Recalcitrant Plantar Fasciitis

[Axe]

**I have done searches for plantar fasciitis, plantar, and heel spur here. I have done my due diligence in searching other internet sites and Pubmed as well.

Please excuse the drawn out story here. I figured it is better to lay everything out to make it easier for anyone who reads this who might have suggestions as to what I should do next.

I am a 41 y/o male, 6'00". was 235 lbs, am now 250 due to lack of exercise. I am having issues with Recalcitrant Plantar Fasciitis.

For a number of years, I walked 3-6 miles per day. I walked on asphalt road surfaces during snow season and on soft ground when the snow wasn't covering the ground.

I did not run, nor did I ruck. I have had an ACDF, and could use a laminectomy as well, but am trying to avoid it if possible, so I avoid jarring or strong weight hanging from my back/neck/shoulders.

In April 2009, I started developing very minor (1/10) pain bilaterally in my dorsal calcaneal region that was present only during exercise. I was already taking Mobic 15 for the neck and a right ankle which has minor OA.

I reduced my walking to 1-2 miles per day,began icing and elevating after activity, and started doing some minor stretching.


By July 2009, despite the measures I was taking, my pain was at 5-6/10 when walking, 4/10 at rest 24-48 hrs following any necessary walking of more than 1/8 of a mile. I began to notice that standing for more than 6 hours caused pain equivalent to the pain caused by ambulation.

I stopped walking for exercise and avoided other walking and unnecessary standing except when absolutely necessary. I continued icing, elevating, and stretching. I also then developed s/s of minor Achilles Tendonitis in my left ankle.

I made a visit to one of the best Orthopods in the area in January (Team Doc for the Packers). He gave me pain medication to get me through the SHOT Show, gave me a Medrol Dose Pack to be followed with Voltaren in place of Mobic, and Rxed Physical Therapy. The Medrol pack helped for the time I was on it, but then lost its efficacy.

I did physical therapy, which consisted of stretching and ultrasound treatment on the heels. The ultrasound made a huge difference for 24-48 hours, relieving pain completely. By the next appointment, necessary daily walking would cause the pain to recur, and the ultrasound treatment would remove it again.

The PT stretching relieved the Achilles Tendonitis, and I gained flexibility in the foot, soleus, gastro, and other muscles/tendons of the ankle, but did not achieve relief of the plantar fasciitis pain issues.

At this point, walking more than 1/8 mile or standing for more than one hour caused pain 7-8/10. The ultrasound was like a magic wand, but wouldn't last past two days of minor activity.

I underwent Cortisone injections in both heels in late May 2010, which gave significant (roughly 99%) relief of pain, allowing normal ambulation. I avoided any serious walking, but was able to handle being Scoutmaster at Boy Scout camp in July (1-2 miles per day walking at a fairly slower pace), get a mile or so of normal up and down office work ambulation weekdays and outdoor chores on weekends, and able to remain standing for more than 4-6 hours without extreme discomfort. I was able to remain standing without severe pain well enough to cut up and split 3 cords of wood, which was my major chore goal for the summer, and get my son through his Eagle Scout project ( 4 days X 12 hrs per day of standing/walking.)

About a week ago, I needed to walk approximately one mile on soft ground. 48 hours later, I was at a 8/10 pain level when walking, 6/10 pain level standing, and an intermittent 4-5/10 pain level when at rest. I am back to no activity, ice, elevation, stretching.

I visited the Orthopod 2 days ago. He is confounded at the lack of improvement. He did not want to do more Cortisone injections because of the pf rupture risk. He wrote me another script for PT, a script for night splints, and wrote me a script for painkillers for my upcoming family vacation to Yellowstone next week.

I have tried different shoes, and different OTC orthotic inserts. Nothing has really worked. I have pretty much exhausted the options I can think of short of surgery, which I know is a last resort and beset with morbidity issues all its own. My Orthopod strongly recommends against it as well since it causes so many arch issues.

I have read some research about a technique called dry needling, which involves repeated jabbing of the plantar fascia followed by ultrasound-guided injection of Cortisone. The reported results sound promising, but I can find little detailed information on the procedure studies and protocols. (I can only read abstracts on Medline as I do not have an account). I also can not find a lot of people who perform the procedure using internet searches, which leaves me questioning the true efficacy of the procedure. My Orthopod had never heard of it.

