The back of your heel is a small area, but there are a few different problems that can cause pain here.  This isn’t plantar fasciitis we’re talking about.  The area where your Achilles tendon attaches to your heel is what I want to discuss.  You can imagine that since this involves your Achilles tendon the more you walk or run the worse it gets.  Shoes that push on the back of the heel can cause horrible pain.  Achilles heel pain is all in this one small area on the back of your heel so it can be easy to confuse what is causing your pain.  If I play tic-tac-toe on the back of your heel I can tell exactly is causing your Achilles pain.

Just this week a resident surgeon diagnosed one of my patients with a “pump” bump.  This is a lump of bone on the back outside “shoulder” of the heel that was thought to be caused by high heeled women’s shoes.  Unfortunately in this case the patient was a man.  How was I going to diagnose the cause of his heel pain without embarrassing my resident or the patient?  We played tic-tac-toe.  I drew a grid around his Achilles tendon attachment to the heel.  Next, I pushed on each square and marked an “X” if he felt pain.  When finished I stepped back and looked at the pattern of X’s.  All of a sudden the true cause of this patient’s heel pain was staring me in the face.

The center square is where the Achilles tendon attaches to your heel bone.  If my X-pattern involves the center row or even sometimes the bottom your problem is with the Achilles tendon insertion.  An X-pattern in the upper squares are a sign of Haglund’s deformity.  This is a lump of bone extending across the top portion of the heel.  The Achilles tendon sits right over this area and is separated from the bone by a fluid filled sack called a bursa.  The tendon, bursa, or both can be involved in this pain pattern.  If my X’s are more along the outside of the heel (right side of the picture) this would be the “pump” bump my resident had suggested.

You can see from the picture that my patient has a problem in the central square.  This is pain at the Achilles tendon attachment to bone.  Fortunately anti-inflammatory medicine, ice, stretching, a lift under his heel, night splints, and physical therapy will usually make this better.  Some times a heel spur can form in this tendon attachment and needs to be removed, other times an arthritic condition such as Rheumatoid arthritis or systemic lupus can inflame the tendon attachments to bone.  This is called enthesopathy and requires medical care with arthritis medications besides the ice, night splints, and physical therapy we just talked about.

The other areas of heel pain in this part of the foot are lumps and bumps.  If the pain is across the top squares, a Haglund’s deformity, or along the outside squares, a pump bump, I will recommend starting with the relief of inflammation like I always do and add a change in shoes that won’t push on this painful area of the heel.  If your pain does not go away with stretching, night splints, ice, anti-inflammatory medicine, changing shoes, and physical therapy that pretty leaves us with only one option, surgery.

Even though there are 3 causes of heel pain in this area surgery always involves the Achilles tendon because either the tendon is the cause or it lies just over the problem area.  For this reason no matter which diagnosis you have the recovery from Achilles heel surgery is the same.  Your game plan for recovery will include 2 months completely off that foot using crutches or a knee walker.  I will begin your physical therapy at 2 weeks.  Your first steps will be in a cast boot with the help of a physical therapist around the 8 week mark.  From there I’ll teach you how to gradually return to shoes.  Your total time out of shoes will be about 3 months.

I don’t think my resident will ever forget how to diagnose Achilles heel pain after this.  Using a simple child’s game to make a complex diagnosis is just one of the things I love about my job.

Seeing a new patient is like an athlete getting ready to go onto the field or an actor waiting in the wings preparing to go onstage.  I have to get psyched, this is your first impression of me.  I pick up the paperwork you filled out and see that the reason you came to see me was “foot pain”.  Imagine my reaction.  I start sweating, my heart is beating in my throat, I might pass out.  Foot pain is just about everything and anything.  I need to find out where exactly in your foot the pain is located, what it feels like, and when it hurts.  This is why I write this article.  Help me help you.  Below is a list of common causes of “foot pain”.  There is a brief definition of the problem, where it is located, and in general what the pain feels like.

Bunion:

A lump behind your big toe caused by the big toe going one way, towards the 2nd toe, and the bone that supports the big toe, metatarsal, going the opposite way.  The lump is the metatarsal.  Pain can be divided in two:  on the lump is usually sharp pain with pressure from shoes, redness, and sometimes swelling, while the other pain is deep in the joint described as aching or throbbing that gets worse when you walk.

Bunionette or Tailor’s Bunion:

Similar to a bunion, but at the little toe.  This is where the 5th toe moves toward the 4th and the bone supporting the toe, 5th metatarsal, moves the opposite way making a lump on the outside of your foot.  Pain can be described just like it can for a bunion.

