Foot Injury - Runner

TITLE: Foot Injury – Runner HISTORY: A 63-year-old female runner presents to the clinic complaining of progressively worsening left sided burning heel pain for 4-6 weeks. Pain is in the bottom of her heel and medial foot, worse with movements, and improves with rest. Flexeril and Gabapentin for her fibromyalgia, ice, and topical NSAIDs all did not help. Pain is constant throughout the day and not necessarily worse in the morning. No history of direct trauma, diabetes, fall, swelling, instability, ecchymosis, overuse, back pain, weakness, or numbness. PHYSICAL EXAMINATION:Left ankle/foot-Mild Pes cavus, with no obvious swelling, bruise, or deformity. -There was diffuse tenderness over the calcaneus, plantar fascia origin, base of the fifth metatarsal, peroneal tendons, and Achilles tendon. -Thompson test: negative-Calcaneal squeeze: positive-Single leg raise: able to perform DIFFERENTIAL DIAGNOSIS: 1. Plantar fasciitis2. Medial Plantar nerve entrapment 3. Peroneal tendonitis4. Lumbar radiculopathy5. Achilles tendonitis TEST AND RESULTS:Left ankle X-ray in 3 views: Small calcification over the Achilles insertion but otherwise unremarkable. US: evidence of plantar fasciitis, insertional Achilles tendinopathy, peroneal tendonitis with possible longitudinal split tear FINAL WORKING DIAGNOSIS: Medial Plantar neuropathy TREATMENT AND OUTCOMES: Patient had a complex picture with multiple pathology and pain generators identified on exam initially. Diagnostic tibial nerve block with Lidocaine was performed with complete resolution of her pain for 1 week.Given her response, an USG Medial Plantar nerve hydro-dissection was performed using Lidocaine and D5W at the 2 week follow up, and the patient had experienced complete resolution of her pain. Patient still had no further pain upon 2 months follow up. This is a case where despite multiple abnormal findings were identified, there was one primary pain generator explaining patient’s main symptom.