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Tuesday, August 16, 2016

Plantar Fascial Tear: Email Advice

One of the athletes that has emailed me has severe heel pain. I had him email me his MRI CD which clearly showed a plantar fascial tear. I asked him to read my protocol and email questions. Here they are. 



OK Dr. Blake, here's what I can think of...  I'm sorry it's so long but this is really playing on my mind - not just the cause, but the 3+ months in a boot and the rehab afterwards, the reinjury avoidance and the building back up to where I am now will be a task and a half - I'm up to it; I understand it could be much worse; I'm just not overjoyed! 


Background on me: 
I’m 50, in excellent shape and thin.   I’ve never had any foot problems; my arches are high (but not unusually high).  Pretty much all of my shoes and sneakers have good arch support.   I used to run a lot but I slowed my running down to only 2 days per week long before (12-18 months before) the 1st sign of heel pain.  The other days I’m not running I would either be on the recumbent bike in the gym or out mountain biking.  I'm a little bow legged and walk more on the outside of my feet (underpronate?).

Regarding the injury:
I realize you can’t be 100% sure but how much in your professional opinion did the 4 cortisone shots play a role in this? 
Dr Blake's comment: I have a patient now that I injected the area around the plantar fascia, and it sounds like it may be torn. It is considered safe if you do not inject right into the plantar fascia, which I did not. But, did the cortisone migrate up into the fascia weakened it? Was the chronic pain due to a plantar fascia weakened and ready to tear at any moment? I am not sure. If the MRI on my patient comes back as a tear, it will be the first in my 35 years of practice that has a possible link to my shot. I hope it was not my shot. I hope it was not the shots you received. Everyone is trying to help you athletes and shots are vital in the final healing of so many of these heal pain issues. 

Could one or more of the shots been misplaced and that’s (at least partially) the cause for weakening the medial slip enough to cause it to tear? Yes
How many shots are enough? 
Dr Blake's comment: I give 10 mg of long acting cortisone in a heel injection, and that is considered safe. Up to 3 of these shots over a 2-3 month period is considered safe in chronic conditions. I have seen patients with 10 shots in 3 months, only to find out that each shot only had 1 mg per shot. So, if you had 4 shots into the heel, you need to find out how much long acting cortisone was in each one. One of our orthopedists routinely gives 40 mg per heel injection. She says she has never had a problem. I can only tell you what sports podiatrists consider routine for them. 

Is this a common injury?  
Dr Blake's comment: Very, I have one or two patients weekly in some stage of healing, and they heal. I also had a patient come in a year ago saying he had chronic 10 years of plantar fasciitis. I told him plantar fasciitis never lasted that long. We got MRIs on both sides documenting bilaterral plantar fascial tears. After 3 months in a removable boot for one foot, and then 3 months in a removable boot with the other foot, he was well and kicking himself for self diagnosing all those years. 

I have pain on the opposite side on the heel about an inch forward from the back of the heel – ½ way between the side (of the foot) and the bottom of the foot/heel.  Especially felt when squeezed (like a massage or at PT).  Is this likely part of the same problem? 
Dr Blake's comment: Yes, the inflammatory fluid sits somewhere under the heel (which is where I inject) and can be just as painful as the plantar fascial tear. I typically have my patients walk on their heels. If that hurts, then heel bursitis is documented. I have them massage for 5 minutes with a frozen sports bottle just the 2 inch area under the heel, 2-3 times per day. 

Did you see anything else in the MRI?
Dr Blake's comment: I will have to relook to answer that. Sorry, but I am at home, and the CD on my desk at work. I do not remember seeing anything else exciting. 

Regarding the boot:
Are there risks associated with waiting to start to wear the boot?  I was thinking about waiting until winter or at least the cooler weather. 
Dr Blake's comment: Now that you have a diagnosis, get the ideal treatment. Yes, patients wait, but if you don't heal well, and it could be related to waiting, you will not forgive yourself, and I could not recommend it. 

Are there other options (taping perhaps)? 
Dr Blake's comment: The basic treatment is to restrict big toe joint motion. So, find a stiff hiking boot, and/or a hike and bike shoe from Shimano or Pearl Izumi, or a rocker shoe like New Balance 928 or Hoka shoe line. See what limits the motion enough that creates that 0-2 pain level consistently. 

Is there more than 1 type of boot?  If so, any preference? 
Dr Blake's comment: I love the Anklizer or the mid calf Ovation medical boots the best for these injuries. 

I assume I remove to bathe but must I be careful about putting any weight on that foot while showering? 
Does one walk on a boot or are crutches necessary? 
Sleep in the boot?  If not:
If I get up at night to use the bathroom must I “reboot” for the walk? 
Dr Blake's comment: All of the questions above can be answered together. You only hurt yourself with an active pushoff. You only need to walk flatfooted to the shower, bathroom. No need to sleep with the boot on. No need for crutches.

Is driving possible?  If not can I remove it to drive or is that not recommended?   
Dr Blake's comment: You have to remove to drive. Typically it is okay. If it is your right side and you are having too much pain driving, you have to get a cab or car pool. That part should only last 1 month or so, even when you are in the boot, stiff shoe for 3 months. 
Are there ANY exercises for cardio I can do (like rowing or swimming or the recumbent bike on an easy setting)? 
Dr Blake's comment: Yes, but you have to have the foot positioned so there is no heel lift. And, definitely no pushing off the wall in swimming and no fins. 
Is scar tissue going to be an issue?  How can I get rid of scar tissue? 
Dr Blake's comment: We want scar tissue to scar in the tear. 6 months after the healing, if another MRI documents too much scarring, some PT will be in order. But, 6 months no plantar fascial stretching, and we have to allow scar tissue to do its thing. 
Can I stretch (calves, hamstrings, quads) while wearing the boot or should I avoid it all together?
Dr Blake's comment: No PF stretches, but the rest of your body is fine. 

Finally (yay!):
Any preference on how/what I should do for rehab after the boot is removed for good?  
Dr Blake's comment: So the boot creates this nice 0-2 pain level for 3 months. During this time, you have been cross training. The next 6 weeks you have to gradually wean out of the boot keeping the 0-2 pain level (can take as minimum as 2 weeks). Then I start you on the famous dreaded Walk Run Program all along keeping the 0-2 pain level. Based on how you do with this, we process you, or slow you down and get PT. We are definitely months away from this. 
Do you have any helpful advice to insure success during the boot and post-boot?
Dr Blake's comment: The boot phase is easy. Maintain the 0-2 pain level, while trying to cross train, and experiment with stiff shoes, rocker shoes, orthotics, etc. The post boot phase is broken into the weaning out phase, the walk run phase, and the return to activity phase. Typically a good sports physical therapist or podiatrist can help you along. And, you are strengthening the foot daily all along from now until you are back full time. The exercises are met doming, single leg balancing, post tib and peroneus longus theraband, and at 4 months double and single toe raises. 
What's my best bet for orthotics (considering my arch and supination) for every day?  Custom or off-the-shelf?  Any specific ones you can point to?
Dr Blake's comment: High arch and supination is only custom made in my mind. 
Any specific shoes/sneakers you recommend?
Dr Blake's comment: See the Hoka line, along with the New Balance 928. Both have good rocker soles to limit pushoff. Good luck!!!!!!

Thank you for your time!

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.