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DPM changing PF diagnosis--after 2 years?!?

Posted by Scott Mc on 7/30/04 at 14:00 (156571)

I have had chronic foot pain (both feet)for 2 years. It was caused by wearing too-stiff soccer shoes and possibly re-injured by hiking. I have been thru every therapy -- anti-inflammatories, cortisone, PT & other stretching, ice, & orthotics. (I have been unabable to tolerate the night splint prescribed by my DPM.) I bailed out on ESWT because insurance would not cover ($2500). My DPM seemed uncertain re using cyro-injections and my communications on this site were inconclusive.

Because I no longer describe my foot pain as 'heel pain in the morning' and because none of his treatments have worked after 2 years, my DPM seems to want to back off from the PF diagnosis.

Presently, heels hurt only slightly in the morning but the pain builds over the day. By evening, the pain level is quite high, making it difficult to sleep. The pain runs from the heel thru the arch to the ball of the foot. That's still PF, right? My DPM is talking about things like neuropathies, (I am convinced it is not a neuropathy--I am well read and experienced with neuropathy) or who-knows-what.

So, even though the pain pattern (both location and time) has changed, I say it's still PF. Do I keep trying to treat it on my own with the above therapies or let my DPM 'go fishing'? Thanks.

Re: DPM changing PF diagnosis--after 2 years?!?

Ed Davis, DPM on 7/30/04 at 14:54 (156581)

It sounds like a nerve conduction velocity test may be a good move. It can yield some very specific information so I would not consider doing such a test as 'fishing'. My 'reading between the lines' on your post leads me to suspect that PF is not the main culprit.

Re: DPM changing PF diagnosis--after 2 years?!?

Scott Mc on 7/30/04 at 16:02 (156595)

I have a condition in my calves and hamstrings known as the 'muscular pain-fasciculation syndrome'. There is no effective treatment. I have had this syndrome since 1990, it is characterized by the contant firing of nerve endings. In the last 2 years, I have had $2,500 worth of NCSs, ALL NORMAL. The fasciculations show up on the EMGs but can also be easily observed. Some of the NCS electrodes were on my feet. I can forward these NCSs to the DPM but can he intrepret them? Or, do I pay yet another neurologist for a yet another consultation? Or, worse yet, MORE expensive NCSs?
The PF started with classic symptoms but the pain pattern slowly changed. I can definitely tell you that the foot pain never has remotely felt like the feeling and pain in my legs. Also, the ankle provides a clear zone of separation and has no pain or odd feelings.
What 'between the lines' leads you to believe that I don't have PF? (Or, that I have not had PF for the past 2 years!?)
Thank you.

Re: DPM changing PF diagnosis--after 2 years?!?

Ed Davis, DPM on 7/30/04 at 19:11 (156611)

I beleive you are referring to NCV or nerve conduction velocity studies when you use the abbreviation NCS? Were all the tests done by the same testor? I am not sure what the test costs so how many tests did you have?You mentioned that some electrode were placed on your feet. Do you remember how high up they went? Did they place electrodes on your back?

It sounds like you had symptoms consistent with classical plantar fasciitis but more recently the symptoms have shifted. Based on the information you have provided now it seems that a neurologic cause is less likely. Yes, many DPMs could interpret the test results so he may want to look at what you already have done before ordering more.

Please describe what you are feeling as specifically as possible in your feet. Some possibilities that are related to plantar fasciitis include 'atypical' plantar fasciitis which is a variety in which the fasciiitis is more diffuse, tends not to have rest pain and not necessarily centered at the heel. Another possibility, if the pain is getting worse with time and is related to PF is midtarsal joint strain. The plantar fascia is like a guy wire holding up the joints of the foot.
The guy wire can be overstretched, mechanically, and painful. Say that the fascia was cut or even stretched to the extent that it is not an effective supporting mechanism, then strain is transmitted to the joints of the foot, particularly the midtarsal joint (runs across the middle of the foot).

