A 55-year-old woman attended our service in August 2018 complaining of bilateral plantar nodules; at initial presentation only the right foot was symptomatic. The patient's medical history included type 2 diabetes mellitus of 12 years duration (recent HbA1c 52 mmol/mol) and essential hypertension. Current medication was empagliflozin 10 mg od, linagliptin 5 mg od, gliclazide 80 mg bd, ramipril 10 mg od, atenolol 50 mg od and amlodipine 15 mg nocte. There were no known allergies and no relevant family/social or surgical history.
When assessed the patient described a 12-month history of a symptomatic mass within the medial longitudinal arch of the left foot, a VAS of 8/10. Symptoms were exacerbated by prolonged periods of ambulation and weightbearing. Orthoses and footwear adaptation had not yielded any symptomatic reprieve. Clinically, a solitary mass could be palpated within the medial longitudinal arch of the right foot, and tenderness was apparent on palpation. The mass was rigid, overlying tissue unremarkable. Neurovascular observations were unremarkable. Subsequently, an USS examination was requested (Figure 6). The proximal plantar fascia appeared normal; however, a large solitary well-defined hypoechoic mass was seen within the medial band of the plantar fascia measuring 24.1 mm in length and 7 mm in width. Appearances again were consistent with LD. As conservative treatment options had failed so far, a CSI was suggested. Informed written consent was obtained, backed up with a patient information leaflet. Written permission to use images for publication was obtained.
In September 2018, the patient underwent a single injection, without fenestration, of 40 mg (40 mg/mL) methylprednisolone acetonide pre-mixed with lidocaine (10 mg/mL) under USS guidance. While moderate improvement was seen at 6 weeks post procedure, the patient returned 3 months following the injection noting complete recurrence of symptoms. The patient was subsequently listed for the triamcinolone acetate injection with fenestration under USS guidance. This was performed in March 2019: the injection technique mirrored that described in case study 1. At 6 months post final procedure, the patient reported VAS as 1/10 and return to full activities.
For audit purposes, the patient was contacted for review at 12 months post procedure and USS examination performed in March 2020. The VAS was 0/10; clinically the mass was significantly smaller with only minimal deciphering on manual palpation. The USS demonstrated a small hypoechoic mass sited in the same area as previously demonstrated but with reduced dimensions, as seen in Figure 7 (note: as this coincided with the start of the Covid-19 pandemic, the lesion was scanned by ourselves rather than by the local sonography team who were only taking emergency cases at that time, and therefore no definitive dimensions are offered). No adverse signs or symptoms were noted and no further treatment of any sort had been required.