David D. Juehring, D.C., D.A.C.R.B.*
management and treatment comprise the ongoing interplay of the patient's
subjective complaints and objective findings. These components should be
continually monitored to follow the progression of symptoms needed to arrive at
a flexible and evolving working diagnosis. In the case discussed here, the
initial findings led to the working diagnosis of plantar
fasciitis. After a short course of treatment, the findings quickly changed to
the potentially serious diagnosis of osteomyelitis, cellulitis,or both. Based on
bone scan findings, a course of treatment was prescribed for the cellulitis that
led to resolution of symptoms. On resolution, the patient's initial symptoms
again were addressed, and the appropriate plantar fasciitis treatment protocols
were resumed. Diagnosis and treatment of plantar fasciitis, along with the
utility of bone scans, are also discussed. This case report 'supports the idea
that even a relatively simple case needs constant monitoring of the patient's
response to ensure proper care.
Chiropractors are faced with
numerous decisions and complicating factors in many clinical cases, even the
relatively simple ones. Constant monitoring and flexibility in terms of
differential diagnosis and treatment are a must. Even a Simple, benign
presenting condition deserves the chiropractor's utmost respect and knowledge to
ensure the best possible care.
fasciitis is a regular condition seen by the chiropractic physician. Various
passive and active treatments are often used to address presenting symptoms as
well as biomechanical concerns relating to correction of the condition. [1-7] The
general course of symptomatic relief with passive means (e.g., ice, electric
muscle stimulation, ultrasound) is used as part of the management program. [4, 6-8]
Once there is a reduction of symptoms and a particular modality has succeeded,
active therapy can be focused on the biomechanical alterations involving the
proper motioning of the ankle and foot articulations, along with the global
activity of the involved leg. [2, 4, 5, 7]
29-yr-old woman treated conservatively for 1 week using the above protocols had
no response to the initial symptom-reduction phase of her plan. This article
details the change in her working diagnosis as a result of her subjective
reports and changing objective findings. The changes in the working diagnosis
resulted in advanced diagnostic testing to determine the pathology, which was
used in selecting the most appropriate and effective therapeutic route. The
results of the advanced diagnostic testing and treatment led to the ultimate
diagnosis of cellulitis. Cellulitis is an infection of the skin and subcutaneous
soft tissue, superficial to the deep fascia, caused by organisms such as
staphylococci or streptococci. [9, 10] The portal of entry is generally a break in
 A review of Medline (1976 through July 1998) found no literature
suggesting biomechanical or myofascial dysfunction as an etiology for cellulitis.
On successful treatment of the cellulitis, the initial plantar fasciitis
treatment protocol resumed, with resolution of symptoms.
A 29-yr-old female
day-care worker developed insidious mild intermittent right foot and medial
plantar arch pain of approximately 1 week's
duration. She stated she had not had any current trauma to the involved area,
and described the pain and discomfort as a dull, achy sensation. She stated she
did not have any change in activities or changes in footwear over the previous
week. Walking without footwear exacerbated the symptoms within the arch, whereas
nonweight bearing relieved her symptoms. Approximately 6 months earlier, she had
fractured the right proximal phalanx of her first toe. A fracture of the distal
aspect of the proximal first phalanx was noted on the initial radiograph, along
with a central subchon-cyst in the head of the first metatarsal and
osteophytosis the first metatarsophalangeal (MP) joint, both indicative of degenerative
joint disease of the MP joint (Fig. 1). She reported no residual symptoms or
complications since approximately 6 to 8 weeks after the trauma. In the review
of her past history, she said she did not have any relevant ankle or foot
examination was performed on the right mid- and forefoot. No discoloration or
visual swelling was present on her medial longitudinal arch or first MP joint.
