Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Daily Calcaneal Heel Pain and No Diagnosis After ~12 Months

Discussion in 'General Issues and Discussion Forum' started by evanwebster, Feb 20, 2017.

  1. evanwebster

    evanwebster Welcome New Poster


    Members do not see these Ads. Sign Up.
    Ongoing calcaneal heel pain is significantly impacting quality of life. No diagnosis after 13 months. Please help.

    CC:
    A 31 y/o white male with around 10 months history of consistent, relatively sharp pain in the left calcaneus. Somewhat posterior and medial. 5'10" and 160 pounds.

    HPI: Pain is made somewhat worse by weightbearing activities, oftentimes delayed hours to days following activity. Reducing weightbearing activities did not eliminate pain. Moderately sharp pain. Some tingling in medial calcaneus. No numbness. No strenuous physical activity has been performed since early 2015 but pain has remained. Painful to walk or stand still on feet. When weightbearing somewhat sharp pain is felt at the bottom of the calcaneus / calcaneal tuberosity. Pain is consistently better in the morning and gets worse through the day. Different styles of shoes have no effect on pain. OTC NSAIDs have minimal effect on pain. Treatment with over-the-counter orthoses have been of little relief. Four months of physiotherapy including deep tissue massage and ultrasound were of little relief. Attempted to treat issue with walking boot for 6 weeks. No improvement. Primary diagnosis of postalcaneal bursitis along with Haglund's deformity from orthopedic surgeon. Left calcaneus resection surgery underwent in late June 2015 followed by six weeks in walking boot. No material improvement. Physical therapy, low inflammation diets, and rest until January of 2017. Saw a doctor who noted that the plantar fascia is in good shape and diagnosed tarsal tunnel and recommended PRP to fix torn ligaments and tendons from multiple ankle sprains dating back to a high ankle sprain in high school. Underwent a PRP treatment three weeks ago. No change at this time. Saw a physiatrist who did EMG testing and ruled out tarsal tunnel. Suggested gabapentin for neuritis.

    PMH: Overall exceptionally healthy. High left ankle sprain in high school and then multiple (~12) left ankle sprains over the next ~12 years. Torn right ACL due to trampolining in 2010.

    PE: No swelling or redness. Sensitivity to touch in the medial calcaneal area. Full strength in the leg and ankle. Have had no swelling or loss of strength for entirety of heel pain. Able to go on tiptoes without a problem. Dorsiflexion not a problem. When standing still on two fait, pain increases as weight is shifted from front of feet to back of feet. Pain felt in calcaneal tuberosity.

    Musculoskeletal: Notably loose left ankle. Was diagnosed with functional hallux limitus, working on fixing this at physical therapy.

    Gait examination: Overpronation and flat feet (never problems prior to injury in January 2015).

    Neurological:
    Dermatological:WNL
    Vascular:

    Tests: None available.

    Diagnosis:

    Treatment Plan:

    Any help would be a huge relief. I can answer any follow-up questions, please let me know if there's anything I did not address in the information above.
     
  2. gingerphysio

    gingerphysio Member

    sciatica.
     
  3. Ina

    Ina Active Member

    If I were the patient, I think my next step would be a doctor with a special interest in tarsal coalitions in adults to rule the latter out.
     
  4. efuller

    efuller MVP

    A difficult heel pain work up. A lot of things point to referred pain except the pain with direct pressure. Straight leg raise, slump test? If the range of motion of the rearfoot is normal I doubt it is a tarsal coalition.

    The location is a typical plantar fasciitis. (to state the obvious)

    That is a lot of ankle sprains for someone who has a lot of pronation in gait. Sometimes people with laterally deviated STJ axes will show late stance phase pronation. It is pretty rare that you get a flat foot with that many ankle sprains. You can have a laterally deviated STJ axis with a flat foot, though this is rare. The laterally deviated STJ axis could explain the ankle sprains. Often with lateral STJ axes you will see late stance phase pronation that is caused by muscle activity attempting to overcome the supination moment from the ground. Does the foot look "overpronated" in stance?

    Check the maximum eversion height and consider a forefoot valgus wedge. A forefoot valgus wedge has been shown to reduce the tension in the plantar fascia. It might not help the heel pain, but it could reduce the ankle sprains. Tough case.

    Eric
     
  5. gingerphysio

    gingerphysio Member

    pain with direct pressure is a common feature of a referred pain event. When proximal nerve roots are irritated there are four nerve effects.
    altered sensations
    altered patterns of recruitment
    pain
    autonomic changes

    pain with direct pressure indicates hypersensitivity( an altered sensation)

    sciatica.
     
  6. Ina

    Ina Active Member

    The original post gives a detailed subjective history, past medical history with omissions and no objective clinical examination findings whatsoever. Surely, protocols of clinical examination are very different in different countries among different professions, but is it professional for any allied health practitioner to seek outside opinions without having done clinical examination on their own? Hence, I assume, the OP is the patient in question who has done a very good home work. If I misread the OP I am sorry but I will speak my mind for what I feel is ethical:

    If the OP is an allied health practitioner, they ought to have a mercy on the patient and refer him to a qualified specialist who can do a thorough clinical examination and ensure that the patient's multidisciplinary treatment is coordinated and integrated.
    If the OP is a patient, is it safe for their health to receive what is likely to be a misinformed piece of advice?
    If the OP is a student, they should first do their assignment on their own and disclose that this is an assignment. It is not fair play in realtion to those fellow students who work on their own.
     
  7. Dieter Fellner

    Dieter Fellner Well-Known Member

    Patient needs a good, thorough work-up in addition to any clinical findings. That can include XR, CT scan, NCV / EMG tests and MRI. One of these will surely shed light on the cause of the pain.

    Based on the information this has some of the hallmarks of Baxter's Neuritis.
     
  8. Admin2

    Admin2 Administrator Staff Member

    The OP is having a problem posting, posting on their behalf:
    "Thanks for your reply and thoughts Ina, it's spot on.

    I am the patient and have talked to many different professionals over the past 13 months. My reason for posting is that there has been little to no progress and every person has a different opinion, oftentimes directly contradicting another professional.

    So ... I am looking for guidance from this community to see if there's anything that I have missed or any other paths that I should go down. I hope that clarifies my intent and as I said in the original post, I'm happy to answer any questions about my foot, physical history or anything else.

    Also, I will respond to everyone's responses (thanks!) when I have time to review them adequately."
     
  9. Dieter Fellner

    Dieter Fellner Well-Known Member

    The reason you are getting diverse opinions is very likely because pieces in the jigsaw puzzle are missing. An accurate diagnosis is always a process: history / examination / investigation. See above - TESTS: NONE AVAILABLE. With ALL of the pieces in place a doctor can formulate a theory of what's wrong and devise an appropriate treatment plan. Medicine & surgery is never black & white.

    When a doctor is provided only part of the picture you will, out-of-necessity, get many diverse opinions and recommendations. There's a reason why a doctor needs to see a patient in the office, and there's a reason a diagnosis cannot be made with any great degree of confidence on an internet blog. Moreover a doctor risks medico-legal penalties doing so.
     
  10. Admin2

    Admin2 Administrator Staff Member

    This is from the OP (still having trouble posting - we working on it):
     
  11. Dieter Fellner

    Dieter Fellner Well-Known Member

    The Podiatrist reviewed tests ... and what does that show? A second opinion wouldn't go amiss, and take along take the original films / MRI / EMG report for the doctor to review.

    My office is in New York City (along with 900+) others ....
     
Loading...

Share This Page