Dedication Simple Solutions Experience

30 year-old woman with pain in thighs and legs for 18 years, now concerned about recent onset heel pain

I met this mother of two little boys today; her husband came as well. She's seen podiatrists, osteopaths, rheumatologists, neurologists, orthopedists, internists, physiatrists, and had blood tests, arthritis work-ups, MRI's bone scans, and PET scans for this 18 years' pain in both thighs and lower legs. No one has been able to give her a diagnosis. Within the past four months she's had heel pain, and wanted me to help her figure out if it was an extension of the long-term problem or something independent. She was also terribly distressed, as the doctor she'd seen two months previously for her heel pain told her it was definitely part of the bigger problem and it would probably be with her for the rest of her life.

After a little Sherlock Holmes work, I felt fairly certain to have nailed both the diagnosis and cause of her heel pain. I didn't think the foot problem was part of the old issue, nor think it would be lifelong. I also gave her some ideas to pursue about the long-standing problem in her legs. By examination I determined her heel pain was due more to bruising than the well-known and dreaded plantar fasciitis. And though she could recall no injury, activity or body-weight change which could have set it off, the clue for me was the time that it started. Right in the middle of the summer. The summer shoe of choice this year?...flip flops. When I asked if she'd worn flip flops this summer, and did she wear them more than she'd ever done before, the answer both times was yes.

Since flip-flops don't enclose the heel, they don't protect it from bruising by keeping the heel fat pad in place. But that alone didn't seem enough to perpetuate the problem, since it's January 5th and she's long been out of flip-flops. I checked her calf flexibility: overflexible. Her calves lack a bit of tone. A normally strong calf acts as a parachute against heel impact. This is something which can easily be strengthened, and since her neurologic exam was normal, I didn't hesitate to show her the exercises. That also explained why she was getting worse quickly since she'd seen a different podiatrist two months previously. He took X-rays and showed her heel spurs. He'd given her hard orthotics, which she complained about, but he told her to keep wearing them, and he's also sent her to physical therapists with the diagnosis of plantar fasciitis, and a prescription to massage her heels and stretch her calves.

She'd feel worse after each physical therapy session, and the worsening was accumulating. I've never believed in massaging a bruise. If Mike Tyson punched me in the nose, I wouldn't pay someone to massage it three times a week. I also never believed in prescribing stretching exercises unless I examined the part and found it to be tight. These calves were loose, and the stretching was further lessening their ability to protect the heel bruises.

The orthotics? I am going to be critical. They were hard, not cushiony. Her heel fat pads were very thin, and the entire underside of her heel bone was tender to light palpation. The arch portion of the orthotic was flat, came nowhere near her natural arch, and afforded her no support. She would have been much better off with $15 gel cushions instead of these $500 orthotics. And to ice the cake, there was a thicker heel lift glued to the left orthotic. I asked her how the doctor determined she should have the lift. She said he didn't measure her leg length. I did. As I've done routinely for nearly 30 years, I used nine different measurement techniques to be as sure of her leg length as I possibly could. The heel lift was under her longer leg! An inappropriate heel lift can cause an array of new symptoms. I advised her to discontinue the orthotics and gave her some gel pads.

Let me tell you a little story about heel spurs. Just because you have a heel spur, it doesn't mean you are condemned to heel pain for the rest of your life. In fact, just because the X-ray shows a spur, that does not definitively nail the diagnosis. I give a lecture about heel pain. I start the lecture with seven slides. Each slide is an X-ray of an individual's right and left heel. There is a heel spur on one foot only in each of the slides. The reason I start my lecture with these slides? Because in each patient, it was the heel without the spur which was causing the only symptoms. This means the doctor has to do a little more delving before setting you up for a standard treatment regime. You might, as in this patient's case, get worse.

But my greatest objection to the previous practitioner was his assertion that this woman's pain was going to last her whole life, and was part of the thigh/leg issue. How did he know? He didn't know what the thigh/leg issue was. It left her in terrible distress. I suggested she visit a pain management doctor to see if her problem was a mild variation of reflex sympathetic dystrophy, a disorder which turns normal sensory nerves like those which conduct temperature and pressure sensation, into pain conductors. I also suggested she talk to her internist about am MRI of her spinal cord and possibly head/neck, in case there is a lesion causing the problem from above. She'd only had MRI of her thighs.

There are lots of websites out there which will teach you about standard foot problems. Feel free to read them. But unless your doctor approaches you as an individual, and makes an evidence-based conclusion, you may do just as well by treating yourself based on what you read in these links. I hate to harangue, but this website is up to teach you to think outside the box, including piping up and asking the doctor for a reason for everything he and his charges do. Ask why a problem, which is being treated three times a week, should be getting rapidly worse. The doctor's first response should be, "Maybe what I'm doing is hurting you." This is honesty, we are all human, and if we are not afraid to look at our work critically, we can modify a treatment plan and learn from our mistakes to the ultimate benefit of our patients. If the doctor responds, "I don't know," during an active course of his treatment, without even offering you a colleague for a second opinion, I recommend you cease your relationship with this doctor.

I will let you know how she's doing. She's following up in a month.

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