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Monday, January 15, 2018

Advice for Plantar Fascial Tearing and Intense Inflammation

This is a patient I have been helping, along with her imaging. The plantar fascia has a partial tear and the inflammation since she is not addressing this properly is intense. I had her email me a full story, plus she gave me other feedback from her doc's visit today. 

Here are the images of the partial tear and intense inflammation.
http://www.drblakeshealingsole.com/2018/01/plantar-fascial-tearing-with-intense.html

Hi Dr. Blake,

That is very interesting, I am so appreciative of you taking the time to review these images...as soon as I got the report from the MRI I felt it was off...it just didn't add up that everything I tried had failed if it was "just" plantar fasciitis. The story is rather long but here goes:

I am a distance runner, and around March of last winter (2017) I began to experience pain in my left heel. Unlike typical plantar fasciitis which usually presents almost out of thin air as pain in the morning one day, this came on during a run. As symptoms gradually worsened, I decided to take time off. I knew the body's inflammatory response usually lasts a few weeks, so I refrained from running for about 2 1/2 weeks. The pain didn't get worse, and it didn't get better. It was always the worst after getting up in the morning, stepping out of my car, and getting up from my desk. I figured, if the pain wasn't going to improve with rest, I might as well run! I am also a huge believer in Mind-Body Syndrome (TMS), and I was 95% convinced this was the cause of my heel pain, and that I could continue to run and eventually the symptoms would dissipate. Running actually wasn't painful, but afterward (especially following long runs), the pain was pretty intense. It took a few months, but as crazy as it sounds, the pain did go away. I considered myself completely healed and didn't even remotely fathom the pain could or would return.
Dr. Blake's comment: This could have the initial tearing of the plantar fascia, so small a tear, that it would heal and re-tear no matter what you did. I had a runner in several years ago that this syndrome went on to some degree for 10 years. We finally placed him in a removable boot for 3 months, with no achilles or plantar fascial stretching, and the other 3 months of keeping the pain level between 0-2, and he allowed the plantar fascia to get stronger intrinsically, and he has not had problems for 2 years. Knock on wood!!!

 Fast forward to October, I was happily plugging away training for the Philly Marathon. I had just gotten word that my qualifying time from 2016 got me in to Boston 2018. I was super excited. During a 15 mile training run at an extremely hilly course in Valley Forge Park, the heel pain returned quite unexpectedly. I was absolutely convinced it was in my head. I had run through this "plantar fasciitis" before successfully, and I was about 3/4 of the way through my training plan, and I really did NOT want to shut it down and rest...so I continued to train. Only the pain did not get better, it continued to get worse, to the point where every single step of running was painful. I must have started to compensate in some way in anticipation of the pain, because I ended up with a calf injury. 
Dr. Blake's comment: First of all, my son Chris went to Cabrini in Wayne, PA, and I love Valley Forge Park. Secondly, this time you increased the tearing, which had never gotten perfect in the first go around in March. I am linking to my blog post on Good vs Bad Pain that should be your bible from now on. 
http://www.drblakeshealingsole.com/2013/12/foot-pain-dilemma-of-good-vs-bad-pain.html

My calf bothered me running, but I could power through...afterward, however, I could barely walk. At this point I decided the situation had gotten dire enough that it warranted a visit to my PCP. He ended up recommending x-rays and referring me to a podiatrist. X-rays revealed a heel spur (not a surprise), but not a stress fracture. At this point in time, my main (and most painful) concern was my calf (I had pretty much gotten used to the heel pain which was admittedly pretty bad). The podiatrist advised the standard protocol for plantar fasciitis (rolling with an iced water bottle, stretching, prescription anti-inflammatories). I wasn't keen on the idea of an injection, so he said we could follow up in a week and do the injection then if necessary. I asked if I could continue to run, and he said yes. That plan failed miserably. Despite stretching, rolling, icing, heating and doing everything imaginable to baby my calf, after a 17 mile long run I couldn't walk for two days. The podiatrist then recommended a venous duplex to rule out a blood clot. He was also suspicious of exercise-induced compartment syndrome. The venous duplex (was expensive) and negative. At this juncture, I knew there was nothing left to do but shut it down and rest so that I would be healthy in time to start training for Boston (which would begin at the end of December). I rested for about a month and a half. My pain subsided. 
Dr. Blake's comment: I must say that there is a lot more to healing than having the pain go away. The pain is inflammatory usually and can improve, but the tissue may not be close to healing. You can not be seeing a sports doc since your advice is questionable. What that diplomatic?? Pain like this in your heal is from either 3 things: pinched nerve (which can give you the calf pain also), tearing of the plantar fascia (which your later MRI showed), and stress fracture of the heel bone (which your MRI ruled out).

