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Failure to diagnose 10+ years chronic heel pain right foot

Discussion in 'Ask your questions here' started by KLD, Dec 5, 2016.

  1. KLD

    KLD New Member


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    32 year-old M 5'11 168lbs, athletic (18% BMI), no history of illness, (pain limits mobility and causes gait/stride issues that now affect knee and left lower back)

    1. Where does it hurt?

    Bottom of Right Heel slightly medial of center. There is a palpable thickening of the ligament or fascia attachment (dime sized).

    2. How long has it hurt for?

    Approx. 13 years (Since 2003)

    3. How bad is the pain (Scale 1-10)?

    At rest it can be a 4-6. After a few minutes of standing or walking it can get up to a 8 where it is cognitively impairing ( I can't focus on anything else). In extreme cases its nausea inducing to continue to stand or walk as it feels like I'm standing on a foreign object in a very sensitive portion of my foot.

    4. What where you doing when it started?

    Closest I can attribute to is repetitive stress and severe ankle sprains during my time as a US Marine. I served during the age of 17-21. Operational tempo was high so I had little downtime between injuries.

    5. What have you done for it so far?

    At an almost 1-1.5 year interval since 2003 I have seen military then VA doctors. It wasn't until 3 years ago that I began to seek sub-specialized doctors with my private insurance.
    I have tried:
    - Maintain a consistent low-inflammation diet.
    - 20+ varied types of off the shelf, semi-custom, full custom (1/4 to full length) orthotics
    - Capsaicin cream
    - Oral serotonin supplements
    - Neuropathic medicine (Gabapentin)
    - 1 cortisone injection (ultrasound guided) as I feared fatpad atrophy
    - 1 Hydrodisection (Saline and Lidocaine injectant)
    - 5x X-rays to rule out bone spurs
    - 1x admittedly very low quality and non-valuable VA Healthcare MRI
    - 1x diagnostic ultrasound
    - 3X EMG tests with varied results from extremely abnormal (50% less nerve induction in the Plantar compared to baseline) to normal.
    - diagnostic lidocaine at either the peroneal or calcaneal nerve (successfully determined it wasn't centralized sensationalization as pain went off like light switch when injecting at ankle.)

    6. Anything relieve it?
    Simply staying off the right foot and massage.

    7. What have you been told about it so far?
    - A plastic surgeon assessed with low confidence that I might have an entrapped nerve although he could not corroborate that with the small dime sized thickening in the area of typical plantar fasciitis fissures. He offered to move the branch or terminus area of the surrounding nerve and implant it into a different portion of my foot or leg.
    - An orthopedic that performed the hydrodisection didn't think the thickening shown on the ultrasound could be a cyst or fibrosis and thought it was more likely to be some kind of nerve or vein compartmentalization. (Pain subsided for about 16 hours after procedure)
    - Aside from this, individual healthcare providers that weren't interested in my history assumed plantar fasciitis.

    8. Is it affecting your ability to work or play sport?
    Affecting my ability to simply walk around the house. I can no longer "tough it out" at this age and the recovery period from walking around the grocery store with my wife is days and no longer hours. I can mountain bike with minimal weight bearing thus minimal pain, but I have to carefully choose what I hike, lift, or how I train in the gym.

    9. Do you have any other sorts of symptoms?
    No radiating or shooting pain from foot. No foot drop symptoms. Mild to severe sciatica.

    10. What country you are in (different countries have different health systems; different scopes of practice of different disciplines; access to care might be different)
    USA. I have access to any and all doctors. I am able and willing to see any specialist out of pocket or w/ insurance.
     
  2. Craig Payne

    Craig Payne Active Member

    Complex.
    Where do you live - see if I know of anyone near by worth seeing.
     
  3. KLD

    KLD New Member

    Thank you Craig. I live in Seattle WA, but am willing to fly anywhere for help.
     
  4. KLD

    KLD New Member

    There doesn't seem to be an option to edit the original post but I forgot to mention:
    -I have a slight heel pad adipose tissue displacement in the affected foot. In photography my right heel appears 15% bigger than the left and there is a medial spilling out of the pad.
    - I'm not convinced its a simple nerve issue since I got significant relief when a physical therapist supported the heel fat pad with leukotape in an elaborate taping pattern. I did this successfully for about 2 weeks before developing a nerve pain in the back of the hell at a bony feature. I also get a little relief from using an "x-brace" from amazon.
     

    Attached Files:

  5. Craig Payne

    Craig Payne Active Member

  6. It's possible that some of the tissue in the plantar area of your heel has died and become necrotic due to poor blood circulation. Essentially, blood supply to that area of your foot may have been cut off by improper footwear since childhood.

    Your Plantar Fasciitis may actually be Plantar Fasciosis.

    One indicator of this is to evaluate the resting position of your big toe.

    Does the big toe on your right foot point inwards towards the middle of your foot?

    This simple big toe deformation can pull your abductor hallucis muscle (the triangular muscle located underneath of your arch) tight against your ankle arteries and veins cutting off circulation to the plantar area of your foot.

    A great explanation and illustration of plantar fasciosis is shown in the following YouTube clip by Sport Podiatrist, Dr. Ray McClanahan DPM:



    He suggests the simple treatment of wearing silicon toe re-aligners the return your toes to their anatomically correct position in an effort to restore blood supply to those tissues.
     
  7. KLD

    KLD New Member

    Thanks for the reply Modern Manimal,
    This is a very intuitive explanation, it might explain the edema, feeling of what I could only explain as "compartmentalization" , and sensation of heat/blood flushing. I'm going to start incorporating these stretches while I continue to research. I bought toe separators years ago and completely forgot about them, will give them an honest shot.
     
  8. Best of luck with healing your foot KLD...I'll be curious to hear how your recovery goes!

    I found Dr. McClanahan's Correct Toes YouTube channel not long ago in search of a way to solve my big toe mobility problems. His videos gave me an even deeper understanding about modern foot disorders and how important even proper toe health is to the entire foot!

    I suffered from all sorts of foot pain, ankle pain and achilles tendonitis up until about 6 years ago when I switched to a minimalist shoe lifestyle (wearing VivoBarefoot shoes and learning how to run anywhere completely barefoot). With the exception of my big toe problems (caused by some serious toe stubs over 10 years ago), my feet feel awesome now.
     
  9. KLD

    KLD New Member

    Thank you for the link Modern Manimal, I like his approach, I've been incorporating these stretches and strengthening exercises into my daily routine. I think it might be helping a tiny bit. Given the nature of this 13 year old, possibly necrotic tissue injury, I'm not optimistic about not surgery solutions any more, but I'm not completely defeated yet :)

    Curious did you ever notice differences between your left and right foot fat pads?
     
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