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xray images ... how bad do these look?

Posted by Matt H on 1/16/04 at 22:48 (142244)


I have been struggling with constant heel pain and nearly crippling stiffness following running sessions. I've not run for the past year or so, but my heel pain is still with me.

I posted my xrays online. I'd like to get some opinions/feedback on what you see here.

Some say there is no surgical fix ... other tell me there
is an option for a surgical fix for me.

What do you think?

Right heel: http://www.pbase.com/image/25197011

Left heel: http://www.pbase.com/image/25197100

Needless to say, I am frustrated that I can no longer run.

What should I do???


my e-mail: (email removed)

Re: xray images ... how bad do these look?

Dr. Zuckerman on 1/17/04 at 11:01 (142268)


X-ray are only one part of the evaluation. It does show any soft tissue structures. You x-ray are negative for any plantar heel spur but ther is spurring on the back of the heels where the achilles tendon inserts. Without an examination I can make any correlation with your pain . An MRI and or ultrasound is much more important along with a complete examination

Re: xray images ... how bad do these look?

Julie on 1/17/04 at 12:47 (142280)

Dr Z, I believe you meant to say the xray does NOT show soft tissue structures; and that without an examination you canNOT make any correlation...'

I'm sorry to butt in, but this is a new poster who doesn't know your little ways!

Re: xray images ... how bad do these look?

Dr. Zuckerman on 1/17/04 at 16:25 (142285)

thanks. Have to stop doing two things at once

Re: xray images ... how bad do these look?

Julie on 1/18/04 at 03:25 (142298)

Matt, have you seen a podiatrist? It's essential to have an accurate diagnosis and a full evaluation to determine the cause of your PF so that it can be addressed with a full, comprehensive treatment programme. A good foot doctor will be able to give you all of this (but there are some that are not so good, so you may have to look around).

As Dr Z says, Xrays don't show soft tissues, so they're useless at diagnosing PF which is a soft tissue injury - inflammation of the plantar fascia. Read the heel pain book on this website for information about the many conservative treatments for PF. Most people get better with conservative treatment; very few need surgery and you shouldn't even be thinking 'surgery' at this stage.

Do steer clear of running until you are fully healed - running in all probability contributed to your PF in the first place.

All the best for your healing.

Re: xray images ... how bad do these look?

Pauline on 1/18/04 at 18:39 (142323)

Dr. Z, I think this was the first time we've had a poster post their x-rays on this board for interpretation and I must admit it made me a bit uncomfortable.

In the past, you've had posters send you their films or MRI's which I personally think is in keeping with your professionism. I don't think any of us should expect a diagnosis from this site.

Hopefully Matt will contact you at your office for a complete follow up

I would imagine interpretating x-rays over the internet is a whole new ballgame for the doctors on this site.

As you said with out a full examination, a complete history, and perhaps other tests correlating the reason for a posters pain via the internet is somewhat impossible if not dangerous to both parties.

Re: xray images ... how bad do these look?

Dr. Zuckerman on 1/18/04 at 19:17 (142331)

Interesting . I receive intrpretations from radiologists all the time without the physician seeing the patient or examining the patient. X-rays are tranferred digitally all the time now across the USA
I have no problem looking at x-rays so long as the poster understands that all it is an x-rays that needs to be combined with an examination.
I think in this case. Matt was only looking for anything on the x-ray and nothing else.

Re: xray images ... how bad do these look?

Pauline on 1/18/04 at 19:37 (142333)

Dr. Z,
Isn't that a radiologist speciality and why doctors rely on them to interpret films? I'd consider that a doctor to doctor transfer.

He's doesn't provide his findings directly to the doctors patient. In fact I don't think he is allowed to perform any test on that patient without the treating doctors consent or Rx. Also isn't there a provision that states he cannot directly provide his findings to the patient that must be provided to the patient by the treating doctor?

Re: xray images ... how bad do these look?

Dr. Zuckerman on 1/18/04 at 21:17 (142339)

I am not sure about a radiologist not allowed to order tests . They do have a medical degree and a liscenure to practice. It probaby isn't good business for them to order testing when all of their referrals come from
referral sources. I am also sure if he is NOT allowed to report his findings to the patient. I have heard of that rule or law.
I am sure of your analogy to the radiologist and this specific example with Matt. Not really sure why you would be uncomfortable with Dr. Z reading x-ray for a patient such as Matt so long as he completely understands that a physical examination must be done to give the diagnosis and that a x-ray is only one conponent of the examination

Re: xray images ... how bad do these look?

