Healing Plantar Fascial Tear Images: Dark, Intact, but Irregular

This is my grandson, and one of my best friends, Henry. Henry is shown here starting Kindergarten about 3 weeks ago. He says his favorite is "Math" because he loves looking for "Patterns". Just an Angel. 

Here is an MRI image for a plantar fascial tear healing well. The plantar fascia is this dense band of fibrous tissue that runs from the heel to the front of your foot. This image is at the 6 month point, therefore a second MRI. The fibrous bands look mainly dark, but very irregular, as this process of healing is a bit different from patient to patient. If you look first at the heel bone, and then 2 inches in front, you can see normal looking dense regular plantar fascia that we hope will happen over the next 6 months. 

Old Plantar Fascial Tear: Email Advice

Hi Dr Blake,
I have just experienced a severe pain in my left arch reminiscent to the tear in my plantar fascia from 8 or 9 years ago.  You treated the tear and I was in a boot for 90 days.  Since then I have worn the orthotics you designed...religiously.  No problems until yesterday.  The pain feels like the pain I had years ago just before it tore.
What should I be doing?  I don’t want to go through another torn plantar fascia?
Please respond and let me know next steps.  Your next appointment is not open until 2/8.
Thank you.

Dr. Blake’s comment: It is so important that you create the 0-2 pain level consistently as quickly as possible. If that means you have to be back in a boot until I see you, please do it. Remember to ice 3 times a day 10 minutes each for the next 4 days, than cut to twice a day. No achilles stretching or arch massage until we feel sure it is not a tear. See if anything you are doing really picks on it, and try to avoid for the next 2 weeks. Normally takes 4 to 14 days to either be obvious an injury, or just a small strain of the tissue. Hope this helps. Rich  

Tip for Plantar Fascial Tears: Hoka One One Shoes

Hi Dr. Blake, got the HOKA shoes, and I'm loving them.  I can move so much easier in them, and very little pain (definitely 0-2 range).  I can also put both the right and the left orthotics in, which balances things out pretty well.  I feel like I'm walking more naturally, and I think my legs are getting toned too!  Anyway, thanks a bunch, and I'll see you soon for a follow-up appointment (the 8th, I think).  

Hope you are well!  

Dr. Blake's comment: These are shoes that roll through the forefoot, limiting toe bend at push off. This is valuable for many forefoot problems and, in this case, plantar fascial tears where you are limiting toe bend and the pull of the fascia for up to 6 months post-injury. 

Plantar Fascial Tear: Email Advice

Hi Dr. Blake,

     I had sent you my MRI disc back in January, and you confirmed what I had suspected for a while, that I indeed had a plantar fascia tear. I have to admit, I have not exactly followed your advice to the word. I did wear the boot, but only for 2 months...as it turns out, my dog had to have her third surgery in 7 months on her leg, and it was extremely difficult to help her with the boot on (she's a large dog, 70 lbs, and it required walking next to her on leash at all times, lifting her, etc.).

Dr. Blake's comment: Very understandable. I would have had you switch to Mountain Bike shoes with the cleat embedded into the shoe. Mountain Bike Shoes with Built In Cleats 

     I gradually weaned out of the boot over a few weeks. Things are not going as well as I had hoped. My foot still bothers me on a consistent basis, which I don't understand, because up until last week I hadn't even *tried* anything that should irritate it. 

Dr. Blake's comment: Were you able to attain the 0-2 pain level in the boot? You have to be in the boot for at least several months at that low pain level. If not, either go back into the boot or try the mountain bike shoes. Your orthotic devices should shift the weight into the arch and feel protected and soft under the heel. 

     One night last week I was sitting on my couch, and I thought you know what? I'm just going to give a quick run a shot. It was probably about .35 mile. I knew not to try anything crazy. I have attempted the same a few times since then, and it feels like I'm back to square one again. It doesn't necessarily bother me during the run, but afterward. My foot is still sore in the mornings (but that never really went away anyway), but it's not like PF pain...it's kind of just diffuse soreness that is more noticeable around the PF attachment to the heel...I'm wondering if this morning soreness something I'm going to have for the rest of my life? It also doesn't take as long to go away as it did at its peak.

Dr. Blake's comment: We use our general rules on time, but one person can be different than the next, unfortunately. You need to be so much better day after day before you can run. Your symptoms can mean that things are healed, but not strong. Day to day has to be good first with the boot or shoe before you can wean from the boot or shoe. Then you need to build up your walking so that you are at a minimum of 2 weeks, no pain, walking at least 30 minutes at a nice clip before you start a walk run. You probably should be wearing the boot or shoe during the day to rest the tissue, use the support the foot taping 5-6 days at a time, continue icing and try some contrast bathing to see how you feel. 