Corns: 

Hard skin on any side of a toe that usually causes sharp pain to pressure or shoes.  You might notice that the toe has changed position or shape.

Calluses:

Hard skin on any surface of the foot other than the toe, usually causing sharp pain while walking.  Why is a corn on the toe and callus on the foot?  I have no idea.

Exostosis:

This is an abnormal growth of bone.  Places where you might be able to see this are on a toe, top of the 1st metatarsal, or on the top of your arch.  These cause sharp pain when pressure is applied, but are caused by arthritis in the nearby joint.  Arthritis pain is deep aching, throbbing and yes it does get worse with the weather.

Hammertoe:

A toe that is buckled, curled, or bent any way other than straight.  Pain from the toe is usually related to a corn, but the joints can cause deep aching pain when walking.

Hallux limitus or hallux rigidus:

The hallux is the big toe and these conditions describe the joint at the base of the big toe.  The motion in this joint can be limited or completely gone, rigid.  These are forms of arthritis commonly described as deep aching, throbbing, or even sharp.  Anything that makes the toe move aggravates the pain such as walking especially in heels or up hill.

Metatarsalgia:

This is a general term for inflammation of a metatarsal.  It has fallen out of favor recently since it is not very descriptive.  Now-a-days this would be inflammation of the joint in the ball of your foot called capsulitis.  This is deep aching or throbbing pain when the joint moves, such as when walking, but usually better in supportive shoes and worse in heels or on stairs.

Metatarsal stress fracture:

A stress fracture is true inflammation of the bone that weakens the structure of the bone and can become a real break.  This is deep aching and throbbing with swelling of the foot in the area of the break.  Usually you have increased your activity or changed shoes before this started.

Neuroma:

A pinched nerve in the ball of the foot.  This causes sharp shooting pains that might travel out the end of your toes, most commonly the 3rd and 4th toes.  Some people can describe a clicking feeling in the ball of their foot when they walk.

Peripheral neuropathy:

The sensations of burning, tingling, or insects crawling on your skin worse when you have no other distractions like when you lay in bed.  These usually follow nerve patterns and can travel up and down the foot or leg.  This can get worse leaving you with loss of feeling.  You would think that loss of feeling has no way to be described, but since you had feeling then lost it patients are able to describe this lack of sensation.

Plantar fasciitis:

Arch pain in the muscles that is often described as cramping, aching, pulling, or even sharp when you walk.  This pain is usually worse with the first steps in the morning or after a period of sitting.  The plantar fascia is a big strong ligament running from the heel to the toes, but it is actually the muscles that sit just beneath the fascia that are inflamed.  The heel is usually involved in the pain as well.

Sesamoiditis:

The sesamoids are like knee caps for your big toe.  They sit in the ball of your foot behind the big toe and help the tendons hold your big toe on the ground.  These can be injured directly or by forceful upward motion of the big toe.  Aching in the ball of the foot at the base of the big toe with or without swelling is usually described by patients.

Tendonitis:

The muscles in your leg travel to your foot by tendons.  Any of these tendons can become irritated, injured, or inflamed.  The pain is usually along the line of the tendon and is commonly described as sharp, stabbing, aching, or throbbing depending on your activity.

Ulcer:

An ulcer is a break in the skin.  Obviously this would hurt, but most patients with ulcerations on their feet are lacking the ability to feel pain.  This can be hidden under callus or develop from a blister next to a callus.

These are the most common causes of “foot pain”.  I hope this will help when you need to explain the pain.  My heart can only handle so many complaints of “foot pain” in a day.

Paul trained for his first marathon.  He was smart about it going first to his doctor for a physical then having his feet and shoes checked in my office.  His training program included strength training, flexibility, and running.  Paul said the race was hard on his body, but he was happy to have finished.  About 3 weeks later I saw Paul again.  This time he was a wreck.  He was in pain from his low back to his toes.  Paul hadn’t been sleeping well and was just not as happy as he expected to be after completing his first marathon.

I asked about his recovery from the race.  I heard about the celebration that night soaking in a hot tub with friends drinking and eating whatever was there.  His wife had scheduled him for a massage the day after the race.  Paul said it hurt more than it felt good and had no lasting effect.  Stretching was impossible because of the pain and stiffness.  The tight muscles made it nearly impossible to run the few times he had tried.  When I asked if he was following any schedule or program he reminded me of his pre-race training program, but had nothing to follow for recovery.  Do you know what Paul did wrong?