I would like to regain the ability to ambulate for normal daily activity. I would also like to be able to exercise by walking. I am willing to travel for treatment if I need to see someone with special expertise.

Does anyone have any suggestions as to how I should proceed? I am running out of ideas.

[Boomer-61]

Axe,
Sorry to hear about your problems. I had it in both for 9 months.
I have very little experience with the needling, I have one pt who has had it done with limited success. Kind of like the ultrasound, she had to have multiple treatments and none gave her lasting relief.
As for the traditional treatments, it sounds like you've done most: icing, stretching etc. Did you try night splints? What helped me was to get rid of all my shoes and buy Ortho recommended shoes and orthotics which were professionally made. The only other thing I would recommend is weight loss. You're ideal body weight should be around 185 or so. You can exercise in a pool or on a stationary bike without exaccerbating your feet. Reduce your caloric intake by about 500 per week and the weight will come off a pound at a time. Yes it will take time but it will work and you are less likely to rebound. I truly believe that if you reduce the load/stress on your feet, i.e. weight loss, and support your feet with good shoes and orthotics you will get relief. I would avoid surgery. I haven't been bothered with it in 15 years but I still stretch two and three times a day. I don't ever want it to recurr. I sympathize with you 100%. I wish I had a quick and easy cure for you but I don' know of one.
Good luck.

[Blitzzz (RIP)]

What you've tried is understandable, but obviously not done the trick.
First, the Plantar Fascia will shorten over time and not be painful until it's late. Not to late though. The heel spur comes much later as a result of the extra tension on the calcaneous at the anchor point of the Plantar Fascia.
The fix will be aggressive stretching of the Plantar Fascia. this can be done with a "Pro Stretch" or by standing at the kitchen sink with doors open, placing your toes on the bottom shelf (about 3" from the floor), then stand straight legged until you feel the stretch.
You can PM me for better explanation. Dave.

[Eagle5US]

Caution when using medical terminology if you aren't exactly certain what it is you are saying. I am going to separate the following statements for clarity:

Your post is very confusing....
Recalcitrant Plantar Fasciitis? Or RECURRENT / REFRACTORY Plantar Fasciitis?

You mention considerable pain in the DORSAL (top) part of your calcaneous...if it were also POSTERIOR (to the BACK) that would be Achilles Tendonitis.

Pain to the inferior (bottom) anterior (front) of your calcaneous could be plantar fasciitis.

You stated you had Achilles Tendonitis in your ANKLE - Achilles Tendonitis does not occur in the ankle, it occurs on the POSTERIOR (BACK) of the foot.

You mention Ultrasound Tx of your heels...I am assuming you are talking about TENS or UltraSONIC treatments? Ultrasound has no effect on relieving inflammation.

A few clinical questions...
-Have you had any imaging done? X-Ray will probably demonstrate significant heel spurs to the anterior portion of your calcaneous in the event of Plantar Fasciitis and/or to the posterior portion of your calcaneous with Achiiles Tendonitis.

-Do you wear splints at night when you sleep?

-Is your pain THE WORST when you first step on the floor (first episode of weight bearing) in the morning, getting better throughout the day unless you sit down for an extended period?

-Is your pain on the BOTTOM of your foot, or the BACK of your foot.

Once you can clarify the above questions...they may lead to more questions, but I can probably provide some additional guidance for Tx and palliative therapy. For either / both conditions if refractory (Plantar Fasciitis and Achiiles Tendonitis with associated spurs...) after failure of more conservative measures, Podiatrists often can surgically shave the spurs and provide significant relief of symptoms.

Eagle

[guinness18er]

Hello everyone, I hope I'm not double tapping this issue. While Plantar Fasciitis is the topic of discussion I would like to present my case and ask a couple questions to the QP's who have possibly been in a similar situation to mine.

First, here is the short version of the injury history. February 2008, after combatives practice I had a sharp pain in the ball of my foot, and some slight swelling. At the time I was working on some kicks, pivoting a bare foot on the floor of a basketball court. Drove on without seeking any medical attention and the pain gradually wore off. May of 2008 attended and graduated the Sapper Leader Course. Put the ruck down for a couple weeks, then began train up for SFAS. After ruck marches, and runs on pavement the ball of my foot would be aching so bad, that my form was falling apart and I would run/walk on the very outside edge to keep pressure off the ball. After training events the pain would subside and I could walk as normal. Through out the train up and leading into SFAS the pain moved from the ball of my foot, through my arch and to the point just behind where my arch meets the heel. One week into SFAS the pain was excrutiating, and I was losing mobility in the foot/ankle, and couldn't walk without a limp, and could barely run.

