How to deal with refractory plantar fasciitis despite trying all possible treatments?
Good afternoon Doctor
I have seen several cases of patients diagnosed as having plantar fasciitis who had severe pain bilaterally in the soles of the feet with mostly weight bearing who ended up having tarsal tunnel syndrome. The symptom of burning is consistent with a dysesthesia involving nerve root compression through the tarsal tunnel
So perhaps, one suggestion I would make is to consider that in the differential and have a neurologist do a very good sensory and motor assessment of the foot with an eye toward ordering an EMG/NCV if the exam is consistent with possible TTS.
I would caution on the use of solumedrol since this can be tricky. Steroids actually can cause destruction of cartilaginous tissue due to direct toxic effects and repair of this type of damage occurs very slowly while during the interim the structural and functional integrity of the tendons, ligaments, or fascia in this case is reduced thus causing other satellite structures to be overtaxed in what they need to do in terms of performance and stabilization function.
Have you tried medications for the neuropathic symptoms such as gabapentin, pregabalin, nortriptyline, or mexiletine? Careful with mexiletine since it is associated with cardiac arrhythmias but it is a very good antineuropathic drug when all the rest of failed. Sometimes doses have to be pushed in the high normal ranges before they are effective.
Also you mention that your fascial thickness is 5-6 mm. Have you performed some type of diagnostic study because I have sent patients with neuropathic pains in the foot suspected as having plantar fasciitis vs. nerve entrapments for ultrasounds as well as MRI's look for mass lesions which are sometimes either palpable or visible especially when talking about a fibromatosis. Do you have plantar nodules of any type? If not then, perhaps you have not got the fibromatosis part of this problem.
In your case, I would only look to do any dissolution of the plantar fascia ONLY IF you can pretty much prove that you are suffering from a FIBROMATOSIS. In that case your options would be radiation therapy, cryotherapy (high rate of recrudescence), collagenase clostridium histolyticum (not sure if this has passed FDA approval yet), surgical removal of the nodules (chance of recrudescence as well as additional postsurgical scarring).
I have also had some modest success using ULTRASOUND/DIATHERMY treatments on patients. Treatments would be 2-3x/week, escalating timed sessions of the diathermy and Ultrasound starting from 5min. and titrating to 10 min. for the Ultrasound. Diathermy would be held at 5 min. pre-Ultrasound treatment. This regimen is done for 6 weeks.
I would also suggest foot exercises as a conservative adjunct measure in order to cool down the fasciitis if you haven't tried those. Have you already done things like foot towel crunches, heel raises, and independent dorsi and plantarflexion exercises of each toe which can strengthen foot muscles thereby reducing load upon the plantar fascia.
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