Re: DPM changing PF diagnosis--after 2 years?!?

Scott Mc on 8/02/04 at 16:18 (156773)

Yes, I have had 4 separate nerve conduction velocity studies done by 4 of 5 neurologists. All normal. Along with the velocity studies, the EMGs document that the visible twitching can be measured by expensive testing. The last 2 neurologists produced massive amounts of paper; lots of graphs, etc. But, the write-up was always 'normal'. They put electrodes on about 3 or 4 places on my legs (both hamstrings and calves) and another 3 or 4 places on my feet. I cannot remember precisely where on my feet the electrodes were placed. The placements may be indicated in the pages and pages of test results. As all 5 neurologists agree that my neuropathy is peripheral (and I agree with them), no electrodes were placed on my back. I wonder if my DPM can or will wade thru all the pages.

I still wake up with heel pain, although not severe. The mild heel pain continues and and new pain develops in the arch and ball-of-foot as I stand and walk during the day. By evening the pain is throughout both feet, the heel thru the arch and into to the ball of the foot, the area corresponding to the fascial bands. Less activity during the day equals less pain in the evening.

Here's my hypothesis: My DPM overdid the arch height on my lastest pair of orthotics and has worsend the condition. I definitely noticed more arch pain. I have just (today) relocated and gone back to my old orthotics. Could the overbuilt orthotic arch have been creating the midtarsal joint pain (and ball-of-foot?)pain to which you refer?

If so, just go back to my old orthotics and 'standard' treatment...rest, night splint, icing, and stretching? (And, find a new DPM?)

Re: DPM changing PF diagnosis--after 2 years?!?

Pauline on 8/02/04 at 22:14 (156796)

I'm not a doctor but remember YOU are the employer when it comes to selecting a doctor. You hire and you fire so if you want a new doctor by all means start interviewing.

You also can go back to your old orthotics, continue to use the ones that hurt or even just try Scott's taping methods. We sometimes forget who really is in charge of our health care and that it's to our advantage to partner with the doctors we select to achieve the best medical care.

Keep on top of your treatment, continue to research and interview, yes interview several new doctors. Give them the details and see what plan they have before you hire time.

You might also give some thought to changing directions. Since you've seen a Pod you may want to give an Orthopedic Surgeon M.D. who specializes in Foot and Ankle a try or interview an Orthopedic Sports Medicine M.D. or another Pod. that a friend recommends.

There are doctors on every corner. Our job is to connect with the ones that help and you can't do that unless you interview them and get second opinions. Just because you visit one doctor doesn't mean he becomes your immediate treating doctor. By a process of research, interviewing and elimination you look for the best person to help you.

Re: DPM changing PF diagnosis--after 2 years?!?

Dr. Z on 8/03/04 at 07:59 (156807)

Small correction. There are also foot and ankle orthpedic surgeons that have a DO degree. Doctor of Osteopathetic medicine.

Re: DPM changing PF diagnosis--after 2 years?!?

Pauline on 8/03/04 at 08:32 (156810)

I don't know what your correcting Dr. Z because I meant exactly what I posted, M.D.

I realize there of also Orthopedic Surgeons who are D.O.s, however, I specifically said exactly what I intended to say in my post.

Re: DPM changing PF diagnosis--after 2 years?!?

Dr. Z on 8/03/04 at 11:02 (156824)

Didn't know you knew that both can have the same training in foot and ankle orthopedics. Didn't want any of the posters to not go to a DO Foot and Ankle Orthopedic doc

Re: DPM changing PF diagnosis--after 2 years?!?

Pauline on 8/03/04 at 11:13 (156827)

By now Dr. Z I think you know I mean exactly what I post. If you want posters to visit D.O.'s you should post that.

Re: DPM changing PF diagnosis--after 2 years?!?