Palpatory findings revealed tenderness localized to the plantar surface of the distal
first metatarsal head, along with the entire medial longitudinal plantar
fascia. Active and passive ranges of motion of her ankle were compared
bilaterally for plantar flexion, dorsi-inversion, and eversion, with all
measurements appearing equal bilaterally. Decreased motion was present on
dorsiflexion of the right first MP joint by approximately 10° to 15° using
bilateral comparison. With dorsiflexion overpressure of this joint, she reported
pain and tenderness to the plantar surface of the first MP joint and medial
longitudinal plantar fascia. No gross abnormalities were detected on visual
examination of her gait. For static evaluation, no excessive pronation was
detected. At the end of the examination, a working diagnosis of right foot mild
plantar fasciitis secondary to first MP joint osteoarthritis was made.
of the patient's work schedule, I recommended that icing the involved structures
for approximately 15 minutes four or five times periodically throughout the day
at home with minimal weight bearing would yield optimal symptomatic relief. I
explained that this approach would be successful at reducing any possible
irritation that was occurring and would need to be performed in this acute stage before active corrective measures could be
implemented. The patient was scheduled for a re-evaluation at approximately 7
days after the initial examination to monitor her condition and update the
On re-evaluation, the
patient reported that the pain had escalated in intensity and had become
constant. It had begun to awaken her throughout the night, and she was unable to
find any positional relief. She stated that icing
had no effect on her symptoms despite reported high compliance of icing three or
four times per day. She also stated that the pain had begun to localize to the
plantar surface of her first MP joint.
gait was altered to minimize pain on right forefoot dorsiflexion. Over the
medial and plantar surface over the first MP joint surface appeared a red,
raised discoloration approximately 2 cm in diameter. The patient reported
intense localized pain on light palpation of the involved lesion. There was a
noticeable elevation in skin temperature at the lesion site. Generalized
dorsiflexion and plantar flexion, along with compression and distraction of the
first MP joint, resulted in exacerbation of symptoms.
Re-examination of the involved foot resulted in the working diagnosis being changed to
cellulitis, postfracture os- or both; this led to the decision for further
Radiographs of the right foot
using anteroposterior, oblique, and lateral projections were taken to rule out
osteomyelitis. The healing fracture of the proximal first phalanx of the right
foot was noted, along with metatarsal head soft-tissue swelling (Fig. 2).
Measurement of the first metatarsal subchondral cyst secondary to degenerative
joint disease revealed no visible interval change from previous radiographs. No
other bony or joint abnormalities were noted. The decision was made to order a
three-phase radionuclide skeletal scintigraphy or bone scan to rule out
osteomyelitis or cellulitis.
bone scan, the patient was imaged multiple times at three distinct time
intervals or phases after an injection of Tc- MDP.
During phases one and two of the scan, the
plantar aspect of the right foot revealed increased radionuclide uptake (Figs. 3
and 4). In the third and final phase of the bone scan, uptake was detected at
two distinct sites on the right foot (Fig. 5). Both sites were localized to the
dorsal aspect of the foot, focusing on the first MP
joint and the distal region of the proximal first phalanx (Fig. 6). Given the
patient's past fracture and first MP degenerative joint disease, along with the
anatomic proximity to the lesion in question, there was still difficulty in
distinguishing between osteomyelitis and cellulitis.
after the scan, the patient was referred to a medical physician for concurrent
care. Per the physician's examination, review of previous findings, and
interpretation of the bone scan, osteomyelitis or cellulitis was still in
question. Treatment for osteomyelitis would have consisted of a 7-week course of
intravenous antibiotic therapy. This option was declined by the patient because
she was nursing a baby; she decided to follow a 10-day course of amoxicillin for
the cellulitis. At the 3-week follow-up visit, no visual remnants were detected
involving the medial and plantar surface of the first metatarsal region. The
patient's gait appeared normal, with total reduction of symptoms to the
first MP joint. Mild arch pain persisted. At
approximately 7 weeks after the initial examination, the patient reported no
complicating or residual factors of the lesion site.
presentation of this patient led to a working diagnosis of plantar fasciitis.
