Question
I am becoming desperate for relief from chronic heel pain.  I am a triathlete and am very active.  I swim and bike most days but have run only four times since my last race 6 months ago, which was completed in severe pain.  I have not entered any races since then.  There now seems to be three types of pain and it got very severe about 10 months ago.  

At that time I was running on the beach when I experienced a burning, ripping sensation on the lateral side of my heel (not on the sole of the foot but on the side and at the edge).  There was no swelling or bruising but I was unable to walk.  Now there is always discomfort in this area, as well as the back of the heel, which sometimes becomes severe pain.  

I also seem to have some slight decrease in sensation of the skin in a small area in the back of the heel now.   When I run my finger down the sural nerve on the back of my leg I get a paresthesia into this area.   The pain seems unrelated to time of day, is usually worse with activity (but sometimes at rest), and has occasionally kept me up at night.  Inversion and dorsiflexion of my foot duplicates/exacerbates this pain.

There is also pain on the bottom of my foot that is worse upon arising, and diagnostic ultrasound confirmed plantar fasciitis (8mm thick).  It originally started about 12 years ago and was almost resolved when it started to worsen 10 months ago after the lateral heel pain started.  

I stretch it, ice it, take Celebrex intermittently when it gets very bad (see PMH below), and have had a course of PT.  I had cryoanalgesia about two months ago but cannot tell if it helped due to so much other pain. I have worn custom orthotics for about a month and a half.

The third pain I have is in the ankle joint itself.  This started suddenly while riding a stationary bike about three months ago.  It was originally painful with each step but now is primarily painful if I invert and dorsiflex the foot.  It feels like a sprain but there was no precipitating trauma, no swelling or bruising, and it has not resolved after partial improvement.

After 4 months without running I ran two miles without pain.  A few days later I experienced the ankle pain on the bike and when I ran it felt like a partially healed sprain.  After another month off I tried running again and had severe pain (all three types), primarily on toe-off, after a quarter mile.  Since then I only run in the pool where I have no foot pain.

I had a foot MRI that was not really remarkable.  A lumbar MRI showed degenerative disk disease, especially at L5-S1 and a very mild spondylolisthesis of L4 on L5.  Nerve conduction study of both lower extremities was normal but an EMG showed a chronic L5 radiculopathy on the affected side.  I have had some pain in my posterior thigh which I had attributed to tight hamstrings but now realize is probably sciatica.  It does not seem to correlate well with the foot pain in intensity or timing.  

Diagnoses have ranged from plantar fasciitis to possible entrapment of various nerves at various locations, to sciatica, to sural neuropathy or some combination .  Steroid injections in the heel produced no improvement though there was significant temporary improvement with a Medrol dose pack.  I am considering a diagnostic/therapeutic epidural steroid (with local) injection.

I have had about 12 severe inversion injuries to this ankle including a fracture to the cuboid bone, several sprains, and several injuries that were not specifically diagnosed (after a while I quit getting them X-rayed and just RICE抎 them).  The most recent injury  was about three years ago.  Other pertinent past medical history includes Crohns Disease for which I take Asacol (I cannot take NAIADS except Celebrex).    

I have not taken a pain free step for ten months.  My lifestyle is severely impacted.  I cannot seem to get a definitive diagnosis and would appreciate any thoughts or suggestions you may have regarding diag


Answer
Hi Susan,

I don't think your pain is atypical.  You have lateral sural pain because the nerve is being injured while running and likely scarred or pinched from inversion injuries.  Cryosurgery of the sural nerve works very well for this condition.  Your ankle will never be the same after all of the stress and injuries that you've experienced.

It may be time to look for other sport or exercise options. Your activities are obviously taking a large toll on your feet and ankles.  They can never heal with all of the activity.

In addition you have spine damage which worsens the whole issue.

Sincerely,

Marc Katz, DPM
Tampa, FL
Advanced Podiatry
www.thetampapodiatrist.com
www.tampacryosurgery.com

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