Calcaneal Stress Fracture: A Cause of Acute Heel Pain

https://youtu.be/8xxbQwogdb8

I love Dr. Nabil Eberheim. He runs a simple straight forward You Tube channel with great medical education. Please review some of my other posts on calcaneal stress fractures, a common cause of acute heel pain. 

https://www.drblakeshealingsole.com/2012/11/calcaneal-heel-bone-stress-fractures.html

https://www.drblakeshealingsole.com/2020/07/how-i-approach-problems-plantar.html

https://www.drblakeshealingsole.com/2020/07/how-i-approach-problems-heel-pain.html

https://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-11.html

Use of Sleeping Splints for Plantar Fasciitis

Good morning Readers, 

     It is a beautiful Sunday morning in San Francisco, although the Fires in the West of USA are frightful!

I pray for all those that have lost their homes to these fires. 

     The question today concerns the efficacy of the posterior sleeping splints for plantar fasciitis. I have attached a link to a video I did long ago still applicable.

https://youtu.be/lyd9HAv9e9o

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I use it for the patients with morning soreness when they wake up. It is important to find out how long they have symptoms when they arise. A simple case of plantar fasciitis normally hurts for 5 minutes or so. I am surprised when I ask when the patients say that it can take an hour or so. I have even had patients tell me the pain either never feels better, or they never have morning soreness. In both these cases, if your diagnosis is plantar fasciitis, you may be wrong. There are so many other causes of foot pain incorrectly diagnosed as Plantar Fasciitis. 

So, plantar fasciitis is normally diagnosed by historical review, but a good examination is also important. I have left the link from my video on Heel Pain Examination. 

https://youtu.be/plbBvPASXwM

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Can Plantar Fasciitis occur in other areas of the foot? For sure!! But, a non-heel diagnosis of plantar fasciitis is always suspect. 

Calcaneal Stress Fracture: Last Patient of 2019

     My last official patient of 2019 was the 95 year old mother of a wonderful patient of mine. He brought her into the treatment room in a wheelchair with acute one day pain in her right heel. There was no incident of trauma. She has been struggling with pain in her left knee for a long time and perhaps is favoring her right foot. I went right to an MRI which they were able to get within the hour at our hospital fearing broken bone with this age and history until proven otherwise. Xrays can take weeks show subtle signs of a stress fracture, but the MRI images below (both T1 and T2) dramatically show the stress fracture non-displaced. I will keep her off her foot for the next month and start an Exogen bone stimulator if I can get approval for. Interestingly, her son fractured his heel bone doing ball room dancing 10 years ago in the same place. Genetic do give us weak spots. You can tell by the MRIs that the stress fracture was not due to weight bearing compression forces, but to the pull of the achilles tendon similar to many cases of Severs. Look how strong the achilles looks and the overall bone density seen on T2 throughout the area looks fine and not demineralized like in disuse atrophy. 

On a side note: This is my 2000th Blog Post since my start of blogging in March 2010! No one cares but me, but that will not stop me from raising a glass of champagne or bubbly tonight! Happy New Years. 

Sometimes Heel Pain is Not Plantar Fasciitis: A Case of Wrong Self Diagnosis

Rich, 

Thank you again for lifting my spirits today. Honestly can’t express in words how much the appointment meant to me. 

AND - I forgot to tell you!  You fixed my mother-in-law’s foot!  Basically she was having heel pain that she had labeled plantar fasciitis. I hadn’t seen her in a while, and wasn’t sure if that was the right dx. So, I sent her one of your plantar fasciitis summary pages from the blog (it has a video of you doing a heel pain exam/eval), and this is what I got back a few days ago:

https://youtu.be/plbBvPASXwM

“Thank you so much for sending me that video.  I watched it and decided I didn't have the typical symptoms of plantar fasciitis.  I pushed at the places he pointed out and the pain was wrong.  I saw my physician today.  She decided that it was not plantar fasciitis but a thickening of the skin on the heel.  In one spot because of a wart and in the other spot probably some foreign object.  She scraped and scraped and miracle of miracles----no more pain.  I can't believe it!  I have been off my feet for almost two months eschewing hiking and walking.  I gained more weight.  I feel like a fool not to have researched it myself or at least made an appointment much earlier.“

Amazing!  