Given the patient's increase in intensity of arch pain on first MP joint
dorsiflexion,  nontraumatic onset,  aggravation of symptoms during gait, and
reduction of symptoms during non-weightbearing activities, the initial diagnosis
and consequent treatment were merited. Even though the patient did not have
classic anterior medial heel pain, [6, 7, 13]
I believed that this presentation of
medial longitudinal arch pain and plantar surface first metatarsal head pain
merited the working diagnosis. [6, 14] Various diagnoses at the initial presentation
were considered, with specific attention to midfoot and hindfoot fixations,
along with the possibility of excessive pronation. Through chiropractic
evaluations, fixation pain patterns of the suspected midfoot and hindfoot joints
were unremarkable. The osteoarthritis of the first MP joint was not considered a
source of symptomatology because of the low correlation between radiographic
findings and patient complaints. Tarsal tunnel syndrome was quickly ruled
out because of the reported lack of numbness or tingling sensations, combined
with the absence of pain at night. [7, 13] No x-ray or laboratory studies were
clinically merited because of the relatively benign initial working diagnosis.
A course of
passive therapy was initiated with this working diagnosis. Because of scheduling
difficulties and choice of home therapy, cryotherapy and rest was used to
minimize symptoms. [6-8] This procedure is classic and well defined in the
literature for acute pain reduction and ease of application, using the pattern
of 20 minutes on with at least 1 hour before repeated application. During the
initial stages of plantar fasciitis, treatment focuses on reducing symptoms
before restoration of function is attempted. [6, 7] Passive modalities, such as the
abovementioned cryotherapy, along with pulsed ultrasound and various electrical
muscle stimulation  applications, have been consistently used in the initial
stage of acute symptom reduction. Stripping massage is one treatment method that
can be used during the beginning of therapy.  However, because of the patient's
acute condition, additional irritation to the plantar fascia and the head of the
first metatarsal did not appear to have clinical merit. With the reduction of
symptoms, ranging from approximately 3 days to 2 weeks, the transition from
passive care to active care could occur.
treatment of plantar fasciitis consists primarily of mechanical stretching of
the plantar fascia. [4, 7] This can be accomplished by passive or active stretching
techniques that focus on dorsiflexion of the MP joints. [4, 7] One such technique is
accomplished by having the patient stand while dorsiflexing the MP joints
against a wall and flexing the involved-side knee into the wall. The patient
should feel a mild stretch to the plantar fascia and a centralized stretch to
the medial longitudinal arch. Ankle dorsiflexion should also be addressed by
stretching the soleus and gastrocnemius muscles [2-5, 7] of the involved leg. Each
muscle should be stretched individually.  One method involves having the patient
stand on the edge of a stairstep while producing ankle dorsiflexion. The
majority of the stretch is focused on the gastrocnemius muscle by keeping the
knee in extension, whereas with knee flexion the soleus can be more readily
stretched. Treatment after icing is used to minimize iatrogenic pain and
pertinent at the onset of this case, the initial working diagnosis and
differentials were clinically not relevant after reevaluation. New differential
diagnoses were developed because the patient's symptoms were unresponsive to
treatment and indeed increased; this led to new objective findings of alteration
of gait and discoloration with warmth over the plantar surface  and medial area
of the first MP joint, along with added information regarding her past history.
On subsequent focused questioning, she revealed that approximately 2 to 3 months
previously she had cut very deep into her skin while trying to remove a piece of
callus from the undersurface of her great toe. She did not recall any bleeding
or discharge that occurred at the site. These changes in the patient's
subjective and objective findings and past history narrowed the possibility to
osteomyelitis or cellulitis as the two major differential diagnoses of
importance. Because of her previous fracture site and its possibility of
infection, plain radiographs of the region were taken to determine whether
osteomyelitis was present.  This decision was based on possible visualization
of lytic destruction of the old fracture site, with the
chance of enlargement or changes of density in the
area of the geode. As previously stated, the radiographs appeared negative for these
possibilities. A three-phase bone scan was ordered to rule out osseous
involvement as a result of the relatively short duration of symptoms, which may
not be reflected on plain radiographs and the potential severity of osteomyelitis.
mentioned previously, a bone scan is a series of multiple images taken at three
time intervals. Various types of radionuclide injections can be used for
specific diagnostic functions. In this case, the standard Tc-99m MDP was used.