What you do immediately after the race is as important as what you did to get there.  You know that running 26 miles is serious business, that’s why you were so careful in your training program.  After the race you will be exhausted mentally and physically.  Your recovery plan has to be set before you race so you won’t have to think about it.  Your muscles have worked hard for 26 miles and all nutrients in your body have been used.  When your body works hard for a long time you get inflammation.  Treat your body right and this will go away quickly so you’ll be running again in no time.  Ignore the inflammation and you’ll suffer.  I’m sure you’ve heard stories about people who ran a marathon and were never able to run again.  If you ask them about their post-race recovery I bet you’ll get a blank stare.

As soon as you finish the race:

You’re exhausted and legs feel weak, but this is the time you need to keep walking.  Don’t stop and get a chair massage, don’t chat at the booths.  Get your packet, medal, snack pack, and drink water as you walk around.  Make a mental note of what hurts.  I don’t mean big areas like your entire leg.  I mean specific areas like your calf muscle, front of your thigh, back of the thigh, front of your leg, arch, heel, toe.  Pay attention to any pains so that you can address these after a thorough cool down.

Your kidneys have been fighting to balance your hydration and electrolytes.  All the waist products coming from all that muscle action of running 26 miles is filtered by your kidneys.  They have worked overtime and need to recover.  Anti-inflammatory medications stress your kidney more.  This is not the time to take anti-inflammatory medications like Ibuprofen or Naproxen.  Refuel by drinking water, electrolyte drinks are OK, but water has to continue even if you’re drinking electrolytes.  Eat like you did while you were training.  Protein helps repair muscles and carbohydrates help with fuel. 

I don’t know how to describe it, but there’s an excited feeling in your legs, some people tell me a throbbing, others say it’s like their legs are just revved up.  Don’t stretch until that feeling in your legs goes away.  You can ice the sore spots and gently stretch.  When you get home take a cool bath.  Use a foam roller or gently massage sore muscles.  If possible schedule a massage in the evening, at least 4 hours after the race.

Things to avoid:

1. Sitting for more than 10-20 minutes
2. Soaking in warm water or hot tub
3. Sauna
4. Anti-inflammatory medications

The first week:

Inflammation can last 24-72 hours.  You will have to pay close attention to your body. If you treat the inflammation right you’ll be running again after a few days.  Ignore the inflammation and it can become a repeating cycle that is difficult to break even with my treatment.  Have more massages, practice yoga, swim or bike.  Don’t be aggressive, your goal is to stay loose.

If you have no aches and pains by day 3 you can begin gentle-paced, low mileage runs.  Do not exceed the mileage you did the week before the marathon.  Begin every three days with light resistance training on off days.  Any aches and pains need to be addressed.  Don’t wait to see me for any pains that remain.  The sooner these are addressed the easier they are to treat.

The 2nd week and forward:

If you’ve made it this far without needing me you’re doing well.  Gradually increase run frequency and distance back to your training levels as tolerated.  You might find that you are more easily fatigued, but that is normal for the first month.  Anything more than that and you should seek medical attention.  Don’t forget to have your running shoes checked.  During this return to training period you will need to have new shoes.  At Desert Foot Surgeons we offer video gait analysis to see what the naked eye cannot.  Come have your gait analyzed in or out of shoes.

Congratulations, you did it!!

Grab a pair of sneakers and go.  That’s all it takes to run, right?  Maybe that’s why more people than ever are running marathons.  Running a marathon is an admirable goal, but the philosophy of just grabbing a pair of shoes and running may be why I’m seeing more running injuries than ever before.  Training for marathons has turned into big business.  You can join a club, buy a magazine, or purchase a plan online.  My problem with these training schedules is a lack of individual attention.  Remember my saying, “feet are like snowflakes, no two are the same”.  Some people have feet that can run 26 miles, but does that mean your feet can?  Well there’s two mind sets:  1. you’ll never know until you try, or 2. I’ll follow a training program.  But what’s missing?  Neither approach is designed with you in mind, so when you get hurt you end up needing me.

Recently three people came to see me for the most common running injuries.  Even though these people had different pain, were different ages, lived in different cities, and had different lifestyles, they all had similar stories about training for a marathon.  All three had not run for exercise consistently in more than 5 years.  A friend had convinced each one to train for the marathon.  Not one of the 3 had a training program made specifically for them, but all were using a group training schedule from either a magazine, the internet, or joining a training group.