This was my demise in SFAS, and I should have pushed it back, but I thought I could suck it up for 2 weeks. After returning from selection and licking my wounds for a while, I went to a Podiatrist, at the time on Fort Leonard Wood. X-Rays showed a small fracture in one of the metatarsal heads (the one next to my big toe), which in her opinion, led to a small case of arthritis, which caused me to change the way my foot struck the ground when running or rucking. The change in my form, led to Plantar Fasciitis to develop.

Initial treatment was 2 weeks rest, stretching, and insoles with a lot of arch support. After 2 weeks, I ran, at the time I was a BNCOC instructor and running with students so I could not fall out when the pain came back. Went back to the Podiatrist, this time treatment was the same, but with 1 month rest. After one month the same thing happened. Back to the Podiatrist, this time, a steroid shot in the foot, and another month rest. First run back after 6 weeks, it comes back.

At that time I was on orders for Fort Bragg, and to a unit I knew was about to deploy. I got to Fort Bragg and did an 8 mile BN run which left me limping bad for 2 days, however I completed it with my platoon. From there, we deployed, have been deployed for 8 months and conducting dismounted route clearance for 5-10km 5 days a week. The only way I have been pain free is by taking 1600-3200mg of Ibuprofen a day, wearing ym night splint, and wrapping my foot with 2" tape (before applying 2" tape I wrap my foot in Pre-Wrap so the duct tape doesn't take the skin off). I'm getting by, but the condition is not going to heal until I can rest it for a long time. A little more info about me, I'm 6'0, 190, bodyfat ranges from 6-10%, I'm a Crossfit fanatic and take my fitness very serious. I also run in the POSE Technique, and before injury had 2 mile times in the 11 min. range, 4 miles in 24 min., and rucking 18 miles in 4.5 hours. I would primarily run in cross country racing flats on trails and gravel.

I can get through the deployment fine, but here are my questions:
First, will wrapping my foot in duct tape when I do a dismounted patrol or run ultimately lead to a weak arch that won't support me in the future, or some type of deficiency?
2nd, I know this won't heal until I can rest for a few months. I start PSYOPS school in January, and am hoping to be able to rest it during the language phase which should be 4-6 months. Can anyone tell me if it is reasonable to be able to do PT on your own during the language phase of PSYOP Qual Course, or should I just push the school back, and attempt to rest at the 27th ENG BN while I'm a PSG?

Lastly, I'm a huge Crossfitter and do a lot of heavy Olympic lifts. All though these lifts do not involve running, jumping, or any type of shock trauma, due to the heavy weight of squatting, deadlifting etc, am I continuing to damage the Fascia?

I know this was long winded, and I hope I'm not wasting anyones time here. Just wanted to get as many facts out as possible in order for more timely and sound advice. The Army, and my own mentality is to suck it up and it will pass. However, I have goals to achieve, which include going to the Ranger Regiment PSYOPS Detachment and then to Selection again in a couple years. I don't want to be walking with a limp in 10 years when I'm 40, but I also have a job to do, and simply can't rest at this time. Thanks for all your help in advance, and if necessary I will refer to the 18D posting which takes you to the Vagisil web page. Have a good one.
Also, just remembered, I have a golf ball and baseball which I roll my foot on, I also massage it nightly. When my foot is taped, I'm taking 1600-3200mg Ibuprofen, wearing my SOF or Superfeet Insoles, and wearing my nightsplint, I can run about 2 miles, or patrol app. 5km and remain pain free. Anything less as far as treatments go and I run 1/2 mi. or do a short patrol and I'm at a 4-5/10 in pain.

[Eagle5US]

The most important point of your post s the fact that you are taking 1600-3200mg of IBU daily.

1. Your body can only absorb so much IBU (2400mg) in a 24 hour period
2. By doing this for long periods of time, you place yourself at SIGNIFICANT risk for a GI Bleed. Believe me, I know.

As far as your foot goes, it was injured. It was injured in a bad place that doesn't get much of a "rest" unless you are in a wheelchair and you may need to consider changing your activities and future plans secondary to your injury and chronic pain.