Oofos: A Soft Sandal for Heel or Ball of Foot Conditions

Oofos is a very cushioned sandal that many of my patients with heel or metatarsal area pain are raving about. They will not replace a removable boot and/or crutches when you need those, but they can help if you are in a more chronic stage. I am really not sure if there is a difference between them and the softness of crocs, but they have various styles to at least experiment with. If I have taught anything on this blog, I hope I have imparted the need for experimentation to help with foot problems. 

https://www.oofos.com/  

When Something is not Plantar Fasciitis: Email Condition

Dr. Blake,

I've been diagnosed with Plantar Fasciitis 3 months ago,  however I'm not sure if  I actually have that condition.

The Doctor did zero testing. I had googled heel pain and up came Plantar Fasciitis and I have high arches.  I found a local podiatrist and I sent a message asking if she treated this condition as well as plantar warts.

Turns out I don't have plantar warts but I definitely do have heel pain which came on suddenly for no apparent reason and has gotten steadily worse. 

Dr Blake's comment: Typically plantar fasciitis (an inflammatory condition) has a gradual onset over weeks, and usually months. 

I've been told that usually PF cause pain first thing in the morning but not for me. I have no pain in the morning. My pain appears after I been walking slowly and gently for a limited period. 

Dr Blake's comment: Definitely this is not plantar fasciitis, more like a heel bruise, heel bursitis, or some tendinitis/myositis of the local muscles. 

The doctor suggested the following treatment which I have done.

I purchased a compression sock and I wear it .

I take Aleve on off for selected period of times.

I soak my foot in Epsom salt until its a prune

The doctor taped my foot (made it more painful).

The doctor wrapped my foot in gauze with a cushion inserted and then applied a lite casting plus another wrap on top for a sprain. This was a disaster because the cushion had slipped to a position on the top of my foot where the foot and ankle meet.  I took it off in two days it was supposed to stay on for 7.

I have a prescription for PT but have yet to attend as I am not convinced about the diagnosis.

Dr Blake's comment: Sometimes PTs just blindly follow the Rx, and sometimes they try to give you an independent diagnosis. They can still follow the doc's RX if it is general enough. Definitely ask around to find a good independent thinker. 

The doctor has also suggested cortisone shots which I have declined.

Dr Blake's comment: Good for you. If you have a small fracture or small tear, these can be made worse. 

I also have all sorts of inserts which maybe ​contributing to making things more painful.

Dr Blake's comment: You have to try these, and sometimes you will be surprised what feels good, and what increases your heel pain. Amazing how many people continue to wear inserts that bother their feet in some way, although sometimes they have no other option. 

The issue  is that this condition is getting worse a case of the creeping pain, which is now gone up to the ankle and calf in the affected​ foot and also to a lesser degree in the other leg/foot which I believe is responding to my change in gait. I am hobbling around almost to the point of immobile.

Can you help me. I live in Emeryville CA . I have Medicare and AARP Supplemental policy. This situation is rapidly becoming debilitating and I really need to do something.

Dr Blake's comment: I am just across the bay. Come see me after an MRI if you can get it, and bring anything you have. 

Thanks

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.

Sincerely,

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. 

Heel Pain: Adjusting the Removable Boot

Sometimes I am very proud of myself. This nice lady tore her plantar fascia and was prescribed a walking boot for 3 months. When she came in with the boot, and since her heel was swollen, she was still hurting about at a level 8 out of 10. Here I am using two 1/4 inch pads of adhesive felt from Moore Medical to fashion an off weight bearing pad for her heel on my work bench. With the instructions to land full foot, not heel strike, the pain decreased to the healing 0-2 pain level. She has a lot to do with the inflammation over the next 6 weeks with icing and contrast bathing also. 

You can see the heel is floated with the weight on the 1/2 inch front pad.

