stretch for 30 seconds with five repetitions three different times during the day. The arch stretch depicted in the photo at right has been proven in two studies to be effective in helping to treat plantar fasciitis.^3,4

In Conclusion

It is important to understand that not all heel pain is plantar fasciitis. Always keep an open mind during your treatment phase. If patients are not improving as expected, then reevaluate your diagnosis and consider further testing such as MRI.

Dr. Fullem is in private practice at Elite Sports Podiatry in Clearwater, Fla. He published the book, The Runner’s Guide to Healthy Feet and Ankles, in 2016.

References

1. Schmitz C, Csaszar NBM, Rompe JD, et al. Treatment of chronic plantar facsiopathy with extracorporeal shock waves (review). J Orthop Surg Res. 2013; 8:31.

2. Gollwitzer H, Saxena A, DiDomenico LA, et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study. J Bone Joint Surg Am. 2015; 97(9):701–8.

3. Saxena A, Fullem B. Plantar fascia ruptures in athletes. Am J Sports Med. 2004; 32(3):662–5.

4. Digiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006;88(8):1775-81.