In hindsight, a technetium-99m-labeled or indium-111-labeled leukocyte scan
should have been used due to their specificity for areas of infection and
phase one of the bone scan, the radionuclide angiogram, images are taken every 2
seconds of the involved structure for the first 40 to 60 seconds after injection
of the radionuclide tracer. In phase two, the blood pool stage, static images
are taken for 1 to 3 minutes after the phase one radionuclide angiogram. Phase
three (delayed bone phase) images are taken 3 hours after the injection. [11, 19]
phase is accented by increased tracer uptake indicating the involved histology.
With cellulitis, there is increased activity detected during the first two
phases of the scan, whereas the third phase is negative for activity.
Immediately after the injection of the radionuclide tracer, areas of increased
blood flow, such as in an infection, will localize the tracer to that site; with
osteomyelitis, there is increased uptake during the first two phases but also in
phase three. The difference during phase three is localization of the tracer to
areas of increased bone activity. Healing fracture also has a similar imaging
appearance in all three phases. Degenerative joint disease has focal increased
tracer uptake only during phase three. [11, 19]
work was another option entertained but was not used because of the urgency of
clinical consequences, its lack of sensitivity in detecting early bacterial
changes of such a small focal site, and the ease of obtaining a bone scan.
the bone scan in this case, there were numerous underlying complicating
conditions that made it difficult to rule out osteomyelitis as a pathology. With
the increased radionuclide uptake during the third phase from the degenerative
joint disease of the first MP joint (see Figs. 5 and 6), uptake during all three
phases in the region of the proximal first phalanx (see Figs. 3-6), and the
positive images during the first two phases of the scan from the potential
cellulitis (see Figs. 3 and 4), all of these conditions could be explained.
Because osteomyelitis yields tracer uptake in all three phases, and given the
proximity of the above conditions, the small size of the involved structure, and
the limitations of bone scan image clarity, difficulty in diagnosis persisted.
Plain film radiographs could not conclusively rule out osteomyelitis as a source
of a positive finding on a bone scan.
the potential seriousness of this condition, and based on the physical
examination findings, the patient was referred to a medical physician. From the
physician's examination findings and interpretation of the imaging reports, two
treatment options were recommended: 7 weeks of intravenous antibiotic
therapy to address the potential osteomyelitis, [17, 20]or a 10-day course of
amoxicillin to address the possible celluli- osteomyelitis, or both. At the
patient's reques t,the latter treatment was used. This course of
treatment proved to be effective in reducing symptoms and was also a major
determinant of the ultimate diagnosis of cellulitis. As discussed previously,
the patient reported no symptoms of the involved cellulitis site at a 3-week
chiropractic follow-up, the patient continued to have plantar fascia tightness
and tenderness. The working diagnosis of plantar fasciitis was again made, and
because of her lack of acute symptoms the active phase of initial therapy was
started. She followed a daily regimen of passive stretching to the plantar
fascia, gastrocnemius, and soleus muscles. This program was performed daily for
a 3-week trial, with the patient reporting total reduction of symptoms of the
plantar fascia at the end of the treatment period.
is a reminder to chiropractic clinicians about the evolution of case management.
Although the patient's original diagnosis of plantar fasciitis proved to be
correct after her cellulitis treatment, proper monitoring of objective and
subjective findings and how they related to the treatment plan was paramount in
determining the potential seriousness of the added condition. This proved far
different from the initial diagnosis. In this case, it would have been very
difficult to determine whether the patient's initial symptoms were based solely
on plantar fasciitis or in combination with the development of cellulitis. This
case is a prime example of the importance of proper monitoring of patient
progress through a treatment plan. Any unresponsiveness to therapy should lead
to a change in the working diagnosis for the ultimate benefit in patient care.
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