Here is the roll of 1/4 adhesive felt I was using. If you don't want to wait, use other materials, like shoe inserts, and try to create the same float idea. You too can be as brillant as I was this day. LOL

https://www.mooremedical.com/Index.cfm?Ntk=all&No=0&Search=Search&Ns=TotalRevenue%7C1&Ntx=mode+matchpartialmax&Ntt=adhesive+felt

Generalized Heel Pain: Email Advice

Hi Dr. Blake!
I noticed that one of your hobbies is hiking. I feel like you might have some good advice to get me through a field season. I was recently diagnosed with PF and Haglunds Heel and my heel is on crooked.  I hike 10ish off trail miles a day for work. Several of those miles are in streams on river rock, jumping off of log jams, etc. And all of these miles are done in waders and wading boots.
I have insoles, my right foot is taped (I haven't had my left foot examined yet), cortizone injection 3 weeks ago and I am a frequent user of Ibuprofen. I'm not completely weight bearing yet. 
Do you have any stretches that I can perform out in nature? I watched your stretching video, but I don't have any walls around me. I've been doing the stretch you say is a no no. But, I do it one leg at a time. I hang my heel off the river bank or a log. I do try to find a good boulder to try to stretch on, but it's difficult to get a balanced stretch.
I usually, but not always will have time in the work truck between sites where I use a tennis ball over my foot~ is there any stretches I can do in the truck?
OH, and is backpacking possible?  
Thanks so much for this service you do with your blog,

Dr Blake's response: Shannon, first of all, tell me what hurts (ie bottom of heel, arch, back of heel, achilles, calf), and when it hurts (getting out of bed in morning, putting boots on, walking at work, evening hours, sleeping), and what makes what better or worse. Rich

Thanks for your speedy response!

Since having the cortisone shot in my heel, that spot is pain free. The shot is in the heel (center left (my left)).   But, everything around it feels pain.  The back of the heel gets painful. My Achilles is often sore. I don't feel the morning pain since the shot, and I do stretches before getting on my feet. I do get stiff after I get home and sit a while. When I'm working I have been feeling pain about one mile in. No pain at night since the cortizone shot.  I had to stand on my feet in one spot for 5-6 hours the other day...pretty painful by about the 2nd hour. I notice that I walk on my toes more often and that can't be good for my back.

Ice and heat help.

I'd love to soak it in Epsom salts but my foot is taped.

Ibuprophen ( We call it I-be-broken in our household) helps. I recently took a 4 day break from it and my heel and ankle were sore.

I've been massaging my calf muscle and foot and that helps keep my calf from tensing up.

I hope this is helpful.

Thank you!

Dr Blake's response:

Hey Shannon, switch to support the foot taping so you can get it wet and do Epsom salts, may make a difference. Go to www.supportthefoot.com. Get the regular size. Just seems like the inflammation is out of control. Could you wear an Anklizer boot on in the field 4 hours a day to rest it better? I would love an MRI to see if you have a bone bruise/stress fracture!! At least, making the right diagnosis can help with PT recommendations on what to safely do. Hope this helps some. Rich

Thank you!! I just ordered the Support the Foot tape. I've actually had a big change this week with my foot. I tried the hard plastic insoles and they've helped dramatically! I was dreading hard plastic, but it really did the trick. I did about 9-10 miles each day last week and I'm able to bare weight. I'm so excited! I think I will be able to go backpacking and hiking (outside of work) this Summer. 
thanks for your advice and thanks for doing your blog~ I've learned a lot.

Have a great weekend!

Dr Blake's Response: Great News. Glad getting the right support helped. The support the foot tape will be good for flareups or long hiking for added protection. Rich

Heel or Knee Pain: Removing Hard Rearfoot Posts at times can help

Hard Plastic Rearfoot Posts give great stability, but can be too hard, especially with knee and heel pain. Here the left one has be ground off (It can always be put back on). 

This photo emphasizes the hardness of the post.

Here is a closer look at the ground off post.

I just love Graffiti Art that is all over San Francisco!! Here it is on Market Street seen on a walk today. 