Lastly, your case does not sound primarily like "Plantar Fasciitis" as much as it does (as your podiatrist mentioned) a metatarsal arthritis with an associated fasciitis.
Welcome to the world of chronic, activity dependent, pain.

Understand also, that any weights you lift transfers that energy to the platform you are lifting it on...in this case your feet. Your , no longer perfect, feet.

If you need to wrap your feet with tape to meet mission, by all means do so. The tape does take some of the responsibility for supporting structures from the natural formation of the foot (or ankle / wrist / elbow / digit / whatever body part is taped). In the realm of sports medicine this is designed to be an activity specific (i.e. TEMPORARY) utilization of additional support mechanisms to prevent injury in the event of extreme stressors OR to assist in support of an injured area.

HTH

Eagle

[Pocket NCO]

To Axe:

I will assume that the MD's have properly diagnosed you. With that said, there are a couple of different treatments that you should talk to your PT and MD about. The first is graston. It is a deep tissue technique that encourages the inflammatory process (which your body need to heal). Info can be found here: http://www.grastontechnique.com/

Sometimes the anti-inflammatory drugs that you take prohibit the body from healing on its own leading to increased dysfunction and weakness of a tendon or ligament (or fascia). The ultrasound worked because it was providing heat to the area which allowed the connective tissue to become more elastic and have increased blood flow (which helps the inflammatory process). There is a complex balancing act between beneficial and harmful inflammation, but the bottom line is your body needs it to repair.

The second treatment I would suggest discussing is barefoot walking progressing into very limited barefoot running. Barefoot walking/running allows you foot to move naturally so it self stretches (and self corrects). It also strengthens the intrinsic muscles of the foot and allows for a stronger arch. Some orthotics cause more of a problems than they solve because they allow the arch to weaken due to over support and create an unnatural gait. Again, discuss this with your PT and/or MD. Overdoing it without specific guidance on amount and technique can just exacerbate the problem.

The last thing I would discuss is self stretching and massage. It seems that you are doing the right things with the night splint and stretches but one of the biggest relief techniques I've seen with plantar fasciitis is to stretch and massage "wide". What I mean by this is that you should try to stretch/massage the foot medial to lateral especially along the arch. you will probably feel adhesions along the tissue on the bottom of your foot. The goal is to break those up allowing the fascia to expand some.

I have seen many different athletes and Soldiers achieve lasting relief with these techniques so don't be afraid to ask your PT and/or MD about them and get a second opinion if they want to keep pumping you full of meds without effective therapy. I've never heard of a pill that can truly correct an orthopedic problem.

[guinness18er]

Thank you much Eagle 5. A doc here on Shank did say that it could be a permanent problem due to the mis-alignment caused from the metatarsel fracture. Also, for what it's worth I don't stay on Ibuprofen or Naproxen for more than 2-3 weeks depending on mission, then I take an equal amount of time off, and start the cycle over again. I wish I knew if the Fascia is actually tearing off my heel bone, or just inflamed, and if the NSAID's are just masking the pain, or if their actually taking the inflamation away. Lastly, in most cases of Plantar Fasciitis I have read that the pain starts out bad in the morning, then gradually tapers off. My pain gets worse with activity, and is located where the Arch meets the heel, or just at the beginning of the heel. Thanks again, I will keep the Ibuprofen use in mind.

[Eagle5US]

Originally Posted by guinness18er

Lastly, in most cases of Plantar Fasciitis I have read that the pain starts out bad in the morning, then gradually tapers off. My pain gets worse with activity, and is located where the Arch meets the heel, or just at the beginning of the heel. Thanks again, I will keep the Ibuprofen use in mind.

Being that this is the case, I would be money that if you had lateral views taken of your feet / foot that there would be a prominent spur extending from your heel towards your midfoot.

Traditional PF is worse in the morning because the foot draws up at night while not under weight. Hence, the use of night splints, stretching and massage prior to first morning weight bearing.

As your conditions worsens with activity - it may indicate a mechanical irritation caused by a chronic pulling of the plantar fascia (PF) on the attachment point to the heel bone. This chronic pulling then creates osteoblastic activity (i.e. bone formation) where it shouldn't be and you develop a spike or "spur". Specifically in the area extending into where your PF attaches. So, every time you take a step, you are moving tissue across a hardened structure that isn't supposed to be there. After conservative treatment fails, the next step is to remove the offending "spike" (heel spur)

I hope that makes sense....

