Question
QUESTION: Hi Dr, Katz,
I am an medical doctor (Internist) in New Hampshire. I so hope you might be able to help a collegue. I've had an intractable foot problem for 9 years. It all started after I used some hard orthotics to try and correct a pronation problem leading to anterior knee pain.
I developed pain in the heel/arch just distal to the PF's insertion into the calcaneus. (MRI shows no apparent structural lesion one month ago). I have flexible flat feet. When I used the hard orthotic, my arch came "crushing down" on the raised hard arch of the orthotic and became very tender. The arch has been unable to tolerate any pressure since. If I walk heel-toe quickly and stay off the arch I'm fine. If I stand still, my arch flattens and bears weight on the spot and starts killing me. It's a catch 22. If I wear flat archless shoes my plantar fascia stretches and eventually starts to ache. If I wear arch supports it's worse because of the direct pressure on this tender area. I do not have the classical PF symptom of heel pain when I fist get up. In fact, that is the best time of the day. My arch has "shortened" overnight; my arch is higher; and when I walk barefoot, even on the hard floor, (the arch has not fallen yet), and nothing is pushing on the tender area at the proximal PF, there is no pain. Once I'm up for a while I fall into my catch 22 delema as above. I can run 2 miles without much problem (using the "flatfoot insole insert" which seems to effectively keep weight off this area running, but not standing). But walking slowly or standing still is torture. Any ideas? Surgery to maintain arch? Neurolysis of nerve to PF? EPF?  Thank you so much. JC

ANSWER: Hi Joe,

I question whether you might have injured the posterior tibial tendon and have developed chronic inflammation.  You may also have a component of fasciitis distal to the typical area.  An orthotic should not hurt if it is made properly.  It also sounds like the device may be too rigid and not properly formed to your foot.

Typically I would start you on anti-inflammatories and put you into different orthotic devices. Perhaps a device with a little flex and start off with less arch support.  I would then have you see a physical therapist.  I have also found that MRI's are often poorly read.  I would find a Radiologist that has experience with the foot and tell them your symptoms and have them look at it again.  Or have a Podiatrist look at the actual MRI not just the report.

If you do need surgery, I would advise against release of the fascia and would attempt neurolyis of the nerve.  My preferred method is using Cryosurgery.  I have found that more invasive surgery in an active person will often lead to other problems and at times worse pain.

Hope that helps.  Good Luck.

Sincerely,

Marc Katz, DPM
Tampa, FL
Advanced Podiatry
www.thetampapodiatrist.com
www.tampacryosurgery.com
www.fix-my-foot.com

DISCLAIMER:
This information is offered as free advice and as general information. It may not be applicable to the specific questioner and his/her problem.  It is not based on actual knowledge of the questioner or his/her medical history and it cannot and should not be relied upon as definitive medical opinion or advice.  Reliable medical opinion and advice can only be obtained through hands-on physical contact and exam of the patient to establish an accurate diagnosis and treatment plan.  No doctor/patient relationship is created or established here and may not be inferred through answers on this site.  The questioner and other readers must consult his/her own doctor before proceeding or implementing any suggestions contained within this document and answers on this site.  The questioner is only to act upon his/her own doctor抯 orders and recommendations. By reading this posting which follows, the reader fully understands and confirms that he/she holds harmless this writer. If this is not fully agreeable to you, the reader, and/or you have not attained the age of 18 years, you hereby are advised to read no further.


---------- FOLLOW-UP ----------

QUESTION: Thank you Dr Katz for the reply,
I have already tried every conservative tx in the book, over and over. I've had
at least four different orthotics (firm, medium, soft)  made by different
podiatrists over the years (weight bearing and non-weight bearing). All of
them cause pain/tenderness when my arch comes down on them.
Do you think there's any hope for the cryosurgery given that the pain (and
tenderness), although epicentered at the PF (primarily medially, but somewhat
centrally) just distal to the calcaneal insertion, radiates down the medial band
almost to the first mtp joint? That is, does cryo done at this more proximal
site get the nerve that goes all the way down the medial band? And would
cryo possible help if the tenderness is both at the medial edge and central
aspect of the proximal PF?  The actual MRI images were looked at by a well
respected foot/ankle surgeon at a tertiary medical center in Boston. He was
convince that it was not the posterior tibial tendon, but rather the PF itself.  
Thanks, Joe Cunniff


Answer
Hi Joe,

Well it certainly sounds like you've been through the whole routine.

I've found that many people have pain medially and centrally and I typically treat both areas with Cryosurgery.  I will usually freeze branches of the medial calcaneal nerve and at times some branches of the lateral plantar nerve.  In addition inflammation around the fascia will resolve from the cold temps.

In some cases I have found that patients will have entrapment of other nerves including the superficial peroneal nerve, medial branch at the ankle and this can cause 1st MP pain.  Also running along the medial fascia and musculature is the digital branch of the medial plantar nerve which can be inflamed as a result of distal fasciitis and can cause 1st MP pain.

I have treated all of these areas with Cryosurgery and have had success.  It does not always give complete relief but is certainly far superior to other more invasive procedures.  The good thing is that if that Cryo can be repeated and other procedures may be performed if it doesn't work.

Hope that helps and good luck.

Sincerely,

Marc Katz, DPM
Tampa, FL
Advanced Podiatry
www.thetampapodiatrist.com
www.tampacryosurgery.com
www.fix-my-foot.com

DISCLAIMER:
This information is offered as free advice and as general information. It may not be applicable to the specific questioner and his/her problem.  It is not based on actual knowledge of the questioner or his/her medical history and it cannot and should not be relied upon as definitive medical opinion or advice.  Reliable medical opinion and advice can only be obtained through hands-on physical contact and exam of the patient to establish an accurate diagnosis and treatment plan.  No doctor/patient relationship is created or established here and may not be inferred through answers on this site.  The questioner and other readers must consult his/her own doctor before proceeding or implementing any suggestions contained within this document and answers on this site.  The questioner is only to act upon his/her own doctor抯 orders and recommendations. By reading this posting which follows, the reader fully understands and confirms that he/she holds harmless this writer. If this is not fully agreeable to you, the reader, and/or you have not attained the age of 18 years, you hereby are advised to read no further.