An athlete emailed me complaining of severe heel pain. I had him email me his magnetic resonance image (MRI), which clearly showed a plantar fascia tear.
The patient is 50, and says he is in excellent shape and thin. His arches are high (but not unusually high) and he says pretty much all of his shoes and sneakers have good arch support. He used to run a lot but slowed his running down to only two days per week 12 to 18 months before the first sign of heel pain. When he’s not running, he would either be on the recumbent bike in the gym or out mountain biking. He says he is a little bowlegged and walks more on the outside of his feet.
The patient received four cortisone shots and wonders if the shots played a role in the plantar fascia tear. I have a patient now in whom I injected the area around the plantar fascia, and it sounds like it may be torn. Corticosteroid injections are considered safe if you do not inject right into the plantar fascia, which I did not. Did the cortisone migrate up into the fascia and weaken it? Was the chronic pain due to a weakened plantar fascia that was 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 plantar fascia tear in my 35 years of practice that has a possible link to my cortisone shot. I hope it was not my cortisone shot. I hope it was not the cortisone shots this athlete received that caused his tear. Everyone is trying to help athletes and shots are vital in the final healing of so many of these heel pain issues.
Could one or more of the cortisone shots been misplaced in this patient and would that be at least partially the cause for weakening the medial slip enough to cause it to tear? Yes.
I give 10 mg of long-acting cortisone in a heel injection, which is considered safe. Up to three of these shots over a two- to three-month period are considered safe in chronic conditions. I have seen patients who had 10 shots in three months, only to find out that each shot only had 1 mg of cortisone per shot. One of our orthopedists routinely gives 40 mg per heel injection and says she has never had a problem.
This patient’s plantar fascia tear is very common. I have one or two patients weekly in some stage of tearing, and they heal. I also had a patient come in a year ago, saying he had 10 years of plantar fasciitis. I told him plantar fasciitis never lasts that long. We got MRIs on both sides and they revealed bilateral plantar fascia tears. After three months of one foot in a removable boot and then three months of the other foot in a removable boot, the patient was well and kicking himself for self-diagnosing all those years.
The aforementioned 50-year-old patient also told me he has pain on the opposite side on the heel about 1 inch forward from the back of the heel, halfway between the side of the foot and the bottom of the foot/heel, especially when he squeezes the area. The inflammatory fluid sits somewhere under the heel (which is where I inject) and can be just as painful as the plantar fascia tear. I typically have my patients walk on their heels. If that hurts, then I document heel bursitis. I have them massage just the 2-inch area under the heel for five minutes with a frozen sports water bottle two or three times per day.
The basic treatment is to restrict big toe joint motion. So the patient should find a stiff hiking boot, a hike and bike shoe from Shimano or Pearl Izumi, or a rocker shoe like New Balance 928 or Hoka One One shoe line. The patient should see what limits the motion enough that gets him down to that 0-2 pain level on the visual analogue scale (VAS) consistently. I love the Anklizer or the mid-calf Ovation Medical boots the best for these injuries.
The boot phase is easy. The patient should be able to maintain the 0-2 pain level on the VAS while trying to cross-train. He should experiment with stiff shoes, rocker shoes, orthotics, etc. The post-boot phase falls into the weaning off phase, the walk/run phase and the return to activity phase. Typically, a good sports physical therapist or podiatrist can help this patient along. The exercises are metatarsal doming, single leg balancing, Thera-Band exercises for the posterior tibial and peroneus longus tendons, and at four months, double and single toe raises.
Editor’s note: This blog originally appeared at http://www.drblakeshealingsole.com/2016/08/plantar-fascial-tear-email-advice.html . It is reprinted with permission from the author.