     I also noticed that, while the middle of my heel isn't sore to poke like it used to be, there is a spot that still hurts to touch, and I'm not sure why? (The spot I am pointing to in the photo.) Sneakers really seem to bother me in that spot, I have found only the crocs I use for the yard are comfortable. I have started to wonder if there is not something going on in conjunction with the tear...a nerve issue maybe? 

Dr. Blake's comment: That could be a possibility. You are pointing right to the plantar fascial attachment so that does not like unusual. You could have a plantar heel bursa. Those can be painful. Try to use the frozen sports bottle roll over the sore bottom, but do not roll into the plantar fascia tear. Only the direct bottom of your heel for 5 minutes twice daily. 

     I also noticed after every attempt at a short run, my calf gets really, really tight. I try rolling and using the stick and it doesn't seem to help at all. I know I didn't follow the protocol exactly, but I have been pretty careful, and I just feel so discouraged about the level of discomfort I still experience on a daily basis. 

Dr. Blake's comment: With plantar fascial tears, in the immobilization phase, I allow no stretching of the calf or fascia. The two weeks you are out of the boot, and feeling good, I allow patients to begin to stretch the calf, but still no the fascia. This can give symptoms of tightness, so do not be too discouraged. The next 2 months boot or shoe, ice twice daily, tape daily, stretch the calf as long as the heel is firmly on the ground three times a day. You can get PT so long as there is no stretch of the arch. 

     It is really wearing me down, I just want to feel like I have my life back again. I'm also having a heck of a time trying to find a doctor out my way, and I was wondering if you might be able to offer any advice in that regard? (I have seen 4 podiatrists in person, none of whom helped me at all, which is why I ended up finding you.) As always, thank you so much for reading and for your help!

Dr. Blake's comment: Check the members for the AAPSM (sports podiatrists) in your area!! Typically we can find someone. It is not certain that you say you are a sports podiatrist and practice a conservative meaningful approach. 

Pointing to the attachment of the Plantar Fascia at the Heel

Another email before I could respond:

Hi Dr. Blake,

     So sorry to bug you with another e-mail. I am really struggling with what kind of doctor to see. Two of the podiatrists I have seen previously were members of the American Academy of Podiatric Sports Medicine...and unfortunately, their advice was less than helpful. I thought I would make an appointment with a local foot and ankle orthopedic specialist...except the receptionist (pretty rudely) informed me he will only take on surgical cases. So, I made an appointment with their podiatrist instead, but upon finding this out my PCP told me it would essentially be a waste of time and that this particular doctor would probably prescribe a pair of orthotics and send me on my way. Should I be looking for a podiatrist, a sports medicine doctor who doesn't necessarily specialize in feet, or an orthopedic foot and ankle doctor?
Dr. Blake's comment: I am sorry. I do feel podiatry is the way to go for this. I would call the office of Dr. Stephen Pribut near DC. He is wonderful. Tell Dr. Pribut that I am asking you to see him or recommend someone close to you. My son played basketball in Wayne at Cabrini College so I know that is quite a distance. He may have the exact person for you to see. Are you in good orthotics? What shoes are you wearing? What are your running mechanics like? These are all questions we need answers to help you. Temple University has a podiatry school that may help. There used to be a Dr. Howard Palamarchuk, but I am not sure if he still practices. 

      Do you know anyone in the relative Philly area you could recommend? I am having such a hard time, and I have spent so much already on this issue, my resources are pretty limited...so I can't afford to pick the wrong place again. I also noticed that along with tenderness at that point in the photo from my previous e-mail, my foot is a bit swollen around the back of the ankle and the inner arch...not sure how much concern this warrants?
Dr. Blake's comment: These are areas that fluid from any cause can collect in. Probably not a big deal. 

As always thank you so much for your help!

Dr. Blake's response:  I will sit down this weekend and answer I promise. Rich

Hi Dr. Blake,

     Please take your time! Thank you so much for getting back to me. I somehow managed to forget to mention this...sometimes I will get a stabbing pain in that sore spot in the first photo, it comes in bursts of about 10-30 seconds, it is quick but SO painful. Feels like someone repeatedly stabbing a knife in that spot...and it happens randomly, sometimes even when I’m just sitting at my desk(???)...it happened yesterday after I finished mowing the yard, and I held my foot up thinking if I put it down the pain would be unbearable...to my shock it really didn’t make a difference. I’m not sure if this is a clue to what’s going on???

Dr. Blake's comment: When you tear the fascia, we want scar tissue to get in there and heal the injury. The scar tissue can get bound up in the local nerves giving you these symptoms. These should improve as you begin to stretch the fascia, but that is probably 3-4 months away. Good luck my friend. 

Thank you, Dr. Blake!!

I am attaching for the readers my Plantar Fascial Protocol we give patients in the office. 

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

The following is the patient's response to my questions and comments.