Heel Pain: Email Advice

Hi,

Ive got a question I have been seeing a local doctor and he has gave me a series of 3 cortisone shots in the side of my heal no spreading it around just a prick and done. Now he is telling me that he needs to go in and cut the fascia. I am not comfortable about this. Is there any other options???

Limping in Illinois

Dr Blake's comment: 

     Hey Limping, thank you so very much for the email. And, sorry you are limping!! With perhaps less than 1% of all plantar fasciitis cases needing surgery, I look at this with a bit (a lot) of caution. The plantar fascia is the 3rd supporting structure for your arch (after the ligaments and muscles/tendons), and there are cases of arches collapsing following surgical release (very small percentage also). However, that means you should consider plantar fascia release only if all the stones are turned over. Definitely get some other opinions, but do not tell anyone about what this doc wants to do. Only tell them what you have had done that has not worked so far, and what are your options. Cortisone is part of the Immobilization/Anti-Inflammatory Phase where you are trying to achieve that coveted pain free environment (0-2 level pain). While you are getting the shots (or physical therapy, or a home program of icing and contrast bathing and NSAIDs, or a combination of these things), you should be getting protected weight bearing inserts like orthotics. You may need a removable boot like an Anklizer (purchase online), or need to tape every day (www.supportthefoot.com). Until the pain is under control, I would avoid stretching the achilles and plantar fascia since you may have a plantar fascial tear. An MRI would be wonderful to see what is really going on. If you can not get a referral, you can check the AAPSM website for sports medicine podiatrists. It typically is a good source. 
     You may need surgery, but I would step back, get some opinions, and see what people say. I hope this helps you some. Rich

Heel Pain/Plantar Fasciitis: Email Advice

I came across your website trying to find any other options for the heel pain / fasciitis that I may have. I am from Tennessee. My problems have been going on for 2 years. Both feet.

 About 3 months ago the right heel pain resolved. The left has not. I am seeing my second podiatrist. I have the custom hard inserts I keep in my shoes.

Dr Blake's comment: This is the time to critically evaluate each treatment avenue/modality and possibly make changes. The orthotic goal for patients with heel pain is to transfer the weight into the arch and cushion/float the heel. Do you feel this is being accomplished? If not, see if they can be altered or remade. This is called protective weight bearing and every step you take can be used to make the heel better if done right. 

 I have had my heel injection 3 times by the second podiatrist this year. Helps some but seems to "wear" off and return to pain. 2 times the year before with absolutely no relief which is why it took me a year to finally go again. 
Dr Blake's comment: Cortisone shots can be crucial if there is heel bursitis, but it is a mixed bag with plantar fasciitis. You really do not want to inject the plantar fascia itself, so you have to inject under it (and gravity actually pulls the cortisone away from the fascia) limiting its effectiveness. 

Wears a night splint but not all time because I didn't feel like it was making a difference.
Dr Blake's comment: If you have the classic morning soreness from from plantar fasciitis, the night splints should do wonders if the plantar fascia is tight. When there is minimal results with the night splint, you either do not have plantar fasciitis, your fascia is just not tight, or it is the wrong type of splint (I like the ones where the heel is enclosed and the toes are not bent up). 

 Can't take antiinflammatory long. They hurt my stomach.
Dr Blake's comment: You can use celebrex which is milder on the stomach with or without cytotec. Or, you can use topical Voltaren 1.3% gel or flector patches. Any anti-inflammatory drug, no matter the application, should be done on a 5 day on 2 day off routine, or 10 day on 4 day off routine, to rest the body and prevent some of the side-effects. You typically have to ice more on the days you are not using the medication. 

 Oral steroids may help a little but I know I cant always take them.
Dr Blake's comment: I love an 8 day Prednisone burst to knock out inflammation. See my blog post on that. It is especially good in chronic situations, or acute flares. But, it can also be very diagnostic when it works or does not work. It is for inflammation, but does not help the mechanical or neuropathic aspects of the pain. 