The first patient complained of heel pain that was worse with the first steps out of bed then again in the evenings especially after running.  I diagnosed this patient with plantar fasciitis and relieved her pain by teaching her how to stretch and ice, gave her foot orthotics to support her sudden increase in activity, and plantar fascia night splint for the morning pain and stiffness.  Plantar fasciitis is a common overuse injury.  The muscles in your arch stretch beyond their limits when you walk or run.  A sudden increase in activity, change in shoes, or an injury is usually related to the start of pain, but very few people realize this until I point it out.  In this case the patient had a new activity, running.  She also had new shoes that she bought for this training.  Had I seen her before she started training I could have watched her walk on slow motion video and analyzed how her foot might be effected by running.  Stretching could have been started before training began and help individualizing her training program could have been arranged.  Her heel pain and time away from training could have been avoided, but she will be able to run the marathon.

The second patient came to me with the complaint of pain and swelling in the top of his foot.  He was training for a marathon and noticed the pain increasing gradually as his distance increased.  Pain was present all day long, worse in shoes, and swelling increased the more he walked.  Running had stopped because of the pain.  X-rays showed a stress fracture of his 2nd metatarsal.  This is the bone behind your second toe and is commonly the bone involved in stress fractures of the foot.  Stress fractures are broken bones that happen gradually when you have a sudden increase in activity.  The sudden increased pressure on the bone causes inflammation that weakens the bone, but you’re still not aware of it so you keep on training.  When the weak area of the bone breaks you get the big ouch.  Treating the fracture early is easiest.  A removable cast and anti-inflammatory pills relieve the pressure and inflammation allowing the fracture to heal.  Once you heal the real treatment begins.  There is a reason the fractured bone has more pressure than the others and it’s my job to find out.  Detailed exam of your foot structure including video gait analysis will be done so that custom foot orthoses can be made.  This will correct the pressure problems in your foot and prevent further fractures.  Unfortunately in this case the patient came to me once his bone had broken.  His goal of completing a marathon will have to be postponed until later in the year.

The third patient wasn’t far along in her marathon training when she developed pain in her lower legs.  This pain was very bad when running and improved with rest.  She wanted to run the marathon so bad that she trained until until her leg started to swell.  By the time I saw her my major concern was a stress fracture of her tibia, the main bone in the lower leg.  The beginning of her story was more like shin splints, but I had to make sure so a few tests were done to prove this was not a stress fracture and she improved with treatment for shin splints.  Medial tibial stress syndrome is the newer term used in sports medicine for shin splints.  The cause is always related to pronation, see my article “Are You a Pronator”.  Most foot problems can be related to pronation, but medial tibial stress syndrome occurs in the leg.  To make a long story short, it’s the rotation of your lower leg when you run that causes this pain.  Custom foot orthoses are the only way to make this go away and stay away.  I had to modify this patient’s training program and get her help to strengthen her thigh muscles, but she will be running in the marathon.

Running is good for you!  No one will argue that point, but getting started is the hard part.  Buying a running shoe from a specialty store is a good idea, but now a lot of stores are using pressure mapping to tell you how your foot works.  First of all, you cannot tell how the foot works by standing still on a pressure plate.  At Desert Foot Surgeons I use video gait analysis to see exactly how your foot works while you run or walk barefoot and in shoes.  Second the study of foot motion is called biomechanics.  This takes years of study to master and is only provided in podiatry schools.  I have many friends in the running shoe business and have learned a lot about shoes from them.  Likewise I have taught my friends a lot about biomechanics.  I won’t pretend to know more about shoes than these professional salespeople and all of my friends will not pretend to know more about the function of the foot than I do.

Come see me before you start running.  I can help you with more than just shoes and orthotics.  I can get you personalized training or even physical therapy.  If you have shoes already video gait analysis will show if they are working for you.  Preventing injuries is much easier than treating injuries.  Running is good for you, just do it smart!

You probably don’t even think about them unless you lose one in the wash.  They are left balled up in a drawer.  Half asleep, you reach in blindly and grab the first pair you make contact with.  You give more consideration to them when you use them for dusting rather than when you wear them.

Socks!  What other particle of clothing has so many uses?  They help to keep your feet clean, warm, and dry, fight dry skin, cushion and protect your soles.  Some people use them as a form of expression and others just an accessory.  Even when they are worn out and no longer suitable for your feet you can use them to polish furniture, shine shoes, wash your car, cover your golf clubs, or make a puppet.

At Desert Foot Surgeons, our talk about socks is not limited to just patients with diabetes.  Socks can make a difference and help in your treatment.  Dr. Geller talks about the fibers used to make the sock, thickness of the material and padding.