Hi Dr. Blake,

     I had sent you my MRI disc back in January, and you confirmed what I had suspected for a while, that I indeed had a plantar fascia tear. I have to admit, I have not exactly followed your advice to the word. I did wear the boot, but only for 2 months...as it turns out, my dog had to have her third surgery in 7 months on her leg, and it was extremely difficult to help her with the boot on (she's a large dog, 70 lbs, and it required walking next to her on leash at all times, lifting her, etc.).

Dr. Blake's comment: Very understandable. I would have had you switch to Mountain Bike shoes with the cleat embedded into the shoe. Mountain Bike Shoes with Built In Cleats

Is something like a Hoka One One an acceptable alternative? (I have an old pair I can try before buying new to see if they seem to help at all.) Dr. Blake's comment: Not as good, but you can alternate back and forth for the next 4-6 months. 

     I gradually weaned out of the boot over a few weeks. Things are not going as well as I had hoped. My foot still bothers me on a consistent basis, which I don't understand, because up until last week I hadn't even *tried* anything that should irritate it. 

Dr. Blake's comment: Were you able to attain the 0-2 pain level in the boot? You have to be in the boot for at least several months at that low pain level. If not, either go back into the boot or try the mountain bike shoes. Your orthotic devices should shift the weight into the arch and feel protected and soft under the heel.

Yes, after the first week my foot adjusted to the boot and it really wasn't painful wearing it at all, which is also one of the reasons I felt it wouldn't be too terrible to wean out of it at 2 months when I needed to help my pup! Dr. Blake's comment: Your beautiful dog's photo did not transfer over. The boot did its job, but what you went into after was inadequate to continue the immobilization. It also could have been the orthotics, not taping, doing too much with the new found freedom. 

     One night last week I was sitting on my couch, and I thought you know what? I'm just going to give a quick run a shot. It was probably about .35 mile. I knew not to try anything crazy. I have attempted the same a few times since then, and it feels like I'm back to square one again. It doesn't necessarily bother me during the run, but afterward. My foot is still sore in the mornings (but that never really went away anyway), but it's not like PF pain...it's kind of just diffuse soreness that is more noticeable around the PF attachment to the heel...I'm wondering if this morning soreness something I'm going to have for the rest of my life? It also doesn't take as long to go away as it did at its peak.

Dr. Blake's comment: We use our general rules on time, but one person can be different than the next, unfortunately. You need to be so much better day after day before you can run. Your symptoms can mean that things are healed, but not strong. Day to day has to be good first with the boot or shoe before you can wean from the boot or shoe. Then you need to build up your walking so that you are at a minimum of 2 weeks, no pain, walking at least 30 minutes at a nice clip before you start a walk run. You probably should be wearing the boot or shoe during the day to rest the tissue, use the support the foot taping 5-6 days at a time, continue icing and try some contrast bathing to see how you feel. 

I can't even walk my other golden without pain, so I should have known better than to attempt a run, but I was having a "good" day so I thought I'd test the waters, and also I'll admit I was getting impatient. Dr. Blake's comment: In my world, we need to talk in terms of a consistently good week, over a run of good days, before attempting the next level of activity. That would have been a walk-run program as outlined in my blog. 

     I also noticed that, while the middle of my heel isn't sore to poke like it used to be, there is a spot that still hurts to touch, and I'm not sure why? (The spot I am pointing to in the photo.) Sneakers really seem to bother me in that spot, I have found only the crocs I use for the yard are comfortable. I have started to wonder if there is not something going on in conjunction with the tear...a nerve issue maybe? 

Dr. Blake's comment: That could be a possibility. You are pointing right to the plantar fascial attachment so that does not like unusual. You could have a plantar heel bursa. Those can be painful. Try to use the frozen sports bottle roll over the sore bottom, but do not roll into the plantar fascia tear. Only the direct bottom of your heel for 5 minutes twice daily. 

If it's an inflamed bursa, is it safe at this point to get an injection? Or should I avoid them indefinitely in that foot since it has a history of a tear and that would only further compromise the integrity of the plantar fascia? Before I used to have pain directly in the center of the heel (red circle), now it seems to emanate out from the sore spot into the side of the arch (yellow) and the actual heel has little to no pain...but I should be icing where the circle is? Dr. Blake's comment: Yes, that is where you ice. The bursae are under the heel. Are you having any pain there? Does not sound like a good idea to inject. Yes, I fear the plantar re-tearing some. 

     I also noticed after every attempt at a short run, my calf gets really, really tight. I try rolling and using the stick and it doesn't seem to help at all. I know I didn't follow the protocol exactly, but I have been pretty careful, and I just feel so discouraged about the level of discomfort I still experience on a daily basis. 