Scott Mc on 8/03/04 at 15:05 (156836)

Helena is a small town. Montana is a big state. Not that many choices. Will go back to old orthotics and stretching. Will try to find tolerable night splint. May have only other DPM compare two sets of orthotics and re-evalutate them and foot. No DO's or orthopaedic MDs in Helena that have knowledge or interest in foot problems.

Will try to find comfortable night splint. Also, will get ESWT done on 8/13 in Billing by Dornier machine. DPM there say will pick up machine cost if insurance won't cover--BC/BS won't cover--(don't know how or why he does this) and that no anesthesilogist needed. So, my out-of-pocket falls from $2500 to $850.

Not going for any neuropathy hypotheses. Lead to a bunch of expensive tests and no treatment. I advise all to wary of tests for neuropathies. They are scientifically valid but usually medically useless.

Re: DPM changing PF diagnosis--after 2 years?!?

Pauline on 8/03/04 at 15:17 (156840)

What is your largest complaint about night splints? The angle? The ones I used were what I belive is standard hospital issue. Solid blue plastic with yellow strips that attach with a tiny valcro sq. They had a terry cloth liner that was slightly padded.

Although not the best design one is able to make them relatively loose fitting so the foot is not put at the complete fixed and stretched angle.

When I started wearing them I had to use this loose position which was rather sloppy. As my length of time got longer I was able to tighten the straps as needed.

I slept in two and in the beginning it was difficult to get used to them, but eventually I had no problems and was able to sleep all night with them.

The warmth was the big issue for me and the reason I went to wearing two was because when I'd turn over I'd somehow hit my ankle all the time so two actually worked better than one and besides I had bilateral P.F.

Eventually after wearing them for over 2 years I purchased a new pair because the straps had broken and the lining had become shredded from wear.

Have you tried the Nice & Ice?

I don't know the issue you had with night splints, but after wearing them for a long time, I know how I would design a better one. Someday I might just do that.

Re: DPM changing PF diagnosis--after 2 years?!?

Dr. Z on 8/03/04 at 16:00 (156844)

Both are fine with Dr.Z so long as they know how to treat feet

Re: DPM changing PF diagnosis--after 2 years?!?

Scott Mc on 8/03/04 at 17:59 (156856)

The ankle stap cuts off circulation and is painful. I get it ridiculously lose and my heel raises way up from the heel 'cup'. The foot is actually in nearly a 'drop' position (pointed down). I don't think that helps. And, I've never made any improvement (I do stretch my calves regularly.) Then, the velcro pops lose because so little is connecting. So, I'm thinking a wider and heavily padded ankle strap would help. I also have bi-lateral PF -- is wearing 2 recommended for bi-lateral PF? I thought I'd alternate one of them from foot to foot. Isn't it difficult getting up at night with 2 on? The Adjustable one on this site ($58) LOOKS like it might be the most comfortable one. You say you like night splints, yet what does your use of them for 2 years say? That they aren't very effective? I have not tried Nice and Ice...are they worn to bed? Are they comfortable around the ankle?

Re: DPM changing PF diagnosis--after 2 years?!?

DavidW on 8/09/04 at 14:05 (157277)

Scott Mc, I believe I have had a similar experience as yours. My initial foot pain started as a throbbing in my heals. Went to 1st POD who prescribed $300 orthotics. After wearing them for a month, the pain was more pronounced in my arches and felt more like a burning. Went back to the POD, who increased the arch support (at my expense). I wore the modified orthotics for several months at which point I had more pain radiating from the heel, to the arch, even the outsides of my feet. Went back to the POD who suggested another adjustment, at which point I refused.

I guess my point is that I think PF pain can change, especially as we try different methods to solve the pain. I think that this is normal, although none of the docs I have seen have any clue. It only makes sense that if pain starts in the heel, and an orthotic relieves some of the heel pressure, that the problem can either go away, or some other part of the foot may take up that added pressure and start to hurt.

As you suggested you might do, I have abondoned my custom orthotics for PowerSteps, and returned to the basics of stretching/icing/ taping. These basic methods are working at least as well as all the doc visits and much cheaper!!