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Tuesday, July 4, 2017

Chronic Heel Pain: Email Advice

Dear Dr. Rich Blake,

I found out about you from the "Physical examination of heel pain" on Youtube. I have chronic heel pain that I don’t even remember when it start. I have seen physicians, physical therapists, two podiatrists and they both said I have plantar fasciitis. However, my symptoms don’t fit into the classic picture of plantar fasciitis. I reach out to you because I need another opinions and you are very knowledgeable and caring (because you take time to write blog and help people that is not in your areas). I just finished my second year of veterinary school. I didn't enjoy learning during labs and farm trips because of the heel pain. I avoid going to clinic to learn during summer because of the heel pain as well… Next semester I will start surgery class, I am now very worried how I can stand still for hours during surgery with the distraction of the pain. I live in Brooklyn and don't have budget to visit San Francisco. I would deeply deeply deeply appreciate it if you can give me some insights via the internet. 
Dr Blake's comment: One possibility is seeing Dr Karen Langone in Long Island, or at least getting a referral from her to someone closer. 

I have bilateral pain in my heels only when standing still for more than ~ 3 minutes. After about ~ 4 minutes, the pain would be too severe that I can't bear it and have to move my feet off the ground. It is very hard for me to stand still. When I wait and stand at the bus station, I have to walk around or shift my weight from one leg to another. The longer I stood on my feet, the worse the pain got.

Walking and sitting can make the pain disappear.  However, if I have been stand for really long time that the pain is very severe, at the moment I take my feet off the ground (e.g. sitting), the pain immediately become more intense and then gradually subside if the feet remain non-weight bearing. Walking for long distance can also produce the pain.

  • The pain doesn’t feel like a sharp pain. I am not sure how to describe it but I think it is more like a dull ache that gradually build up when I stand still.
  • Sitting with both my feet on the floor (bend knee at 90 degree) can also produce the pain (not as painful as standing still). If I bend my knee at more than 90 degree (less weight on the feet), there is no pain.
  • The pain seems to locate at the bottom of my heels, not at the center of the heel but more anterior.
  • It doesn’t hurt when I get up in the morning or walk after a rest.
  • Pain gets worse with continued activity (esp. standing) and increased weight bearing.
  • Pain is also worse while standing on hard surfaces.
  • I don't notice any swelling, bruising, bump, lump in the arch or heel.
  • It isn't painful when I press on the center of the bottom heel and the anterior heel area. (or maybe I didn't press hard enough) 
                         Dr Blake's comment: It does not sound like plantar fasciitis at all. Try to find pain with your fingers when you are sitting or lying. Mark an "x" on the area, maybe different for each foot. If you can not find one, it is referred nerve pain unless an MRI shows us differently. 

  • I am not overweight (normal BMI), don’t smoke or drink.
  • Wearing OTC insoles and custom insoles and shoes that have very good arch support and higher heel drop (e.g. Vonic, New Balance walking shoes ) makes the pain worse, and my arch hurt.)
                        Dr Blake's comment: Sounds like tarsal tunnel or some version.
  • Standing and walking with barefoot also makes the pain worse.
  • Wearing Keen Uneek shoes that has slight elevated heel and mild arch support makes me feel better.

Have you heard of or seen any case that is similar to my case? Do you also think it is plantar fasciitis? I have thought of Infracalcaneal bursitis but the pain is not right underneath the center of the heel. I didn't feel any bump or reproduce the pain when I press on the central heel. Does it sound like stress fracture, nerve entrapment or even partial rupture of the plantar fascia to you? Can you please help with some advise?
Dr Blake's comment: Nerve irritation from a somewhere is the highest possibility. I will have to look up these shoes. A peripheral nerve specialist is your best option right now, along with a podiatrist who is willing to rule out heel pain not caused by plantar fasciitis. Good luck. I have alot in this blog on treating nerve pain in the foot. 

Sorry this is very long. Thank you so much for your time and help. Thank you very much. 


Dear Dr. Rich Blake, 

Thank you very much for your quick reply. After I read the post, I went to my doctor office as soon as possible and convinced her for giving me a MRI referral for both right and left feet. And the reports came out today. During the scan, the technician used different method to do the scan for each feet. When my right foot was scanned, she put something under my heel close to the edge of the heel. For the left foot, that thing was put under the plantar surface of the left foot.  

- Unremarkable MRI scan of the right ankle and tarsal region of the right foot.
- No soft tissue or bony abnormality are seen along the plantar region of the heel at the annotated area of complaint.

- There is a 6 mm bone cyst in the distal tibia at the level of the previous growth plate. 
- There is a small tibiotalar joint effusion, though no apparent disruption of the collateral ligaments.
- No soft tissue or bony abnormality are seen at the area of concern along the plantar surface of the foot adjacent to the heel.
- The remainder of the left ankle and tarsal region of the left foot is normal. 
Dr Blake's comment: This makes tarsal tunnel (nerve pain) the highest possibility, although with bad mechanics of fallen arches, the nerve pain can be secondary. The nerves are not injured, just irritated due to poor mechanics. 