Dr. Blake's comment: With plantar fascial tears, in the immobilization phase, I allow no stretching of the calf or fascia. The two weeks you are out of the boot, and feeling good, I allow patients to begin to stretch the calf, but still no the fascia. This can give symptoms of tightness, so do not be too discouraged. The next 2 months boot or shoe, ice twice daily, tape daily, stretch the calf as long as the heel is firmly on the ground three times a day. You can get PT so long as there is no stretch of the arch. 

I have KT Tape, is that ok to use? Dr. Blake's comment: yes, there are many ways to tape with good results. Start with KT to see how it works for you. 

     It is really wearing me down, I just want to feel like I have my life back again. I'm also having a heck of a time trying to find a doctor out my way, and I was wondering if you might be able to offer any advice in that regard? (I have seen 4 podiatrists in person, none of whom helped me at all, which is why I ended up finding you.) As always, thank you so much for reading and for your help!

Dr. Blake's comment: Check the members for the AAPSM (sports podiatrists) in your area!! Typically we can find someone. It is not certain that you say you are a sports podiatrist and practice a conservative meaningful approach. 

Another email before I could respond:

Hi Dr. Blake,

     So sorry to bug you with another e-mail. I am really struggling with what kind of doctor to see. Two of the podiatrists I have seen previously were members of the American Academy of Podiatric Sports Medicine...and unfortunately, their advice was less than helpful. I thought I would make an appointment with a local foot and ankle orthopedic specialist...except the receptionist (pretty rudely) informed me he will only take on surgical cases. So, I made an appointment with their podiatrist instead, but upon finding this out my PCP told me it would essentially be a waste of time and that this particular doctor would probably prescribe a pair of orthotics and send me on my way. Should I be looking for a podiatrist, a sports medicine doctor who doesn't necessarily specialize in feet, or an orthopedic foot and ankle doctor?
Dr. Blake's comment: I am sorry. I do feel podiatry is the way to go for this. I would call the office of Dr. Stephen Pribut near DC. He is wonderful. Tell Dr. Pribut that I am asking you to see him or recommend someone close to you. My son played basketball in Wayne at Cabrini College so I know that is quite a distance. He may have the exact person for you to see. Are you in good orthotics? What shoes are you wearing? What are your running mechanics like? These are all questions we need answers to help you. Temple University has a podiatry school that may help. There used to be a Dr. Howard Palamarchuk, but I am not sure if he still practices. 

Before I received your reply I made an appointment with another podiatrist who is also a runner for next week. If that doesn't work out, I will definitely call Dr. Pribut, thank you!!! 

      Do you know anyone in the relative Philly area you could recommend? I am having such a hard time, and I have spent so much already on this issue, my resources are pretty limited...so I can't afford to pick the wrong place again. I also noticed that along with tenderness at that point in the photo from my previous e-mail, my foot is a bit swollen around the back of the ankle and the inner arch...not sure how much concern this warrants?
Dr. Blake's comment: These are areas that fluid from any cause can collect in. Probably not a big deal.

Ok!

As always thank you so much for your help!

Dr. Blake's response:  I will sit down this weekend and answer I promise. Rich

Hi Dr. Blake,

     Please take your time! Thank you so much for getting back to me. I somehow managed to forget to mention this...sometimes I will get a stabbing pain in that sore spot in the first photo, it comes in bursts of about 10-30 seconds, it is quick but SO painful. Feels like someone repeatedly stabbing a knife in that spot...and it happens randomly, sometimes even when I’m just sitting at my desk(???)...it happened yesterday after I finished mowing the yard, and I held my foot up thinking if I put it down the pain would be unbearable...to my shock it really didn’t make a difference. I’m not sure if this is a clue to what’s going on???

Dr. Blake's comment: When you tear the fascia, we want scar tissue to get in there and heal the injury. The scar tissue can get bound up in the local nerves giving you these symptoms. These should improve as you begin to stretch the fascia, but that is probably 3-4 months away. Good luck my friend. 

That makes sense to me!

Thank you, Dr. Blake!!

I am attaching for the readers my Plantar Fascial Protocol we give patients in the office. 

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

http://www.drblakeshealingsole.com/2016/12/heel-pain-adjusting-removable-boot.html

Thank you!

Plantar Fascial Tearing with Intense Inflammation MRI Images

The Plantar Fascia on the bottom of the foot should be as dark as the Achilles Tendon shown here.

The Plantar Fascia should be uniform thickness and density. Here it is seen rising up and with gray holes. 

The slice through the bottom of the foot under the heel bone showing a bursae sac of intense inflammation. 

This is the section that is at a right angle to the raised part of the plantar fascia seen above. The fascia above my arrow should be a solid dark fiber like the Achilles. In this image, it is showing 90% torn with the gray signifying fluid and scar tissue. 

The image just in front of the last view looking more solid, although some irregularity and less density.

This is the initial image again in our series showing a section of plantar fascia separated from the bone. 