 Have been in a walking boot for 6 weeks. That didn't help any.
Dr Blake's comment: This is where I would need more info. When you were in the boot, were you 100% pain free. Plantar fasciitis feels great in the boot, plantar heel bursitis may hurt more in the boot. The problem with boots and heel pain is that your heel stays down longer than normal walking, thus increasing the normal pressure on the heel. But, the boots allow you to roll through, not bending the toes at push off, and thus not irritating the plantar fascia. I guess you can see that success or failure with any of these treatments can help us fine tune what is going on and how to fix it. 

 Have used heel cups. Good shoes that are known for stability. Have heel Spurs to both feet. But as a nurse practitioner I understand it is not the spur itself causing the pain. I have wore straps around my ankles that allowed me to strap my foot.
Dr Blake's comment: Does the strapping help? Typically works well with plantar fasciitis. And yes, the spur does not cause pain!!! 

  I do work 6 days a week for the most part with one to two of those days 12 hours.
Dr Blake's comment: I do not have to tell you that working that much can decrease your immune system's ability to heal. Have you had a workup on your ability to heal? Are there other problems that have been slow at healing? Are you always fatigued or have other systemic signs/symptoms?

 I am so frustrated that I cannot make this resolve and wondered if you might have any suggestions on what to do. I would love to be able to walk from the time that I get up til bedtime with no pain. I want to be able to walk run and I cannot. My feet get so sore and it is difficult to walk. Once I get walking it will settle some but will be even worse when I sit or sleep. I am suppose to visit the podiatrist again Monday to consider a 4th injection. Thank you again for any comments you may can give
Dr Blake's comment: I would suggest no more shots until you get an MRI. You could have a slight tear in the plantar fascia that cortisone can make worse. Even if you have to self pay for a Rearfoot MRI without contrast, it would be worth it. Hope this helps you in some way. 

Helen (name changed)
Tennessee

Plantar Heel Bursitis: General Treatment Thoughts

Plantar Heel Bursitis

    A bursae is a sac between the skin and bone that, if the area is traumatized, can fill up with fluid (called bursitis) to protect the underlying bone. Bursitis is common in the feet, knees, hips, elbows, and shoulders. I once had 7 months of shoulder bursitis from incorrect biomechanics while painting a cathedral ceiling in my house. Plantar heel bursitis is often confused from plantar fasciitis. Acute plantar heel bursitis can develop suddenly from impact, but a bursitis can also develop slowly from chronic inflammation (typically secondary to plantar fasciitis or calcaneal bone injuries. If you have plantar heel bursitis, you typically can not walk on your heels without pain. Having my patients first walk down the hall barefoot normally, then on their toes, and then on their heels only, can make the diagnosis of bursitis (although a small stress fracture on the heel bone make still be present. One of the treatments for heel bursitis (not initially) is a cortisone shot. Because the bursitis can be secondary to something else that the shot may hurt, I try not to do a shot unless I have an MRI if possible. And, sometimes, you just have to take your chances if it does not make sense that anything but bursitis exists. Always consider that you make have a bursitis, with plantar fasciitis, if treatment of the plantar fascia alone is not helping.

Elbow bursitis (aka students bursitis from chronic leaning on elbows while studying. Many times heel bursitis looks like the skin wants to explode releasing the fluid trapped.

The top 8 treatments for plantar heel bursitis:

1.  5 minute frozen sport bottle roll just under the heel 3 times daily

2.  Heel cushions to protect the heel (sometimes used alone, and sometimes an arch support to transfer weight off the heel is vital)

3.  Physical therapy to breakdown the bursal sac with a combination of ultrasound to super heat, deep tissue massage to break down or move fluid, and electrical stim to push fluid out.

4. Cortisone shot, if the above is not eliminating problem, and a MRI has ruled out any other problem. These shots are given from the side of the heel, not from directly under, which makes them less painful. A series of cortisone shots may be necessary (see the section on cortisone shots). This is the only heel pain diagnosis that a cortisone shot is used for.

