A Case Of Foot Pain In The Weekend Warrior

HISTORY: A 61-year-old woman with only a past medical history of multiple sclerosis presents to the office with pain in the arch of her right foot. It has been present for approximately 10 months and now it has significantly impacted her ability to exercise. She is very active with activities including regular walking, multiple light sports, and stretching and yoga. Since initial presentation, the pain now increases dramatically as she increases time weightbearing on the right foot and is painful as she awakens in the morning. Previously tried treatments include Botox injections and an external nerve stimulator system BioNest. PHYSICAL EXAMINATION: Examination of the right lower limb revealed tenderness at the center of the arch of the right foot as well as the distal/medial calcaneus. The tenderness can also be traced into the dorsum of the foot and up the lateral calf. The calf itself has increased tone and the Achilles tendon is tight . Strength exam is only significant for 3/5 strength in the right EHL. When evaluating gait, she has a very prominent heel strike and her right lower extremity wobbles leading to her preference for assisting devices for ambulation. DIFFERENTIAL DIAGNOSIS: 1. Stress fracture 2. Plantar Fasciitis 3. Achilles tendinopathy 4. progression of MS TEST AND RESULTS: Xray Lumbar spine- Rotatory levoscoliosis - Diffuse mild to moderate spondylosis with multilevel degenerative discogenic disease FINAL WORKING DIAGNOSIS: Plantar Fasciitis with intensification secondary to radiculopathy TREATMENT AND OUTCOMES: 1. Physical therapy with specific treatment for both L5 distribution radiculopathy and plantar fascia as the patient preferred conservative treatment 2. MRI lumbar spine for the clinical radiculopathy which may be preventing resolution of the inflammation may require further intervention 3. X-ray of the right heel and EMG of the right lower limb if conservative treatment fails. 4. Heel cup and foot orthosis recommended and patient educated on use 5. Return to activity with a gradual return to sport protocol. Light activity after 2 weeks of dedicated physical therapy. increased weighted activity and exertional level after 4 weeks and activity without restriction after completion of therapy course. if worsening or failure to improve at any stage then the above escalation in care to be considered.