A defect in the plantar fascia more to the outside of the foot. The arrow denotes the defect and is surrounded by intense inflammation probably a bursal sac. 

Only slight irregularity noted in the plantar at this section, but see the inflammation is so intense it distorts the normal fat pad below the arrow. 

This is really the best image of the problem. The patient's image shows the split partial horizontal tear of the plantar fascia seen as is there was a layer of Oreo cookie in the fascia. How do we know it is injured, the intense inflammation under the tear where the swelling is pulled downward by gravity. I would not want to walk on that heal. 

This is the same image of the plantar fascia 1/8th inch further under the heel bone. It looks totally fine, so the tear is the 1/2 inch in front of its attachement into the heel. The swelling from infracalcaneal bursitis will travel all under the heel and the reason patients can not walk well. The plantar fascial tear protocol should be started. Plantar bursitis will take some work off-weighting the heel to transfer the weight into the arch. 

Hike and Bike Shoes for Immobilization of the Bend at the Forefoot

I have been using Hike and Bike shoes to immobilize the foot while not having the negative impact of a removable cast in some patients. There is one used in a plantar fascial tear for the 3 months I normally cast the foot with a removable boot. If the patient especially has a back problem, the evenness of wearing a pair of shoes like these can be great. Remember you are not able to bend your foot in push off, or it will hurt you. Therefore, it immobilizes the pull of the plantar fascia. Any metatarsal  problem could be helped by this, even if it is only part of your treatment to vary the stresses 2-4 hours a day. Sesamoid problems, turf toe, metatarsalgia or stress fractures may be helped. 

http://www.fiveten.com/us/kestrel-lace-womens-shock-blue

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

Plantar Fascial Tear: Email Advice

One of the athletes that has emailed me has severe heel pain. I had him email me his MRI CD which clearly showed a plantar fascial tear. I asked him to read my protocol and email questions. Here they are. 

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

OK Dr. Blake, here's what I can think of...  I'm sorry it's so long but this is really playing on my mind - not just the cause, but the 3+ months in a boot and the rehab afterwards, the reinjury avoidance and the building back up to where I am now will be a task and a half - I'm up to it; I understand it could be much worse; I'm just not overjoyed! 

Background on me: 

I’m 50, in excellent shape and thin.   I’ve never had any foot problems; my arches are high (but not unusually high).  Pretty much all of my shoes and sneakers have good arch support.   I used to run a lot but I slowed my running down to only 2 days per week long before (12-18 months before) the 1^st sign of heel pain.  The other days I’m not running I would either be on the recumbent bike in the gym or out mountain biking.  I'm a little bow legged and walk more on the outside of my feet (underpronate?).

Regarding the injury:

I realize you can’t be 100% sure but how much in your professional opinion did the 4 cortisone shots play a role in this? 

Dr Blake's comment: I have a patient now that I injected the area around the plantar fascia, and it sounds like it may be torn. It is considered safe if you do not inject right into the plantar fascia, which I did not. But, did the cortisone migrate up into the fascia weakened it? Was the chronic pain due to a plantar fascia weakened and ready to tear at any moment? I am not sure. If the MRI on my patient comes back as a tear, it will be the first in my 35 years of practice that has a possible link to my shot. I hope it was not my shot. I hope it was not the shots you received. Everyone is trying to help you athletes and shots are vital in the final healing of so many of these heal pain issues. 

Could one or more of the shots been misplaced and that’s (at least partially) the cause for weakening the medial slip enough to cause it to tear? Yes

How many shots are enough? 

Dr Blake's comment: I give 10 mg of long acting cortisone in a heel injection, and that is considered safe. Up to 3 of these shots over a 2-3 month period is considered safe in chronic conditions. I have seen patients with 10 shots in 3 months, only to find out that each shot only had 1 mg per shot. So, if you had 4 shots into the heel, you need to find out how much long acting cortisone was in each one. One of our orthopedists routinely gives 40 mg per heel injection. She says she has never had a problem. I can only tell you what sports podiatrists consider routine for them. 

Is this a common injury?  

Dr Blake's comment: Very, I have one or two patients weekly in some stage of healing, and they heal. I also had a patient come in a year ago saying he had chronic 10 years of plantar fasciitis. I told him plantar fasciitis never lasted that long. We got MRIs on both sides documenting bilaterral plantar fascial tears. After 3 months in a removable boot for one foot, and then 3 months in a removable boot with the other foot, he was well and kicking himself for self diagnosing all those years. 

I have pain on the opposite side on the heel about an inch forward from the back of the heel – ½ way between the side (of the foot) and the bottom of the foot/heel.  Especially felt when squeezed (like a massage or at PT).  Is this likely part of the same problem? 

Dr Blake's comment: Yes, the inflammatory fluid sits somewhere under the heel (which is where I inject) and can be just as painful as the plantar fascial tear. I typically have my patients walk on their heels. If that hurts, then heel bursitis is documented. I have them massage for 5 minutes with a frozen sports bottle just the 2 inch area under the heel, 2-3 times per day. 

