Sep 2, 2013

Case of The Week: Bilateral Plantar Fasciosis

Today's post is centered around a patient that I have been working with lately. This athlete is a sophomore collegiate runner that competes in middle distance running events.


This patient is now a 19 year old male that began running in 4th grade. He was in a running club affiliated with his grade school and was soon running around 160miles a year. He began to suffer minor injuries during middle school and somebody had prescribed him orthotics. He struggled with stress fractures, hip pain, and plantar fascia pain all through middle school. Despite these issues, he still managed to run a 4:43 Mile as an 8th grader.

Throughout high school he continued to struggle with injuries such as hamstring strains/tendonosis, spinal stenosis and low back pain, chronic ankle instability and piriformis issues. He also struggled with plantar fasciitis/osis during this time as well.

Once this athlete got to college he tried to transition to minimalist footwear in attempt to "correct" his heel strike. He did not suffer at all until halfway through his first cross-country season when he had a week long flare up of pain that was similar to his previous plantar fasciitis/osis. He was fine again until the beginning of his first indoor track season. The pain became unrelenting despite being prescribed new orthotics and undergoing an expensive shockwave therapy procedure. The patient decided to just cross train and rest for the remainder of his freshman year as a collegiate runner. 

This is where I entered the picture and had a few small conversations with this athlete regarding his plantar pain and I gave him a few exercises to perform on his own such as a self-mulligan mobilization with movement technique for ankle dorsiflexion and repeated end-range plantar flexion prior to runs. The patient used these few exercises all summer long until he returned for his sophomore year with good results but was not completely pain free.

I heard that he was still struggling with his plantar pain and offered to help him with a proper evaluation and treatment plan.


In my initial evaluation I found that the patient was limited in the 5-inch wall/ankle mobility test. He was limited by about 2.5-3 inches bilaterally indicating a loss of ankle dorsiflexion. He was limited with tibial IR on the left using the seated tibial IR test from the Selective Functional Movement Assessment (SFMA) breakouts and his passive hip IR on the left was limited as well.

I also found this patient to be limited in multi-segmental rotation to the right (dysfunctional non-painful) which I attributed to poor hip and tibial internal rotation. I am not super familiar with the SFMA breakouts so I can't be certain until I attend the course in St. Louis this upcoming October (very excited).

I also evaluated the patients running mechanics/gait and found it to be adequate and not a contributing factor to his injury. We all can tweak minor things and become more efficient obviously but this wasn't the source of his plantar pain.


Based on these findings I decided that I needed to address a few issues:
  • Limited ankle dorsiflexion (bilaterally)
  • Limited tibial internal rotation ( L > R )
  • Limited hip internal rotation ( L > R)
To work on these I used light IASTM during three separate visits to these tissue patterns for no more than 2-3 minutes each:
  • lateral thigh
  • anterior ankle/talus
  • posterior/lateral lower patterns
  • medial tibial pattern & plantar fascia
I then instructed and performed these few exercises:

I then gave the patient/athlete one of my Edge Mobility Bands to borrow and instructed him on turning the three different exercises into his home-exercise program (HEP). He was instructed to perform these for 1 set of 10 reps once an hour.

He has been very compliant and after three visits to me he has been able to increase training intensity and volume with a significantly decreased level of pain. The patient is still dysfunctional when it comes to the 5-inch wall/ankle mobility test but is within an inch prior to warm up/IASTM or manual therapy.
His multi-segmental rotation to the right is slightly dysfunctional prior to IASTM/manual therapy and becomes functional afterwards. 

This case highlights that chronic pain and dysfunctions do not require chronic treatments to address. This patient didn't/doesn't need orthotics, gait retraining, or cross-training. The patient needed to move more with better movement patterns. I hope for the patient to reach the wall and for his pain to totally cease within the next week or two. I will post updates after upcoming follow-ups with the patient as well.


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