Eagle

[Blitzzz (RIP)]

Mostly good stuff here.
I give a big thumbs up to Bare foot walking and running as there has been much research in that direction lately, with good results.
In 18 years of Physical Therapy I'd have to say Stretching the Plantar Fascia relieved the Heel pain. Stretching the Fascia releases the tension on the heel and allows the body to remove the additional calcium from that attachment.
Check with a good PT , and try to get some Myofascial release done to that tendon system.
Lastley as stated, one just decides what one can endure and drives on. Good luck to you.

[Axe]

Originally Posted by Eagle5US

Caution when using medical terminology if you aren't exactly certain what it is you are saying. I am going to separate the following statements for clarity:

Your post is very confusing....
Recalcitrant Plantar Fasciitis? Or RECURRENT / REFRACTORY Plantar Fasciitis?

You mention considerable pain in the DORSAL (top) part of your calcaneous...if it were also POSTERIOR (to the BACK) that would be Achilles Tendonitis.

Pain to the inferior (bottom) anterior (front) of your calcaneous could be plantar fasciitis.

You stated you had Achilles Tendonitis in your ANKLE - Achilles Tendonitis does not occur in the ankle, it occurs on the POSTERIOR (BACK) of the foot.

You mention Ultrasound Tx of your heels...I am assuming you are talking about TENS or UltraSONIC treatments? Ultrasound has no effect on relieving inflammation.

A few clinical questions...
-Have you had any imaging done? X-Ray will probably demonstrate significant heel spurs to the anterior portion of your calcaneous in the event of Plantar Fasciitis and/or to the posterior portion of your calcaneous with Achiiles Tendonitis.

-Do you wear splints at night when you sleep?

-Is your pain THE WORST when you first step on the floor (first episode of weight bearing) in the morning, getting better throughout the day unless you sit down for an extended period?

-Is your pain on the BOTTOM of your foot, or the BACK of your foot.

Once you can clarify the above questions...they may lead to more questions, but I can probably provide some additional guidance for Tx and palliative therapy. For either / both conditions if refractory (Plantar Fasciitis and Achiiles Tendonitis with associated spurs...) after failure of more conservative measures, Podiatrists often can surgically shave the spurs and provide significant relief of symptoms.

Eagle

Eagle,

The Physical Therapy Script from the Orthopedic Surgeon said Recalcitrant Plantar Fasciitis.

The PF has not gotten better since the onset a year and a half ago. I have not been able to exercise without pain. The pain is ameliorated by rest, but returns during and following standing and walking activity. The Orthopedic Surgeon said he uses Recalcitrant and Refractory interchangeably to describe a non-resolving soft tissue condition. He said that in his opinion my PF is not recurrent as it has never resolved.



I meant to say plantar, not dorsal--Sorry. Pain on bottom of feet, underside of the heels, worst pain back part of bottom of heel. The pain is usually distributed in a horseshoe pattern around the outside edge of the bottom of the heel, as well as the center of the bottom of the heel. The pain will extend to encompass the midsole area of the feet as well when I push exercise.


There was Achilles Tendonitis. I felt the pain/tightness in the at about the level of the malleoli, hence I thought of it as the ankle.

It was Ultrasonic treatment of the heels, not Ultrasound.

I apologize for my errors. I generally try to avoid typing faster than my brain can think, but I failed with my original post.

In answer to the clinical questions:

Xrays showed bilateral heel spurs May 2009. May 2010 Xrays do not show significant change to the spurs (ambulation-related pain has increased however).

The pain had been worst when standing or when my heel struck the ground when walking, after prolonged standing and walking.

If I had done a good job of resting for a few days, I could sometimes walk relatively short distances without pain for a day. 24-48 hours following walking, however, the pain would develop with any heel contact and would hurt at rest as well.

For the past month the pain has changed to be the worst when I first get up and after resting. I have been on a car vacation with the family the past three weeks. When I got out of the car to walk at our destinations and for rest breaks, I looked like an 80 year-old man trying to walk initially , then as the foot stretched, the pain and tightness improved and I then could walk normally. (The more I walk, the higher the price I will pay later painwise, however)

I do not currently have night splints as the Orthopod/PT did not think I needed them in January 2010. I now have a script for them and will be getting them.

The pain is on the bottom of both feet, not at the back of the feet.

