A patient I'd last seen sixteen years ago walked in with severe, worsening pain beneath his outer heel. There had been no change in his activity level, shoes, body weight, or musculoskeletal status to cause an injury there. Apparently, it just started all by itself, no trauma. It was getting worse by the day, and had been present for six weeks by the time he came to see me. Unlike most heel pain, it was not noticeable when he got out of bed in the morning. It heightened as the day went on, the more he walked. It was so bad that by 2:00 PM it would stop him in his tracks.
He pointed to the spot assuredly. It sounded like it should hurt to an extreme when I palpated it, but surprisingly, it did not. I had to press really hard to elicit even a little tenderness. There was no swelling, redness, increased temperature, black and blue, or even a little callus. Neurologically, he was intact; there was no compromise in his ability to feel light pressure in his foot. For all the disability, there was very little in the way of clinical signs—truly a disproportionate mix of symptoms and signs.
I'll let you in on a little secret. When there's a disparity like this, there usually is a little gremlin in the mix causing trouble. In the world of podiatry this gremlin is usually shoes, orthotics, or pads, and it may also be exercises ostensibly being performed for "therapy." As we were talking, we uncovered that he'd been wearing the same three pairs of shoes for the last nine years. He kept getting them resoled. Red flag, red flag!
I bent over and grabbed his loafers and peered at their heel counters like an assemply-line robot. There, brazen and blatent, was the answer. Spillover sole! Such a flimsy heel counter, which had migrated significantly over the edge of that robust recently-repaired heel. Looking inside I saw a very dark wear pattern exactly at the site of his pain, at the edge of the sole right at his pain place. He was bruising his heel as the day went on by riding along on this incisional edge. His treatment consisted of a plastic heel cup, nightly icing the area, and an admonition to stop resoling those blasted shoes and start wearing some non-loafers with firm heel counters and rubber heels. He called three days later, pain gone.