Athlete With Plantar Faciitis, Question and Response

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                       Journal of the American Medical Association, October 11, 2016

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The question

Hi Dr. Post,

My name is Thuy Nguyen.  I used to walk 4 miles, twice a day.  The only problem I have was the irritation at the ball of my feet.  I am over weight and it is hard to lose weight with walking, so I was jogging in place barefoot on the trampoline last June.  Jogging in place on the trampoline, I sweated, which I liked it.  However, I got my L heel and arch pain.  

I saw one podiatrist in July.  His diagnosis was that I have Planta Fasciitis.  Since I got heel pain, I insisted with Xray.  Xray showed I have a heel spur.  He recommended calf stretch, and a custom orthotic.  My arch is normal, and it is hard to make appointment with him, so I saw another Podiatrist.

I saw the second Podiatris every two weeks since October.  He prescribed all kind of stuffs for my L foot: night splint, night boot, cortisone shots (twice), fiberglass casting (sawed it the next day because my foot was too loose in the cast, that my skin at the ball of my foot was irritated), and walking boot. Nothing has helped, I am back to the usual pain the next day after he took the cast out.    

Since I noticed the pain kind of better after one day of casting, and the pain returned as soon as I stay on my foot with daily activities.  I decided 1) not to put weight on my L foot as much as I can, 2) stopped going to the gym for exercise (back rest stationary bike (30'), and rowing (30'), and 3) use crutches around the house.  I cancelled my appointment with the Podiatrist this week, because it seems to me that he just sells me stuffs.

1.  Do I need to see an orthopedist?
2.  Do I need a custom orthotics since my arch is normal?, or just by good orthotics from Aetrex Lynco 
2.  Please advice of what I need to do to be able to walk for exercise again? 

Thank you very much for your help.

Thuy Nguyen
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The response

Thuy – heel pain can be an athlete’s dread.  Your mechanism, jogging on the trampoline, is a bit unusual, as most of the athletes I come in contact with get heel pain from running.  And they hate it when you tell them they have plantar faciitis.  Many runners will get this, some only once, a small few repeatedly.  They describe their pain located at the bottom inside of the heel, worst for the first steps out of bed in the morning.  Push off yields pain, but no so much at heel strike, going down stairs, that type of thing.  The doctor also considers problems like stress fracture or tumor in the calcaneus, or heel bone.

The painful spot is located at the insertion point of the plantar fascia, the tissue that makes the arch of the foot, into the heel bone.  It’s an area of fairly low blood flow so that healing can be quite slow in some.  Rest, yep that 4 letter word, is the order of the day along with stretching.  The runner’s stretch that everyone knows followed by the same with bent knee.  Tight calf muscles are often a contributing factor in PF.  People benefit from icing in one of several ways.  Many will freeze a water bottle then roll the arch and foot over it.  Some prefer an ice pack or Dixie cup where they peel off the upper half of the paper using the bottom as a handle.  Judicious use of ibuprofen or other anti-inflammatory drug can help with the pain.  Foot massage with a lacrosse ball helps in some cases.  I’ve had good luck with night splints and so-called Strassburg socks. Pool running, while not in the great outdoors, helps.  I wrote this for Ironman a while back but it's useful today.  http://bit.ly/2h2ie1b

If all of the above fail, there may be a role for a cortisone injection or maybe even PRP, platelet-rich plasma.  This is blood taken from your arm, spun in a centrifuge, and a small portion injected into the heel.  The last result is surgery.  Although this can be done a number of ways including open or arthroscopic, knowing that I favor arthroscopy for knee and shoulders, with this diagnosis, in my mind, the open incision gives a more precise result.

Thuy, in your case, since you’ve failed most of the above, you would at least wonder if a second opinion or further x-ray studies would be of benefit.  My bias would obviously be a an orthopedic foot and ankle surgeon but that’s your call.  Best of luck to you.

John

John H. Post, MD
Medical Director
TRAININGBIBLE TRIATHLON COACHING
You bring the passion. We apply the science.

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