When I started running again, I did so by gradually building up mileage. I tried to play it smart, but while my calf pain seemed 100% cured (I'm going to assume it was a strain), it didn't take long for the heel pain to return. I wore a night splint, I visited my chiropractor for ART, I went to physical therapy where they did a variation of Graston, heat and ultrasound therapy, and stretching...and while the pain generally improved, it still persisted. I discovered that rolling my foot on a little wooden roller for plantar fasciitis was the one thing that actually provided relief, but rolling over my heel the pain was so intense that it would shoot up my entire body. And while stretching was universally recommended to me by every doctor across the board, it always seemed to make things worse. 
Dr. Blake's comment: This is one of the reasons why it is important to get an MRI. Plantar fasciitis improves with stretching, ART, Graston, night splints, whereas plantar fascial tearing is only made worse by these treatments. Historically, you told the world that this was not plantar fasciitis since it came on suddenly in a run, not gradually over time. 

And, the pain started to have different patterns than it did before; suddenly it was worse in the evenings, some days the pain would ebb and flow during runs, and some days it would dissipate after a few miles then come back toward the end, sometimes it wouldn't bother me after a 5 miler and other times it would. I have discovered that while there are time that it may not bother me walking, my entire heel is consistently extremely sore to the touch.
Dr. Blake's comment: These are complex. You have the orthopedic injury that needs a solid treatment plan to heal. You can have the up and down of inflammatory pain which you are experiencing which is influenced by what you ate, how hydrated you are, what you did 1-2 days ago, how much alcohol you consumed, etc etc. And then there is neuropathic pain based on whether you are limping or the injury is next to a nerve etc. 

 I finally decided it was time for answers, and went to a new podiatrist to get a referral for an MRI. The report stated that the findings were "consistent with plantar fasciitis. No plantar fascia tear. Minimal bone marrow edema in the calcaneus about the plantar fascia attachment may reflect reactive marrow edema, stress reaction, or a combination thereof." I was disappointed only because I was hoping to learn something from the MRI other than "it's plantar fasciitis." Since I had tried everything in the book to treat it already (rest, ice, heat, NSAIDs, stretching, night splint, chiro, physical therapy, etc.). Since Boston very well may be a once-in-a-lifetime opportunity (and it was extra special to make it in this year since I qualified for but was cut from the 2017 race), I am hoping against hope there is something I can do now to make it there in April. 
Dr. Blake's comment: I am sorry about Boston. You need to once and for all heal the tear that was seen on the imaging. Sorry the MRI report did not report the tear, but it is there. You need to go into the plantar fascial tear protocol. These things heal, but we need them to get strong also so that it won't tear again. The entire process is typically 6 months. So, you need a goal of running for 2019. We need to get this healed, then 3 months of base running (no goals). Then, you will be ready to start training for something special!! 

http://www.drblakeshealingsole.com/2014/08/plantar-fascial-tears-top-10.html

Thank you, Dr. Blake! Sorry the long-winded story, it's been quite the (unfortunate) ordeal...

Since I hadn't yet answered the above email, this one also came. 

Hi Dr. Blake,

I apologize for bugging you again. I had an appointment with a new podiatrist today and I'm a little upset. She only very quickly looked at my MRI images (even though I showed her your site as well) is recommending 2 weeks in a boot + physical therapy (I have already done physical therapy, but it was focused mostly on the foot whereas she wants to send me somewhere that would address the "glute weakness" that she thinks is the root of the problem). She is not at all concerned about the tear and is calling it "plantar fasciitis." I just really find it hard to believe this chronic issue I've had for a year now will get fixed in 2 weeks with physical therapy. I asked about an injection for the bursitis and she said she is not a fan of them (generally speaking I am not either, but I was under the impression an injection for bursitis would be in a different location from an injection for general plantar fasciitis?) I'm just wondering what your recommendation, in this case, might be?
Dr. Blake's comment: Yes, stay away from the injections, as they can weaken the tissue more. The boot is fine for the next 3 months, and you can get some Hike and Bike shoes to walk around with more and more as the months go on. Even if you only wear the boot for 3 months, you will need to transition out of the boot over a 2 to 6 week period, and that is usually with Hike and Bike shoes or Hoka One Ones. We need to create a 0-2 pain level ASAP, and then keep it there for 6 months. No stretching at all, you can massage the calf. The PT would be for the inflammation, and for the gait, and core strength right now. Get an EvenUp for the opposite side if you can not get things level, and float the heel if it still hurts in the boot (see the post below). Good luck my friend. Rich

Thank you!

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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.