5. Avoid barefoot for continual irritation

6. Use some heeled shoe, like a dansko clog, around the house.

7. Use wedges instead of straight heels to distribute the weight better.

8. Also, consider wearing Crocs for their shock absorption

Heel Bursitis (Plantar/Bottom of Heel): Typical Physical Therapy Regimen

Hi Dr. Blake!

I hope you have a fun-filled long weekend planned!.I'm checking in at the two week mark as we discussed. My stubborn little calcaneal bursitis is still causing me grief. I did try the contrast bath - but it seemed to irritate it, so I've stuck with icing. I have not been jumping in dance class or standing in spin. In fact, releve (going up on the ball of the foot) seems to bug it as well, so I've eliminated turning. Since I wasn't making the progress I'd hope to on my own, I thought I'd finally book the PT. I work in SF, so I would consider coming over to St. Francis, but if you know of another good place in the East Bay, it might be more convenient.Thanks so much! It really is wonderful having someone I've known for 24 years (!!) I can come to with these bothers. And even though it's an injury that brings me in to see you, it is always great to see you! ;-)

Have a fabulous weekend and talk soon,

Tracy

Dr Blake’s response:

Tracy,

    Physical Therapy for calcaneal bursitis (under the heel) should be done twice weekly for 4 weeks and should include in this order: Ultrasound as a way of producing deep heat to the bursitis tissue making it vulnerable to the next two treatments. The ultrasound is following by deep friction massage to break down the bursae. The deep tissue work is following by 5 minutes of vigorous ice massage to calm down any aggravation of the inflammation and further the breakdown process. Since plantar fasciitis is normally part of the problem, the PT may address part of the treatment for that also. If calcaneal bursitis is a major part of the pain, make sure that the 3 components in the order of ultrasound, deep friction massage, and icing are the central part of the treatment. I will see you following the first 4 visits to make sure we are all on the same page. Good luck, and great to see you again as always. Rich

PS. During the time you are in physical therapy, you must continue to ice massage 3 times a day (since the contrast bathing did not help), and do as much physical activity as you can without flaring up the symptoms. It is normally a mistake to go to physical therapy at the same time you are resting an injury completely. The physical therapist never gets a good feel of your improvement, or lack of improvement. Use the information on Good Pain vs Bad Pain to base your Activity Modification Program.

Also, the next step with calcaneal bursitis is cortisone shots, but that requires 2 weeks off activity/shot, and could require up to 3 shots (the response to the shot is evaluated in 2 weeks), so most athletes try to avoid with a passion. Good luck Tracy, email me after 4 physical therapy visits.

New Website for Heel Pain Sufferers: I hope it helps millions!!

Hi-

I wrote to you a couple of months ago and asked if you would mind if I embed one of your videos onto a website I was building about heel pain. The one showing the plantar fasciitis wall stretch is the one that I wanted to use.

Just letting you know that the website is up and running if you want to see how it came out. Your video is located at:

http://heelpainrelief.net/physical-therapy-videos/

Hope you like the way it turned out. I have a link to your site also. I could add another one or two videos if you want; let me know if there is one specifically that would fit.

Again, thanks for your help. I really like your work...

Sincerely,

Heel Pain: Email Advice

Dear Dr. Blake,

I am so grateful to your writing this wonderful blog. Thank you!

For about 12 month I have severe, debilitating heel pain, very similar to plantar fasciitis. I do not have any first step pain and my pain gets progressively worse over the course of the day. 

Dr Blake's comment: Without the am soreness, we are probably not dealing with plantar fasciitis. 

In addition, I experience a burning pain that feels like nerve pain.

Dr Blake's comment: Here is my original video on the differential of heel pain. See if it makes sense that you have plantar fasciitis or another problem. The hardest to diagnosis is nerve entrapment. 

 I am able to only stand or walk for about 3-5 minutes. The inside of my heel is tender if pressed and my heel is painful upon percussion.
Dr Blake's comment: This sounds like possible calcaneal (heel) stress fracture/bone reaction. This diagnosis is only made by MRI or bone scan. 