Did you see anything else in the MRI?

Dr Blake's comment: I will have to relook to answer that. Sorry, but I am at home, and the CD on my desk at work. I do not remember seeing anything else exciting. 

Regarding the boot:

Are there risks associated with waiting to start to wear the boot?  I was thinking about waiting until winter or at least the cooler weather. 

Dr Blake's comment: Now that you have a diagnosis, get the ideal treatment. Yes, patients wait, but if you don't heal well, and it could be related to waiting, you will not forgive yourself, and I could not recommend it. 

Are there other options (taping perhaps)? 

Dr Blake's comment: The basic treatment is to restrict big toe joint motion. So, find a stiff hiking boot, and/or a hike and bike shoe from Shimano or Pearl Izumi, or a rocker shoe like New Balance 928 or Hoka shoe line. See what limits the motion enough that creates that 0-2 pain level consistently. 

Is there more than 1 type of boot?  If so, any preference? 

Dr Blake's comment: I love the Anklizer or the mid calf Ovation medical boots the best for these injuries. 

I assume I remove to bathe but must I be careful about putting any weight on that foot while showering? 

Does one walk on a boot or are crutches necessary? 

Sleep in the boot?  If not:

If I get up at night to use the bathroom must I “reboot” for the walk? 

Dr Blake's comment: All of the questions above can be answered together. You only hurt yourself with an active pushoff. You only need to walk flatfooted to the shower, bathroom. No need to sleep with the boot on. No need for crutches.

Is driving possible?  If not can I remove it to drive or is that not recommended?   

Dr Blake's comment: You have to remove to drive. Typically it is okay. If it is your right side and you are having too much pain driving, you have to get a cab or car pool. That part should only last 1 month or so, even when you are in the boot, stiff shoe for 3 months. 

Are there ANY exercises for cardio I can do (like rowing or swimming or the recumbent bike on an easy setting)? 

Dr Blake's comment: Yes, but you have to have the foot positioned so there is no heel lift. And, definitely no pushing off the wall in swimming and no fins. 

Is scar tissue going to be an issue?  How can I get rid of scar tissue? 

Dr Blake's comment: We want scar tissue to scar in the tear. 6 months after the healing, if another MRI documents too much scarring, some PT will be in order. But, 6 months no plantar fascial stretching, and we have to allow scar tissue to do its thing. 

Can I stretch (calves, hamstrings, quads) while wearing the boot or should I avoid it all together?

Dr Blake's comment: No PF stretches, but the rest of your body is fine. 

Finally (yay!):

Any preference on how/what I should do for rehab after the boot is removed for good?  

Dr Blake's comment: So the boot creates this nice 0-2 pain level for 3 months. During this time, you have been cross training. The next 6 weeks you have to gradually wean out of the boot keeping the 0-2 pain level (can take as minimum as 2 weeks). Then I start you on the famous dreaded Walk Run Program all along keeping the 0-2 pain level. Based on how you do with this, we process you, or slow you down and get PT. We are definitely months away from this. 

Do you have any helpful advice to insure success during the boot and post-boot?

Dr Blake's comment: The boot phase is easy. Maintain the 0-2 pain level, while trying to cross train, and experiment with stiff shoes, rocker shoes, orthotics, etc. The post boot phase is broken into the weaning out phase, the walk run phase, and the return to activity phase. Typically a good sports physical therapist or podiatrist can help you along. And, you are strengthening the foot daily all along from now until you are back full time. The exercises are met doming, single leg balancing, post tib and peroneus longus theraband, and at 4 months double and single toe raises. 

What's my best bet for orthotics (considering my arch and supination) for every day?  Custom or off-the-shelf?  Any specific ones you can point to?

Dr Blake's comment: High arch and supination is only custom made in my mind. 

Any specific shoes/sneakers you recommend?

Dr Blake's comment: See the Hoka line, along with the New Balance 928. Both have good rocker soles to limit pushoff. Good luck!!!!!!

Thank you for your time!

Posterior Tibial Tendon Injury and Long Term Concerns

Hi Dr Blake,

I've been reading your blog archives since I first started having
problems with my foot.  It's kind of a long story, so I apologize in
advance for the length.

I am/was a runner.  I ran anything from 5K through ultras.  I had been
running in the same pair of orthotics for 4 years at that point and
never had a problem.

Then last May (2015) I developed PF in my right foot.  I rested, iced, rolled
and it wouldn't go away.  I saw a Sports Med Doc who eventually gave
me a US guided steroid shot into the PF.  He had me run on it within
three days.  I was fine until two weeks later when the shot wore off
and then I was worse than before.