Thank you for taking the time to respond to my post.

[Axe]

Originally Posted by Boomer-61

Axe,
Sorry to hear about your problems. I had it in both for 9 months.
I have very little experience with the needling, I have one pt who has had it done with limited success. Kind of like the ultrasound, she had to have multiple treatments and none gave her lasting relief.
As for the traditional treatments, it sounds like you've done most: icing, stretching etc. Did you try night splints? What helped me was to get rid of all my shoes and buy Ortho recommended shoes and orthotics which were professionally made. The only other thing I would recommend is weight loss. You're ideal body weight should be around 185 or so. You can exercise in a pool or on a stationary bike without exaccerbating your feet. Reduce your caloric intake by about 500 per week and the weight will come off a pound at a time. Yes it will take time but it will work and you are less likely to rebound. I truly believe that if you reduce the load/stress on your feet, i.e. weight loss, and support your feet with good shoes and orthotics you will get relief. I would avoid surgery. I haven't been bothered with it in 15 years but I still stretch two and three times a day. I don't ever want it to recurr. I sympathize with you 100%. I wish I had a quick and easy cure for you but I don' know of one.
Good luck.

Boomer,

Thanks. I will check into professional Orthotics.

I do need to lose the weight. I have been waiting for the PF to resolve so I could resolve walking. I need to move on and pick a different activity for now, however.

[Axe]

I figured I'd leave an update in case it will be of benefit to someone else out there.

After continuing PT with no definitive benefit for several months, I contacted Dr. Lev Nazarian at Thomas Jefferson University in Philadelphia in January, 2011 to discuss Dry Needling. Nazarian is an interventional Radiologist and a Professor at Jefferson University.

I checked into Dry Needling as the other alternatives such as ECSW Therapy and Platelet-Rich Infusion were deemed experimental and not covered by my insurance.

I left a message for Dr. Nazarian, expecting a staff member to return my call. To my surprise, the Dr actually called me back and spoke with me personally. He spoke with me for about 30 minutes describing the Dry Needling procedure. He said there was a 90% efficacy rate, almost-immediate return to weight-bearing ability, and next to no risk of morbidity.

That made the decision between traditional surgery (significant morbidity risk and downtime) and Dry Needling a no-brainer to me.

I made an appointment and went to Philadelphia on Feb 17, 2011 to have the procedure done.

After a physical exam and view of the plantar fascia using ultrasound, Nazarian gave me a posterior tibial block and then inserted a 3 1/2" needle in the back of the heel. Nazarian then worked the needle in and out throughout the plantar fascia using a sawing motion to break up scar tissue and adhesions.

The procedure was done in an exam room, and took less than 20 minutes.

Nazarian said he can feel the scar tissue as well as visualize it on the ultrasound, as penetrating the scar tissue feels like trying to puncture a rubber ball with the needle.

Following the procedure, I was instructed to remain non-weight-bearing for 24 hours, then walk as tolerated, do PT for 4-6 weeks, and avoid anti-inflammatories for a few months.

To my surprise, I was able to tolerate walking immediately after the 24 hour rest period, though the foot was stiff and painful. The post-procedural pain was MUCH less than I was expecting however. I was in far less pain than I had been in following Cortisone injections.

I had a slowly-progressing recovery that resulted in a complete elimination of pain when at the 8 week point, about two weeks ago. I have been able to start walking again without pain.

If I had the traditional surgery, I'd be getting out of my cast and maybe starting to walk now. With Dry Needling, I was able to stay ambulatory, with far less risk of adverse effects, and am confident that I have made as complete of a recovery as is possible.

I walked 2 miles the other day and didn't have any pain during or after. It doesn't get much better than that after having been on invalid status for almost two years. I wish I had undergone this procedure a long time ago!

I'd strongly recommend Dry Needling to anyone suffering from recurrent/recalcitrant Plantar Fasciitis looking for alternatives to traditional Plantar Fascia release surgery.

[Boomer-61]

Axe,
It just doesn't get much better than that. Thanks for the update.

[prof.tomjohnson]

As one who went to Primary Care, Orhto, Podiatry and even PT to no avail. I tried stretching daily using the yoga face-down-dog. Over two weeks, I had positive results. I continue to do this stretch daily (with occasional missed days) the 'spuring" resolved and has not returned. Just as another message posted, stretching works where drugs fail.
TJ