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Saturday, January 28, 2017

Plantar Fasciitis: Email Advice

Dear Dr. Blake,

I apologize for what will be a somewhat lengthy e-mail, but I'm at the end of my rope dealing with local medical professionals and could really use some advice. I spent hours reading your blog yesterday when I came across it and it was very helpful, but every case of PF is different so I thought I would write in with my story. The foot pain is quite scary and debilitating, and to top it all off it has been mismanaged by medical professionals, making a bad situation worse.

I've had heel and now arch pain for 9 weeks now (12 weeks since the email was answered), not as long as some, but it has become pretty nasty. It started on Halloween after I moved to a new machine at work that required me to stand a lot on metal grating. Treatment was delayed as I was sure that the "bruised" feeling in my feet was simply my muscles adjusting to the different work surface. When it didn't resolve over a four-day weekend with me resting and doing supportive care (Epsom salt soaks and arnica creams) I became worried. I got to where I was almost pain free over the weekend, but when I went back to work my feet started hurting again. When I did make an appointment with a podiatrist, I got hit with a 2-week wait, so I wasn't seen until 11/17. In the meantime, I was taping my feet when I worked (it didn't make me pain-free, but it helped) and trying to rest as much as possible on the weekends. When I finally did get seen by the doctor, they took x-rays, and then he sat down with me for 5 whole minutes, manually palpated my feet (at the time, they were not sensitive to palpation) and cast me for orthotics. Said it would take 3 weeks, but 7 weeks later, I am still waiting. He did not release me for work at all and told me just to "use pain as a guide" even though he knew I did factory work on concrete floors and metal grating. He did not offer to tape or brace my feet even though I told him the taping helped and was the only way I got through the day at work. I have not been back to that office.
Dr Blake's comment: There are 3 phases of rehabilitation: Immobilization (which you are in and were trying to do for yourself), Re-Strengthening, and then Return To Activity (typically why you are preparing orthotics to allow function but still resting and supporting the arch). So, you are out of Phase in your treatment. You need to be immobilized with tape, removable boot, crutches if need be to create the 0-2 pain level environment of healing. It is all about timing, and at the relatively early times of treatment, doctors usually get this right. You not so. 

At the beginning of December, things worsened and I obtained a work release over the phone from the first doctor. I also made an appointment at another office and got in right away. My left foot at this point was very painful and had a big, tight knot right in front of the heel. My foot was now painful to palpation. They taped my feet using the Low-Dye method and extended my work leave for one more week. I kept the tape on, and after a few days, had much better mobility. I went in for more tapings and kept the tape on until Christmas break, when I didn't think I needed it on due to how much I would be sitting around over the weekend. I'm not sure if I did a little too much barefoot walking (it felt great the first night I had the tape off) or if it just wasn't ready to go from support to no support, but I ended up being in a lot of pain over the weekend, even when non-weight bearing. I was able to massage some scar tissue out of my arches and I think some of the pain was from my muscles, but the fascia was definitely tender too.
Dr Blake's comment: So, an MRI to know if you have a plantar fascia tear would be nice. Please order support the foot tape online. Since you have definitely found taping helpful, I would not be without taping for the next 3 months. Hopefully the orthotic devices are coming in now, so they will help. But you also should be spending some time in a boot. Associated with Immobilization is Anti-inflammatory. I am not a big believer in drugs, especially without a definitive diagnosis, so I would rather you lay your foot on a reusable ice pack for 10 minutes 3 times a day to constantly cool your foot off. 

I went back into the second doctor's office and they finally did an ultrasound to rule out a tear. He said everything looked pretty "healthy" except for the fascia being enlarged consistent with being inflamed. He insisted on doing an injection, and I relented. It was ultrasound guided, but I'm not sure the exact location he injected into. The needle went in the side of my foot, not through the back of my heel. I did work immediately after and did 30 hours of work that week, but doing a pretty sit-down job. My foot was painful for about a week (they said it would hurt for a couple days but it took longer than that to stabilize). Meanwhile I found out there was a discrepancy in the paperwork (two conflicting dates as to when I was cleared for work) so I went back to sort that out and he was extremely rude, blowing up at me and accusing me of wanting long-term disability. I reminded him that my work has a rule that unless I'm 100%, I need to be out on disability. They don't do light duty. He ended up giving me another month off but insisted that rest would not help my condition. He has been a decent doctor (better than the first one) but after him blowing up at me over something that was his mistake (not being clear on when I was allowed to go back to work) I'm hesitant to go back there and throw more money at him. He did say the boots and orthotics I had bought myself were beneficial (more on that in a moment).
Dr Blake's comment: Creating a pain free environment often requires time off work and feet are the most needy since you have to stand on your foot. If injection therapy is being used, it can take 3 injections to get full relief waiting one month between injections to make sure of the results of each. I personally would rather start with physical therapy. Ultrasound typically shows thickening of the fascia when there is some tearing (micro or macro scopic). This means that there is some degeneration of the fascia, or weakness, and putting cortisone into the tissue is risky. Do this the least possible. There is no excuse for his rudeness, I am sorry. 