 Over the past few months, we have ruled out plantar fasciitis, as well as nerve root compression originating from L5/ S1. As a treatment I had received a steroid injection into the plantar fascia, as well as an epidural steroid injection. These treatments have not produced any results. I try to stay very active: I do yoga, Pilates, I walk on a de-weighed treadmill, and I work out on a stationary bike in a tireless attempt to get better. I so hope to be able to take a walk with my children again.
Dr Blake's comment: Even though your workup sounds good, why has there not been an MRI or bone scan? You can have nerve pain from the swelling produced from a calcaneal fracture. So get one of those 2 scans. 

Recently, someone suggested to me that I had Baxter’s neuritis. From the literature that I was able to find, this diagnosis seems to fit my symptoms exactly. I do feel a lot of sensation and pain along the course of the first branch of the lateral plantar nerve. What would be the treatment for this?
I am wondering if I should immobilize my foot instead of stretching it and mobilizing it.
I would be most grateful for a reply.
Kind regards,
Dr Blake's comment: Baxter's neuritis can be a cause, but impossible to diagnosis. It is always a possibility in recalcitrant heel pain. You need to rule out bone issues and then inject the lateral plantar nerve with long acting local anesthetic to see if that helps. If it does, try several cortisone shots into the same area, and consider surgery only if the shots give you temporary but great responses. I hope this helps. Rich

Heel Pain: Early Signs of Developing Plantar Fasciitis

Richard 

 I hope this email finds you well.  I have  foot question.  I am having sharp pain in my left heel upon getting out of bed barefoot  in the morning. It improves once I put on shoes and the day progresses.  Is this an immediate ah ha moment for you as a podiatrist and is it simply fixed?  thanks 

Hey Barbara (name changed),

 That is normally the start of plantar fasciitis. I will send you a link on stretching 5-10 times per day, and 2 times a day roll your foot on a frozen sports bottle. You are catching it early. Rich

http://www.drblakeshealingsole.com/2013/07/plantar-fasciitis-educational-video-on.html

Severe Heel Pain (in a friend!): More than just Plantar Fasciitis

Hey Rich
Just saw your You Tube video on Facebook.  I KNEW  I should have called you when

I had plantar fasciitis in July 2012.  

I have been limping around with severe heel pain in my left foot for over a year. Sometimes

both heels if I've been standing in one place for a period of time.  Grandma must be getting

old !!!

My friend and I had been walking for about 3 miles every day until one day I woke up

and couldn't walk.  My friend told me what was wrong as she teaches anatomy at the med

school here.  

I used a wooded thing over which I would rub my foot back and forth and then soak in a bucket

of ice water for about 20 minutes or... until I thought I would pass out ... which ever came first.

The plantar part seemed to get better but the pain in the heel is particularly bad when I've been sitting,

especially with my legs elevated in the recliner.  Ouch !!!

When I get up I limp around for 2-3 minutes until it works itself out.   

Is there anything you can suggest that might help?

I'm so glad that you have developed something that is helping others.

Many blessings,

julie (name changed)

Hey Julie, It is so wonderful to hear from you. I miss seeing you my dear dear friend (our friendship goes back almost 40 years!!!) Definitely let us take this 2 weeks at a time. First of all, if you can not get an MRI to make the diagnosis of a possible plantar fascial tear (good possibility due to the length of time and the severity of the pain), then we should just treat it like that for the next 3 months. I will send you the link to order an anklizer boot and EvenUP. Start wearing and continue icing. There will be enough time out of the boot that you will know that you are healing. Continue icing 3 times daily, but stop all plantar fascial stretching for now. We will put all other conversation on this same post. Love, Rich

http://www.amazon.com/Procare-Evenup-Shoe-Balancer-Medium/dp/B006IUU2TK/ref=sr_1_fkmr1_1?ie=UTF8&qid=1376971934&sr=8-1-fkmr1&keywords=evenup+shoe+lift

http://www.amazon.com/Anklizer-II-Low-Top-Walker-MEDIUM/dp/B001UFN59C/ref=sr_1_14?ie=UTF8&qid=1376971852&sr=8-14&keywords=anklizer+low+profile