As you said, the MRI showed that the plantar fascias are normal. I am not sure if the bone cyst and effusion are significant on this MRI in my case. 
Dr Blake's comment: I doubt it. Typically, the MRI can tell if it is an active cyst or old. If not, then a bone scan to rule out high activity in the cyst is needed. See what the doc says. 

To answer your question, yes, I have both back and neck pain... swayback , functional shorter right leg, upper cross syndrome, carpal tunnel. I have been doing some core exercises (based on my visit to a PT last summer) to improve my postures. My posture is slowly improving. My gluteus medius and right lower back doesn't hurt as often. When I stand for longer than 1 hour, my lower back, hamstrings, calfs start to hurt. Usually my feet hurt before my back starts to hurt so I did not connect them together. My doctor didn't think it is a neurological issue (cause it is not a tingling pain), so she refused to give me a EMG/ nerve conduction test referral today. 
Dr Blake's comment: Tell her that it can just hurt. Nerve problems produce pain alone (1/3 of the time), pain and abnormal sensations like tingling, bugs crawling on your foot, buzzing, etc (1/3 of the time), and only abnormal sensations (1/3 of the time). 

I feel like there are multiple diffused areas and they don't hurt all of the time so it is hard to draw a cross. The anterior plantar region of the heel bone has been hurt for few years and always hurt when weight bearing. Starting this summer, the lateral ankle area starts to hurt as well when I stand or walk. The medial ankle area hurts when I start to rest but disappear after enough rest. However, it is not absolute, sometimes both sides hurt at the same time some time they doesn't hurt. 

When I wear shoes with good and thick arch support, the area that hurts the most is the area of abductor hallucis (Area 1). I feel the arch support is pushing onto my arch and it is very dis-comfortable, pain appear only after 10s I stand on these shoes. Not sure if the pain is come from the muscle or something else in that area. Keen unkeen sandal and crocs helps with this problem. 

Dr Blake's comment: Patients in general love orthotics and that feeling of good arch support. On the contrary, tarsal tunnel nerve patients can not stand that pressure. It is fairly diagnostic in my mind. 

Also, starting this summer, I feel a sharp pain behind the heel but very close to the edge (Arrow 2) once in a while when I walk or stand. 
Dr Blake's comment: There is a good pesky branch of the sciatic nerve that hates shoe pressure, hates achilles stretches, and is often confused with achilles tendinitis or even plantar fasciitis. Someone skilled at the difference with nerve heel pain and tendon/fascial heel pain, can usually sort it out. If it hurts when your knee is straight and you try to bend your toes towards your nose, but does not hurt with the same ankle motion when your knee is bent, then that makes it easy. Or if bending over to touch your toes hurts the heel/foot, but not if you bend your knees first, you always have the diagnosis of nerve pain. 

On the other hand, I feel pain behind the heel (Arrow 3) when I take the first few steps in the morning. It doesn't happen everyday but It will definitely happen after I stretch the calf or take a long walk the day before. On a bad day, it will hurt when I press on it or lay on the bed. It forces me to sleep on my side instead of on my back. Does sound like insertional achilles tendonitis? Or an irritated nerve issue?
Dr Blake's comment: Still irritated nerve. 

Sometimes, I feel my ankles are stuck, especially the right feet. I need to pop it to feel better. If it cannot be popped, the whole day i will feel uncomfortable in the lateral side of the ankle.
Dr Blake's comment: On the photo you sent, your foot is pronated. This can lead to lateral ankle and subtalar joint impingement. When patients can not wear orthotics, they usually can tolerate a 4 degree varus wedge at the heel only. This is something podiatrists make, but are also sold on line. You would want a podiatrist to tell you if it is stable.

Above are all the feet problems that I can think of. Are these symptoms more likely to be related (neurological) or individual problems? If the feet pain is neurological, how to tell if it is come from the ankle (e.g. tarsal tunnel) or from the lower back?
Dr Blake's comment: The tests above give you some idea of the relationship to the back. The neural flossing is another way to tell. One version is when you point your foot and straighten your knee, you always bend your neck and look at your toes. See my video on neural flossing. But, it takes a good neurologist or physiatrist  or neuro-physical therapist to put the pieces together and come up with a logical treatment plan.

What is the next step I should take? Do I still need to see a podiatrist? Which other specialist I should see next? Is nerve conduction test necessary?
Dr Blake's comment: For this you need a team. Podiatrist to work on foot mechanics and treatments, neurologist or physiatrist to work on diagnosis and treatments, and physical therapist to work on diagnosis and treatments. Start with who can see you first. Below is one place you can start. Good luck Rich
Thank you very much for your time and advice!!


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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.