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Sunday, May 18, 2014

Abrupt Severe Heel Pain needs MRI for diagnosis: Email Advice

Hi Dr. Blake,

I found your website while searching for a podiatrist in the bay area. I'm an ultrarunner (multiple trail 50ks, one 50 miler). I developed abrupt severe onset of right heel pain during a 14 mile trail run (running downhill) at 7 miles, finished up the run. This was 12 weeks ago now. 
Dr Blake's comment: Abrupt severe heel pain during a run is either heel stress fracture, plantar fascial tear, plantar heel bursitis, or Baxter's Nerve Entrapment. 

I did lots of icing, stretching, you name it afterward. I am very good about stretching, wearing the correct shoes, etc. I have continued to have heel pain ever since. Initially I took a week off of running, then went back. I run 3-4 times weekly, mileage is never more than 25-35 weekly. I have tried everything under the sun, including MLS laser, Graston/ART, E-stim, rolling, stretching, icing, changing my shoes (was in Pearl Izumi M2, went back to Hokas), heel cups, night splint,  plantar fasciitis cups, superfeet. 
Dr Blake's comment: When patients give me info about past treatment, it is important to know what treatments helped somewhat and what treatments aggravated. You have had treatments in the 3 important areas of heel pain treatment---stretching, biomechanical changes, and anti-inflammatory. However, without a diagnosis, we need the info on how various treatments effect the heel pain for the positive and negative. 

I have stopped running altogether, I'm going on my 2nd week. The symptoms have not gotten better, in fact it is getting worse. I did some research the other night and realize I may have injured my heel fat pad. When I displace the fat over my heel, my pinpoint tenderness, which is in the middle medial of the heel, goes away. I have started taping the heel (for fat pad syndrome). 2 days of that but have not noticed any improvement.
Dr Blake's comment: Typically heel fat pad injuries are chronic, but the lack of heel padding can lead to nerve entrapment, bursitis, or stress fracture/bruise. 

 My heel is swollen, which I believe is unusual for plantar fasciitis.  Prior to this injury, I was in great shape, no aches, pains anywhere. I did have a weird sensation to my 4th and 5th left toes starting about a month prior when I would run; felt like they were squished together, broken.  I have NO achilles pain, no dorsal foot pain or numbness, no arch pain.
Dr Blake's comment: The swelling is typically plantar fascial tear or calcaneal/heel stress fracture. MRI is crucial and definitive for the diagnosis. 

I am completely devastated by this injury. I run on trails, I don't pile on tons of miles, I stretch, get rest, take care of my feet. I am afraid I've done permanently damaged my heel fat pad. I am waiting to get into a UCDavis sports PM&R doc soon and will request an MRI. I did have an xray about 2-3 wks after the injury and no stress fracture was seen, they did see a small bone spur.
Dr Blake's comment: I would not get too excited until the results of the MRI come back. If the the MRI comes back negative, I would be happy to look at the images. If negative for tear or bone edema, which will both heal with cam walkers and time, then the doc soon palpate for a bursitis or neuritis. He/she can compare the fat pad on both sides. Keep me in the loop!!! Rich

I am not interested in cortisone injection as the research doesn't seem to show that helps much and if fat pad syndrome an issue, it could worsen it.

Do you have any recommendations? Would it be helpful to make an appt with you?


1 comment:

  1. Thank you so much for getting back to me so quickly, Dr. Blake. I can't say I have gotten ANY relief with any of the treatments thus far. I have felt some mild reduction in pain w/low dye taping for heel fat pad syndrome as well as wearing a new trail shoe with a 10mm drop and good heel support (Salomon Mission XR). I'm using those to walk around in and they feel better than any other shoe so far. It would be awesome to have you look at the films for me.I will definitely keep you in the loop!


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.