Matt H on 1/18/04 at 22:32 (142346)

I appreciate the time you all have given to discuss my post. I realize the Internet cannot replace a doctor's exam in person. All I was seeking was some feedback on what you see in these views, specifically the spurs on the rear of my heels. This is the best online resource I've found to date to talk about stuff like this. If there was a radiologist bulletin board, I'd have posted to that too. Have not found one yet.

I've been dealing with this pain for six years and have been seen by as many doctors. Opinions on treatment and solution have been all over the board. I happen to be in the military, and running is a requirement to my continued service. All conservative treatment (aggresive stretching, icing, orthotics, night splints, ultrasound) has not provided relief or allowed me to return to running. I am now facing medical discharge after 16 years of service. Needless to say, I am frustrated.

I had MRIs taken and the reading radiologist's comment that there appeared to be evidence of partial tearing of the achillies on both.

The last doctor I saw, a podiatrist, felt surgery to partially remove the tendon and remove as much of the bony spurs build up as possible would relieve the pain and give me the best chance for recovery and return to a running routine.


Re: xray images ... how bad do these look?

Julie on 1/19/04 at 01:44 (142350)

Matt, I'm sorry for getting it all wrong, but you didn't tell us any of this in your first post so I didn't know and I was commenting only on what you did tell us. And I'm very sorry you are facing discharge because of your foot problems.

One more comment. If you've been doing 'aggressive stretching' all this time you might like to consider the possibility that it may have delayed, rather than assisted, your healing. The exercises that are commonly recommended for PF have been found damaging by many people here: they are not appropriate for injured tissue.

I can now see why you are considering surgery after six years of dealing with foot pain. Have you looked into ESWT?

Re: xray images ... how bad do these look?

Pauline on 1/19/04 at 08:38 (142358)

I understand your generousity Dr. Z because that is the way you are, and I'm certain posters appreciates your kindness.

One issue I think that needs to be appreciated though is the new patient confidentuality law along with a few other considerations pointed out in this article. Heck Dr. Z, we know you, but look at some of the issues she points out.

There are legal concerns that need to be considered when communicating with patients via e-mail, says Kristin Olds Glavin, AAOS associate general counsel. The first question you need to ask yourself is 'Is the service a form of medical practice? If your answer is 'yes i.e., you are giving more than general medical information then you need to be aware that you are exposing yourself to potential legal risks.
Legal concerns that need to be considered if medical advice is to be provided include:
Medical licensure. Are you licensed to practice medicine in the state in which the Internet user resides?
Specific informed consent. Do you have the Internet user's consent to transmit personal medical information over the Internet?
Medical malpractice insurance. Professional liability insurance policies do not cover unlicensed medical practice and may also have territorial boundaries.
Errors in use or regulation of technology. If medical information or advice is incorrectly transmitted and an adverse medical outcome results, liability can be assessed against the provider.
Privacy/confidentiality. Patient medical data is protected under state law, under the federal Constitution and under the HIPAA and its privacy regulations. The regulations contain strict requirements for the transmittal of patient data over the Internet. Internet abuses and the potential for hacking, especially in e-mail transmittals that may contain confidential patient data, are real possibilities that could result in physician liability.
Reimbursement. Current Medicare regulations disfavor the practice of telemedicine.
If you decide that you want to respond to specific medical questions only from your long-standing patients, there are still several issues to consider, including:
Make sure that your patients are comfortable with, and have signed any necessary release for discussion of their private medical information via e-mail (informed consent). E-mail may not be secure and in the course of answering your patient's specific question, you are probably writing about their medical conditions.
Make sure that your patients know that any emergency should not be handled via an Internet query. It may be a good idea to post a notice on you web site and in your office that patients should not expect an e-mail response from you for 24 hours and that any emergency or immediate issue should be handled by a phone call.
Be sure to keep copies of all questions and answers to medical questions in the patient's medical record. An adverse medical result stemming from your response to a question containing insufficient information from the patient may be the basis of a malpractice lawsuit.
Make sure that your patients are aware of the potential for technology failures. Instruct them to follow up with a phone call to your office if they don't receive a response to their Internet inquiry.
Stay on top of any state and federal requirements for medical record confidentiality.
Be careful about charging for medical advice you give via e-mail; make sure that any charges are consistent with statutory and health plan requirements.
You should consult your own legal advisor for legal information.

Re: xray images ... how bad do these look?

Dr. Z on 1/19/04 at 13:39 (142377)


We hav used ESWT for this very painful tendon problem. I have treated many
military personal that are in your same position. E-mail at (email removed) and I would be happy to discuss and or send you informaton on ESWT. Ok

Re: xray images ... how bad do these look?

Dr. Zuckerman on 1/19/04 at 20:14 (142401)

Thank you Pauline,