So as it stands now, I'm a couple weeks post-injection. I have not done any weight-bearing stretches (even before the injection, they hurt too much, so I refrained). I stretch (pull toes back) before getting out of bed and wear a night splint for a couple hours before bed and additionally during the day if I have time. I did not have any morning pain up until a couple weeks ago and it is slight and transient (5 minutes or less duration). I have quality orthotics (not custom but they fit my high arches very well) in my shoes and I am trying Z-Coil work boots. I also tape or brace my left foot when I am out and about. I am trying to transition to a brace and get away from taping as the foot muscles are very weak from being taped all these weeks and I would like to try and strengthen them again. The brace seems to work well enough. With that, the orthotics and the Z-Coils I don't have pain when walking or standing (but I haven't really "tested" it yet like I will have to when I go back to work). I also use a cold laser on it every day. 
Dr Blake's comment: Sounds like you are moving in the right direction, just a bumpy road. I would not stop taping until you are back to work for 2-3 months and doing well. The taping has worked for you since day one. As long as the orthotics seem to transfer weight off the painful spot, you are good in that area. If you are worried about foot strength, see my you tube videos on foot and ankle strengthening. Go to YouTube and type drblakeshealingsole foot and ankle strengthening and they will pop right up. If every evening you do 2 or 3 exercises, you will be fine. Just do not push through pain. I should recommend the work Z-coils more often. 

I'm eager to get back to work but also anxious about re-stressing it again too soon. I work 10-hour shifts on concrete floors and metal grating and there is a lot of walking and standing involved. With the taping/bracing, good boots and orthotics, can I chance going back to work, or should I try to rest it longer? I'm so scared of this becoming a chronic condition, and some sources say to avoid stressing it at all costs or it'll cause permanent damage, and others say it won't cause permanent damage and it just has to work itself out. 
Dr Blake's comment: You do not go back to work the first day you feel better, but if you have had 2 weeks of consistent relief, then back to work you go. That does not mean you tolerate pain however, so if you can not modify your job, and you can not keep the pain between 0-2, you have to go off work for another month. This is what we tell all our injured workers. You have to go back to work to test it, but it may not succeed. There is no guarantee that if you rest for the next 2 months, that it will be any better. What you have tried is going back to work, but having physical therapy twice a week during the first month you go back. That, along with your icing 3 times a day, taping, orthotics, Z-coils, some body shifting, and 800 mg ibuprofen 3 times a day for 5 days on, 2 days off can all help you. Good luck my friend. Rich

Feel free to use any of this for your blog (if it's not too boring), and I very much appreciate your time in reading this.

And the Patient's Response:

Thank you very much for your response. I hope your time in Hawaii was good. I agree with what you said, I think I would be better off if I had just kept up with the taping over the past month I would be better off, I actually was doing well for a couple weeks without being taped but I increased my activity a bit and am now hurting again because of it. I got my foot taped up again and will keep the tape on when I go back to work on the 1st. I do have an appointment scheduled for the 3rd so if those two days of work don't go well, I can beg for more time off. 

One other question, what is your opinion of prolotherapy and PRP for my situation? Which (if any) would you recommend? They were both options my doctor mentioned going forward if the steroid injection did not work. They are both expensive (PRP more so) and not covered by insurance but I would rather go that route than trying more steroids. I don't think my doctor will sign off on more time off work unless I agree to another expensive treatment, sadly, so if I have to do that I want to go with the best option. It seems to me that prolotherapy might be more aimed at cases of chronic degeneration, which I don't believe is right for my situation, but I could be wrong.
Dr Blake's comment: That is blackmail, unbelievable!!!
I agree with the role of steroid injections, they are meant to bring the pain from a consistent 5 or more down to a controllable 0-2, and that first one seemed to do the trick. I think prolotherapy has some place in a tear, which you do not seem to have. I think PRP would be good, but it is only in theory, and just have not seen that many patients to recommend it. Are you considering PT which would be a logical next choice? You are really at that stage in my mind. 

My "custom orthotics" finally did come in after close to 8 weeks, and they are absolutely useless. They are not true custom, they are prefabricated and slightly modified according to the cast of the patient's foot (this is according to to lab's website). The orthotics I bought online provide better support. So another option is to be re-cast by my current doctor for orthotics. I'm hesitant, though, as even though I've seen good results with my orthotics and Z-Coils, they still weren't enough to keep me from overstressing things when I tried to ramp up my activity levels a bit with a short hike and some stairs.
Dr Blake's comment: Yes, try to get a custom pair that works, that would be a great place to go. Tell this doc why the last pair did not work. Too low in the arch? Too hard in the heel? Etc. Something that he/she can go off of. Can you get an MRI for more information, especially to see if there is bone swelling? That will not show up on an ultrasound, and can be very sensitive. Rich

And More Response:

Yes, PT was another option he mentioned as well, and while he seemed not as enthusiastic about that option, it might be good to try at this point along with the orthotics. I've been hesitant to try any more injection-based therapies for the reasons you stated, so I appreciate your perspective on the prolotherapy and PRP. I would likely try PRP if it was covered by insurance, but it's not, and due to my high deductible and this injury occurring late last year/beginning of this year I've had to pay for everything out of pocket thus far. I obviously would pay any price for a guarantee to put my foot right, but there are no guarantees in any of this and paying repeatedly for treatments that don't work is disheartening.

One more thing I want to add while I have your ear, I've noticed a light burning sensation in my foot at rest. It's not really a "burning pain" sensation so much as it just feels like heat. It comes and goes, sometimes I notice it more than others. It's not towards the heel or the midfoot, it's more toward the ball of my foot. I noticed it after the initial pain wore off from the steroid injection, and it's stayed. Is this sensation of heat indicative of inflammation? Something going on with my nerves?
Dr Blake's comment: Either. Just make sure you ice the whole foot, and make sure you are putting weight and not limping onto the ball of your foot. You do not want to stress another part of your foot out. Typically, it is just a warning sign that you are favoring your heel too much, and that takes some self correction to fight against. Good luck. 

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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.