Severe Foot Pain in a Runner

Patient Profile:

A 36-year-old man complains of right foot pain of several months' duration that limits his abilityto run. He has been able to keep running by icing the foot and by stopping his running programfor a few days when the pain increases.The pain is worst when he arises in the morning-especially when he first puts his foot onthe floor. The pain diminishes with continued ambulation and recurs with exercise. When heruns, pain occurs when the heel strikes the ground and increases when he pushes off. He experiences no numbness or tingling.This morning he had severe foot pain 4 miles into his usual 7-mile run, in the middle of asignificant hill climb. He was unable to complete the run and walked home with a limp.The patient is in good health and has been running for about 10 years. He had a stress fracture in the calcaneus of the same foot 8 years earlier. Examination reveals tenderness on the plantar surface of the heel over the medial tubercle of the calcaneus (Figure 1). The pain is aggravated by dorsiflexion of the great toe and standing on the tips of the toes. The left foot is normal. The feet arenot pronated; in fact, the arches are high (pes cavus) (Figure 2). Tightness and weakness are noted in the gastrocnemius and soleus muscles. Neurologic examination reveals no sensory or motor deficit.

WHAT WOULD YOU DO NOW?

A.

Obtain a radiograph of the foot.

B.

Order a complete blood cell (CBC) count anduric acid level.

C.

Order nerve conduction studies.

D.

Start treatment; the diagnosis is evident.

THE CONSULTANT'S CHOICE

Choice D

is correct. This patient's history and thephysical findings are very characteristic of

plantar fasciitis.

The classic symptom is pain that begins with the first few steps in the morning. Patients sometimes describethe pain as feeling "like electricity" as soon as the foottouches the floor when they get out of bed. Reproductionof the pain by compression of the medial tubercle of thecalcaneus (see Figure 1) also points to the diagnosis.High-arched feet are predisposed to plantar fasciitis.Tightness of the gastrocnemius and soleus can occurwith a variety of lower leg problems, but when combinedwith the above signs, this clinches the diagnosis.A radiograph (choice A) would be indicated if astress fracture were suspected. However, the pain of astress fracture does not improve with ambulation. Someclinicians obtain a plain film in patients with plantar fasciitisto look for a heel spur. However, a search for heelspurs can cloud the issue. Plantar fasciitis is often calledheel spurs syndrome, but this is a misnomer. Between15% and 25% of the general population have asymptomaticheel spurs; conversely, many patients with plantar fasciitisdo not have a heel spur.1 Heel spurs play no part in thediagnosis of plantar fasciitis, nor does therapy for heelspurs have a role in its treatment.Nerve entrapment syndromes, such as the tarsaltunnel syndrome, produce burning pain, numbness, andtingling. This man does not complain of that type of pain;also, the results of his neurologic examination are normal. Thus, nerve conduction studies (choice C) are notneeded.Gout-or another type of inflammatory arthritis-forwhich a CBC count or uric acid level (choice B) would bean appropriate diagnostic test, is highly unlikely here.Gout in the foot usually involves the big toe.

WHAT WOULD YOU DO NOW?

A.

Prescribe a 10-day course of NSAIDs,relative rest, a stretching routine, and a splint orAce bandage at night to prevent plantar flexionduring sleep.

B.

Inject the foot with corticosteroids.

C.

Prescribe complete rest for 1 month.

D.

Refer the patient to an orthopedist.

THE CONSULTANT'S CHOICE

In most patients, NSAIDs, relative rest, a stretchingroutine, and prevention of plantar flexion during sleep(choice A) constitute the most effective treatment.NSAIDs will reduce the discomfort. They will alsoreduce inflammation-if any is present.Telling an active patient-especially a runner-torest (choice C) usually does not work. Relative rest is analternative such a patient is more likely to accept. Suggestbiking, swimming, or use of a step machine in place ofrunning, and inform the patient of the value of changingexercise routines.The pain of plantar fasciitis is caused by repetitivemicro-tears of the plantar fascia and collagen degenerationat the medial tubercle of the calcaneus. The microtearsundergo some healing overnight. Because thefoot assumes a dorsiflexed position during sleep, thehealing occurs in this position. As soon as weight bearingbegins the following morning, the plantar fascialengthens, micro-tears recur, and what little was gainedovernight is lost. Night splints that inhibit plantar flexionand produce healing in a neutral position decrease painon arising and facilitate the healing process. Nightsplints can be made or purchased from a supply house.For those patients who do not like the discomfort associated with night splints, an Ace bandage is an acceptablealternative.An appropriate stretching routine is also an importantpart of therapy for plantar fasciitis. Stretches such asthose shown in

Figure 3

can help loosen tight calf muscles.Stretching the plantar fascia by rolling a cold waterbottle with the sole of the foot is also helpful

(Figure 4).

Injections (choice B) are somewhat controversial inplantar fasciitis, and orthopedic referral (choice D) is bestreserved for recalcitrant cases. However, keep in mindthat in most patients, plantar fasciitis takes 6 to 18 monthsto heal.

²

Prompt initiation of treatment and faithful adherenceto the regimen can shorten the healing time.

OUTCOME OF THIS CASE

During the first week, the patient took NSAIDs(although not consistently), used a step machine insteadof running, and stretched before and after exercising.After 1 week, he purchased an Ace bandage and began touse it to hold his foot in a dorsiflexed position while heslept. He noticed immediate improvement and resumedlight running within a couple of days.

References:

REFERENCES:

1.

Singh D, Angel J, Bentley G, Trevino SG. Plantar fasciitis.

BMJ.

1997;315:172-175.

2.

Young C, Rutherford D, Niedfeld N. Treatment of plantar fasciitis.

Am FamPhysician.

2001;63:467-474, 477-478.