The fibers used to make socks are either natural fibers or man-made (acrylic).  Natural fibers are cotton and wool.  You didn’t have to grow up in New Jersey, like Dr. Geller, to know that wool is itchy.  Socks made of cotton and wool are criticized for being too tight and the seams too rough, in other words uncomfortable.  When it comes to keeping your feet dry, natural fibers are not as good as man-made materials.

Acrylic materials are combinations of polyester, nylon, and elastic fibers.  When these types of socks are made with increased cushioning, they are better at keeping moisture away from your skin compared to natural fibers.  The material is softer and the seams easily hidden.  Padded socks made of man-made materials have been shown to lower the pressure on your feet.  Elastic can be increased so that the socks can be used to help prevent swelling.

No matter what material they are made from socks cannot replace shoes.  Walking in socks does not provide the support or protection that a shoe does.  Especially for those of you who have diabetes with loss of feeling in your feet, you cannot walk inside or outside in socks alone.

At Desert Foot Surgeons, Dr. Geller does the shopping for you.  We carry special diabetic socks.  These are high quality, padded acrylic socks especially good for our patients with diabetes.  Even if you don’t have diabetes, these socks are good for people who are athletic or work in areas where your feet are exposed to moisture.  Please give your socks the consideration they deserve and dress your feet.

Eli Manning Gets Good Advice For Heel Pain

On October 5th Eli Manning, the quarterback for the New york Giants, was diagnosed with plantar fasciitis after limping off the field in the 4th quarter the day before.  In the NFL pregame show October 18th the treatment for Eli’s condition was discussed.  On the advice of an old football coach he is wearing cowboy boots during the day, using plantar fascia night splints, and wearing custom foot orthotics in his cleats.

Think about this, Eli Manning, a world champion quarterback, franchise quarterback for the New York Giants, brother of Peyton Manning and son of Archie Manning, has possibly the best medical care available second only to the president of the United States, but he is taking the advice of a former coach. Why? One simple reason, the advice is good!

Plantar fasciitis is an overuse injury resulting in heel and arch pain. Wearing cowboy boots takes the strain off of the plantar fascia. Dr. Geller always says, “You can’t begin to heal until the inflammation has gone away”. Taking the stress off the Achilles tendon by wearing cowboy boots plus the physical therapy the Giants training staff is providing for Eli is doing just that.

At Desert Foot Surgeons we often use splints at night. The plantar fascia night splint keeps the Achilles tendon and plantar fascia stretched while you sleep. If you get the severe sharp pains when you get out of bed in the morning this is what night splints are used for. If you can get rid of that morning “zinger” your day will be better.

The overuse part of Eli’s injury and anyone’s plantar fasciitis involves pronation or lowering of the arch. To review pronation is the normal shock absorbing motion of the foot. The foot rolls to the inside, the arch lowers and the heel turns out. This is good, we want to be able to absorb shock when we walk and run. Of course too much of a good thing is bad. When your arch is still lowering at a time when it should be stable is bad and leads to injury. Custom molded foot orthotics prevent abnormal flattening of the arch and heal the plantar fasciitis. Dr. Geller uses video gait analysis and a detailed examination to make the perfect custom molded foot orthotic that will keep your foot stable when walking.

Below are stretching and icing instructions Desert Foot Surgeons has available for patients with plantar fasciitis. Hopefully Eli won’t find this website before the Giants play the Cardinals.

The big toe can develop a lump or bump on the inside of the foot. This prominence initially becomes painful in shoes from pressure, but if left untreated arthritis will set in. The lump on the inside of the foot at the base of the great toe is called a bunion. Often mistakenly referred to as a growth of bone, the cause of a bunion is really the result of an unstable joint. The loss of stability in the big toe joint causes the bone behind the big toe to drift inward leading to the lump or bump. The more the bone drifts, the more your big toe falls toward the second toe.

How the joint becomes unstable is related to the way your foot hits the ground when you walk. A detailed examination of your feet while standing and walking is needed to determine why your foot is unstable. If caught early custom molded foot orthoses can restore stability to the joint and prevent further damage.

If painful, damage to the joint has already occurred. Custom molded foot orthoses will restore stability to the joint, which can improve pain, but usually therapy involving anti-inflammatory medication is needed as well. When pain does not respond to stabilizing the foot, surgery is needed. The goal of surgery is to provide stability to the joint from within preventing further damage. This is accomplished by moving the bone that has shifted back into line with the big toe. The more the bone needs to be shifted, the longer the recovery. So getting treatment early is always recommended.

Dr. Stephen Geller, DPM , AZ Podiatrist