Introduction
Plantar heel pain is well-known in orthopedics, and usually caused by plantar fasciitis. Untreated plantar fasciitis can lead to chronic heel pain. We report a case of intractable heel pain that was diagnosed as plantar fasciitis, and was successfully treated with 4 injections of normal saline within the soleus.
Case presentation
A 43-year-old healthy male patient with right inferior heel pain for 5 years was diagnosed with plantar fasciitis at an orthopedic clinic. His heel pain was aggravated when taking the first barefoot steps in the morning. In addition, he complained of burning pain in his heel area while resting. He had been receiving conservative treatments, such as nonsteroidal anti-inflammatory drugs, physical therapy, extracorporeal shockwave treatment, and wearing custom-made orthotic shoes for plantar fasciitis. However, there was no pain improvement, and surgery was finally recommended, which he refused. Plain radiography revealed nonspecific findings.
Physical examination revealed tenderness of the right medial calcaneal tubercle region, and compared with the opposite side, there was severe tenderness over the medial flexor retinaculum and soleus regions near the soleus tendinous arch. Thus, we hypothesized that the tenderness point of the soleus was tibial nerve entrapment point(NEP), and the entrapped tibial nerve at the soleus tendinous arch stimulated the medial calcaneal nerve originating from the tibial nerve, which caused the chronic heel pain. He was diagnosed with tibial nerve entrapment syndrome within the soleus. As a therapeutic intervention, to release the tibial NEP within the soleus, 4 mL of normal saline was injected at approximately the point of proximal 1/4th of the lower leg—the most tender region—under ultrasound guidance. The injection was repeated at 1, 3, and 6 weeks after the first injection. Before the first treatment, the baseline Foot and Ankle Ability Measure–activities of daily living subscale (FAAM-A), numeric pain rating scale (NPRS), and percent pain intensity difference (PPID) scores were 52, 7, and 100 points, respectively. At 1-week follow-up after the first treatment, they improved to 65, 4, and 60 points, respectively, and further improved to 75, 1, and 20 points, respectively, at 6 months after the first injection (Figure 4). At 6 months, the patient reported comfort without wearing the custom-made orthotic shoes. He had no adverse effects.
Conclusion
This report is meaningful because it describes the case of intractable heel pain in a healthy adult male for 5 years that was diagnosed as plantar fasciitis, and was successfully treated with 4 injections of normal saline into the soleus. This case suggests the importance of detailed history and physical examination before initiating treatment. Furthermore, normal saline injection at NEP of the soleus could be considered in chronic unhealed plantar heel pain, including plantar fasciitis, to release the entrapped tibial nerve. |
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Fig 1. FAAM-A and NPRS scores improved by 13 and 3 points, respectively, 1 week after the first injection, and 23 and 6 points, respectively, 6 months after the first injection.
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