Dr Blake's comment: Patients get cortisone shots for plantar fasciitis all the time when a plantar heel bursae forms. So, the shot is into the bursae, not the plantar fascia. It is always risky to inject right into the plantar fascia with cortisone, for fear of causing a rupture. The odds of a rupture are small, but it can happen. If the pain intensifies following a cortisone shot in the bottom of the heel, assume that the plantar fascia tore, and start plantar fascia tear protocol of 3 months in a removable cast. 

The pain was still bearable, I could walk but not run.  In September,
one month after the shot, I was hiking and felt a pop in my arch just
in front of the heel but more towards the outside of the foot.  The PF
got a lot worse after that.

Dr Blake's comment: This is when it completely tore.

I saw a podiatrist right after that.  The area was red and puffy and
he noted that my ankle rolled in a little more on that side.  I have
very high arches and roll in a little on both sides so I didn't make
note of that.

He had me fit for corrective orthotics.  When they came back, they
inflamed my heel really badly.  I started aggressively rolling and
stretching my arch (I think this is part of where I went wrong and
tore or worsened the tears).  I kept having the orthotics adjusted
because they really hurt my right foot.  They adjusted the left to
match, even though I was fine on that side.

Dr Blake's comment: So you are in the Immobilization Phase. This is the time you should be in a removable boot with heel cushion, or modified arch support to transfer weight into your arch and cushion and protect your heel. 

https://youtu.be/g0sD0gUbEMU

About this time, this is late November now, I was at the gym and
couldn't do a heel rise.  My foot was in almost constant pain, my
podiatrist was very dismissive and told me I was fine.  He didn't
really seem concerned with my pain or inability to do a heel rise.  He
told me that I shouldn't be doing them anyway with the PF (??) but
sent me for an ultrasound "for my peace of mind".

Dr Blake's comment: The inability to do a heel raise indicates the arch has been compromised. As you begin to lift your heel, all the weight goes from the heel to the supporting structures of the arch, and eventually to the ball of the foot. But when you can not lift your heel off the ground, some structure(s) has been injured that helps lift up the arch (Plantar Fascia, spring ligament, posterior or anterior tibial tendons, etc). 

It showed that I had a full thickness partial tear of the PF and split
tear of the PTT.  He put me in a boot and wanted to see me the
following week.  Immediately the boot hurt, it had no arch support so
he put in lifts.

Dr Blake's comment: It is good to have an arch support inside the boot in situations like this. 

By the next day, my foot started to swell and the

pain was excruciating. 

Dr Blake's comment: There are 3 sources of pain: mechanical (due to the injury), the inflammatory reaction to the injury, and the gradual onset of nerve hypersensitivity for your body's protection (the worse of all the pain sources). You were now really triggering nerve pain affecting the sympathetic nervous system with some swelling and possible skin discoloration. Ideally, this gets everyone's attention by now. 

I started using crutches the following day.
By the time I saw him the next week, my foot was painfully swollen and
it was discovered that I developed a blood clot in my calf.  He took
me out of the boot and had me NWB.  This was mid December.  After that
he took one phone call from me telling me to stay NWB and that he
wouldn't see me until I was cleared by a vascular surgeon.  I was
cleared, but that podiatrist didn't take or return my calls after
that.

Dr Blake's comment: I apologize for my profession. It was clearly over his head, but you had a bad reaction, and doctors are human and can behave badly. 

In the beginning of January, I started seeing a new podiatrist.  She
ordered an MRI that confirmed the PF tear and showed a small
insertional tear of the PTT.  She thought I needed surgery but her
colleague came in and said that it was small and he thought most of my
problem was from atrophy.  He wanted me to go from the crutches to my
sneaker.  In a matter of five minutes I had gone from needing surgery
to needing nothing, not even a boot.

I was confused and still in pain so I decided to see an orthopedist
foot and ankle specialist.  He had me go from crutches to a boot,
which I thought was reasonable.  He said that the PTT tear was small
and most of the problem was from the large PF tear.  My arch still
hurt in the boot so he had me wear the orthotics I had gotten in
Nov/Dec in the boot.

Dr Blake's comment: Thank you, finally some reason applied to this. 

Around this time, I started getting tingling and pain in my left PTT.
We thought it was compensation. Mid February I came out of the boot.
I was doing physical therapy twice a week and things seemed to be
improving.  The PF pain was gone.  I was able to do weak but pain free
single heel rises.

Dr Blake's comment: I am so happy when the pain got out of control, with the swelling, that you do not develop a condition called "Complex Regional Pain Syndrome". The Golden Rule that applies here is to get the pain level between 0-2 as quickly as possible. That just did not happen. Pain syndromes from the Posterior Tibial Tendon tend to always be on both sides, with different starting dates, so after you identify the posterior tibial tendon as a source of pain, immediately start doing some preventative things for the opposite side (orthotics, strengthening, or simply just icing). 
I kept having medial ankle pain whenever we would do any balance
exercises.  I took a day trip walking around a city and afterwards I
had swelling all long the left PTT.  I was very concerned and went
back to the orthopedist.  He put me in an aircast PTT brace and told
me that he'd send me for an MRI if it didn't improve.  I asked him why
this was happening and he said he didn't really know.  I have very
high arches and that should protect the PTT.

