Case Presentation
A 25-year-old male with an athletic background presented with a primary complaint of right heel pain persisting for three weeks. He described the pain as "like walking on rocks," rating it between 5 and 7 on the Numeric Pain Scale (NPS). The discomfort was exacerbated by walking and prolonged standing during his job in warehouse distribution, significantly restricting his exercise routine and preventing him from running.
His height was 5'8", and he weighed 209 pounds, yielding a BMI of 31.8, classifying him as obese, yet he had a muscular physique. Blood pressure measured 144/78 mmHg, and pulse was bradycardic at 48 bpm, consistent with his athletic status. Gait assessment was grossly normal, without antalgic patterns or biomechanical compensations. His medical history was notable only for Crohn's disease, well-managed pharmacologically with Inflectra (infliximab-dyyb).
Clinical Evaluation and Diagnosis
On physical examination, he exhibited tenderness at the right medial calcaneal tubercle, with increased sensitivity along the plantar fascia. Enthesopathic changes were palpable at the plantar fascia insertion. Additionally, there was sacroiliac joint asymmetry with restriction in SI motion on orthopedic testing. Based on clinical findings and exclusion of other causes, a diagnosis of right plantar fasciitis with associated SI joint dysfunction was made.
Management and Outcomes
Initial conservative treatment included:
- Pelvic and lower extremity manipulation to correct joint dysfunction
- Low-level laser therapy (LLLT) targeting the right heel and plantar fascia
- Superficial dry needling for myofascial trigger points in the plantar fascia
- Manual therapy (Myofascial Disruption Technique) of the plantar fascia and associated enthesopathy
Home instructions included:
- Ice massage using a frozen water bottle
- Self-myofascial release using a golf ball
- Calf stretching and towel scrunch exercises to improve foot intrinsic muscle function
After two treatments spaced over two weeks, the patient reported full resolution of symptoms and was able to return to work and resume non-impact exercise. He was fitted with Foot Levelers XP3 Run custom orthotics, which initially caused mild discomfort during break-in. He followed the orthotics protocol, starting with two hours per day and progressing to full-day wear, with positive results.
Recurrence and Follow-Up
Approximately three months later, the patient experienced a recurrence of heel pain in the same area. Conservative care was resumed and included three additional treatments over a span of four weeks, utilizing the same protocol. He again achieved symptom resolution and returned to regular running. At a ninemonth follow-up visit for unrelated neck tightness, he reported no heel pain and maintained regular use of his Foot Levelers custom orthotics.
Discussion of Results
Plantar fasciitis is a degenerative, not inflammatory, condition affecting the origin of the plantar fascia at the medial calcaneal tubercle, often seen in active individuals and those with occupational standing demands. Obesity, altered biomechanics, and poor foot support are established risk factors.
In this case, SI joint dysfunction may have contributed to altered lower kinetic chain mechanics, increasing load on the plantar fascia. Chiropractic manipulation addressing the pelvis and lower extremities may help normalize biomechanical stresses.
Low-level laser therapy (LLLT) has been shown to reduce pain and improve function in plantar fasciitis. Superficial dry needling and myofascial release address soft tissue restrictions and may aid recovery by reducing fascial tension and promoting circulation.
Custom orthotics play a crucial role in redistributing plantar pressures and improving foot biomechanics. A systematic review supports the use of custom orthotics in reducing heel pain in plantar fasciitis patients.
Though Crohn's disease can be associated with extraintestinal manifestations like joint and soft tissue inflammation, no direct link to the patient's plantar fasciitis was identified in this case. However, systemic inflammatory factors may influence tissue healing, warranting further monitoring.
Conclusion
This case highlights the effectiveness of a multimodal conservative chiropractic approach in managing plantar fasciitis with associated SI dysfunction. Foot Levelers custom orthotics contributed to sustained recovery. The integration of manual therapy, physiologic modalities, and targeted rehabilitation provided a comprehensive solution, enabling the patient to return to full function.
Patient consent was obtained for the purposes of research, teaching, and training.