Dr Blake's comment: High Arch feet have worse problems with posterior tibial tendons if the arch starts to fall. High Arch Feet are more unstable in general than pronated flat feet, which can have more alignment issues. High Arch Feet need more muscle/tendon strength around the ankles to keep upright. High Arch Feet never get good arch support from shoes, OTC arch supports, and even most custom foot orthotic devices, so relie on tendon and ligament strength. When these are compromised, even by simply favoring one foot for awhile, pain begins.  

Sorry, I know this is long, I'm almost at present day.

The symptoms calmed down and I stopped using the brace after about a
week.  I kept trying to figure out why the left was hurting me.  I
decided to try my old orthotics again, the ones from now five years
ago, and my left PTT calmed down immediately.  The right one
aggravated the heal and irritated my ankle.

Dr Blake's comment: Good detective work!! Something is off. 

I thought the problem was that they were old and needed some tweaking.
I dug around and found the name of the podiatrist who had made the old
orthotics.  He took x-rays and discovered that I have an accessory
navicular, which, he says, is very uncommon in high arched feet.  He
has scheduled me for shockwave treatment on my PTTs.  He wants to have
the old orthotics refurbished and has me wearing them with a gel heal
cup.

Dr Blake's comment: I have no experience with shockwave, but it is to break down scar tissue, and there is good scar tissue presumably helping heel the Posterior Tibial issues. 

The shockwave won't fix the right foot where the arch falls a little
but he thinks that it will help heal the damage.  The plan is to try
to stop it from falling further with my old orthotics.  I've tried
wearing just the old orthotics but on the right foot, the one that
tore, they cause my arch and ankle to ache badly, and the outside of
my foot to hurt.  Yesterday I was limping, my ankle swelled and
something by my lateral ankle sounded like a knuckle cracking when I
walked.  Today I'm wearing the orthotics that hurt the left foot
because they are better, but not perfect, on the right.

Dr Blake's comment: Definitely, you can temporarily wear 2 different generation orthotics on the right and left, or a custom and OTC, on each foot, to handle the pain aspect. Without more complex information, we have to listen to your body and let pain be your guide. 
My questions are:

Can they make me one orthotic to deal with the PTTD on the right side
but not make the same adjustment on the left?  I think that's what
caused the problem on the left side.

Dr Blake's comment: Yes they can. You have very different needs for each foot, so the orthotics made should reflect that with different support. If you were in my office now, before I made anything else, I would try to understand why one orthotic feels good, and one causes problems. It is in knowing that info that you can redesign a new pair to help. 
Can orthotics really halt the progression of my arch falling?

Dr Blake's comment: Never on there own. Orthotic devices are used to stabilize the foot, along with taping, bracing, and good shoes. Then, foot strengthening exercises like the ones in the video below, can triple the strength on the tissue. What you do not know is if there is a degenerative process that will continue in the ligaments or tendons. You have to set a one year goal to perfect your orthotics, your ability to tape as needed, and triple the strength of your ankles and feet. 

https://youtu.be/w3FXx4OFqec

Will I be able to run again if I have proper orthotics?  Will anything
get me back to running?

Dr Blake's comment: Without knowing everything, my expectation would be that you could run again. Once you can walk 30 minutes for 2 weeks without pain, you can start a Walk/Run program with stability shoes, power lacing, great orthotics, and some version of posterior tibial taping like in the video below. I love having you begin to run as soon as possible, when walking is fine, because your feedback is crucial to modifying your orthotics, changing shoes, perfecting taping, etc. 

https://youtu.be/e1JAewWT9Fc

https://youtu.be/AcSSyBfFocE

Is having the accessory navicular removed a reasonable option?  From
what I've read, they anchor the PTT down where it should have been
instead of doing a tendon transfer.  If that's true, wouldn't it be
better to have that done before the tendon stretches out even further?

Dr Blake's comment: I understand completely what you are saying, but right now it is preventative surgery, and that does not sit well with me. I would have a better feel  for that based on the ease or difficulty getting back to running, the level of pain is have to constantly deal with, a repeat MRI and even CT scan looking at the tissue. I have seen plenty of accessory navicular bones that cause no problem whatsoever. I hope this has been somewhat helpful. Rich

I'm really starting to lose hope that I'll ever be able to even go
about my day without one PTT or the other bothering me, let alone run
or hike or any of the other things I love.

Thank you so much for taking the time to read this.  I appreciate any
advice you may have to offer.

Thanks,