Heel pain

[BlackHatGuy]

So on the last couple of trips, I’ve developed a pain at the very back of my foot, about 1-2 inches up from the bottom of my foot. After the last trip, as it was hurting, I pushed with my finger where it was hurting, and serious shooting pain was the result. I wasn’t even pushing that hard. Felt fine later. Did another hike today, just a dayhike, same pain. Sucks. There are no protrusions.

Any ideas of what the issue is? I’m making an appointment with my doc, just wanted to see if anyone else has experienced this pain before so I can know what I might expect from my doc visit.

[Matthew / BPL]

Like where the Achilles’ tendon attaches?

[BlackHatGuy]

I had to look that up. But yes, where the achilles tendon connects to the heel bone is where the pain is. Thanks for pointing me in what seems to be the right direction.

[Matthew / BPL]

I’ve not had that problem but I’d guess it’s some kind of tendinitis due to tight muscles. I wonder if stretching and foam rolling would help?

[BlackHatGuy]

That’s definitely on my list.

Thanks.

[John S.]

Achilles tendon issue until proven otherwise. I started having issues when I went to more flat trail runners too soon. It went away when I went back to regular trail running shoes with a higher heel.

[rmeurant]

I’ve developed Achilles tendinitis, and it is a real bugbear. And it sounds like that is what you might have. Even had an MRI last week, but fortunately don’t need surgery. Apparently it is enlargement of the tendon from healing of a probable tear.

My advice based on what I have been advised and practiced, is firstly rest up. Even consider wearing a splint for 2 weeks. Don’t use your ankle at all if you can help it, for that period. It’s likely either a tear in the tendon, or enlargement from inflammation, so you could take anti-inflammatory pills. Avoid alcohol. Remember your RICE – rest, ice, compression, and elevation, though I was also recommended hotpacks. I found dipping my ankle in cold mountain streams eased the pain when I insisted on shortish hikes.

At its worst, you’ll find you can’t even walk properly, and have to hobble. I dread being backcountry solo and losing my mobility again thru another such attack.

I hated the splint and inactivity, but the ankle support and enforced rest did eventually help, as did the anti-inflammatory pills that I continue to take. I am forced to walk far less now, and also find it easier to have my weight a little further aft when walking. I’m trying to regain my earlier fitness, also trying to be mindful when walking, and to educate my ankle and foot to cooperate. Don’t carry a heavy pack or weight.

See an orthopedist. You would likely have an X-ray and treatment before needing an MRI. Also web search Achilles tendinitis for good online advice.

Cheers!

P.S. The splint I had was removable, could take it off at night. It molds to your foot like an Intuition ski boot inner (but much cheaper), the emergency clinic at my hospital fitted it to my foot. Instead of bandaging it on, I used cheap Velcro straps, so could put it on and off fairly quickly. It was light enough to carry in a small pack when I was improving, so I could use it if needed while out and about.

[Ian]

Just got hit with this.  Nothing seemed to immediately precede it and I can’t determine what the cause was.  I hiked some earlier in the week but didn’t feel any discomfort during the hike or for a couple days afterwards.

I now have a lump on the back of my heel about where the tendon terminates.  Doc can’t see me until next week so I’m hobbling around and no hiking in the meantime.

[rmeurant]

RICE.

Rest, Ice, Compression, Elevation.

[Ken Thompson]

RICE not being recommended as much these days.

[rmeurant]

If Ian’s problem is similar to mine, it is serious, and needs attending to.

Rest is essential to not further stress the tendon. I found that cold mountain streams really help – almost immediate relief (though I shouldn’t have been out hiking), but my doctor also recommended heat packs. Compression doesn’t want to be too tight, but gives the ankle support, so presumably reducing the load on the tendon. A splint (not a cast) will more or less immobilize the joint – a bloody nuisance, but strongly advised. Elevation just seemed to help a bit.

Ian might also try anti-inflammatory medicine, as inflammation is a likely cause, or at least a key symptom. Alcohol should be avoided, particularly if he is prone to gout or arthritis, also foods that should be avoided for those diseases.

 

[Ian]

Thanks Robert.

I only have one or two beers per month so booze is easy enough to avoid.

Vitamin I is currently being used.

I’ll add ice, compression, and elevation at home.  Rest is hard to come by these days but I’ll do what I can.

Keeping my shoe loose and unlaced helps me during the day as I hobble around.

 

[Tom K]

“But yes, where the achilles tendon connects to the heel bone is where the pain is. Thanks for pointing me in what seems to be the right direction.”

That sounds very much like insertional Achilles tendinosis(itis).  I have just gotten through dealing with this problem.  I saw an orthopedic specialist, and he recommended a first line treatment called the Alfredson Protocol.  The video in the link below demonstrates the 2 exercises in the protocol.  However, if your pain is where the Achilles attaches to the calcaneus(heel bone), the exercises need to be modified.  Instead of letting your heel drop below the level of the step, do the exercises on the floor, where your heel cannot drop below horizontal.  This is very important for insertional Achilles tendinosis, as opposed to midpoint tendinosis, as proven by several studies.  Be sure to balance yourself with your opposite hand against the wall.  The protocol calls for doing the exercises twice a day for 3 months.  I am just past 2 months and have no more pain, and am back to hiking normally.  I’d recommend talking to an orthopedist about this, but it sure has worked for me, and apparently a lot of others.

[Michael Gillenwater]

Icing does lessen pain, but don’t confuse pain reduction with healing. Evidence indicates that in some injuries that icing may delay healing, especially for tissues that already suffer from minimal blood flow (e.g., tendons). In these cases you may want to do things that promote blood flow, because that enables faster healing.

Having said that, doing things that actively make an injury feel worse is not smart unless you are under the supervision of a PT or physician while doing so.

[BlackHatGuy]

“I now have a lump on the back of my heel about where the tendon terminates.  Doc can’t see me until next week so I’m hobbling around and no hiking in the meantime.”

My brother has this too, a big bump on the back of his heel. Been there for a few years now. He still hikes, pain or no pain.

Of course, he was a Ranger, not a leg….

[Ian]

Well I’m no Dr but I’m pretty sure my days of running back to back ultra marathons are over.  I guess it’s a good thing that I’ve never run a marathon before or this news would be really devastating.

As I sit on le couch, I have learned that wrapping my foot in ice and then resting it on the couch, thus asserting pressure on my newly formed heel nubbin (I’ve named him Carl), is not the smartest of ideas and actually hurts like hell.

[Ian]

“Of course, he was a Ranger, not a leg…”

Better to be a leg grunt than a REMF.

[BlackHatGuy]

I’m telling Amy you said that…

[BC Bob]

Here’s my 2 cents on Achilles Tendinopathies. Just research and info I’ve found over the years. Just my experiences. My injuries are not other folks’ injuries.

I have Chronic Midportion Achilles Tendinopathy in both my Achilles tendons. One from about 2003 and the other about 2010. For both there was pain, stiffness (especially getting out of bed or off the couch). Both had a lump on the tendon about 2.5 inches off the floor.

Achilles tendinopathy can be “mid-portion” or “insertional” (where it’s attached at the heel).

It’s an overload/overuse injury.

I’ve researched it quite a bit over the years and have rehabed both to some degree. But both are still somewhat wrecked and I think that’s permanent.

Some thoughts….

1. Achilles tendon problems are typically referred to as a “tendinopathy”. They are typically NOT tendonitis. I wouldn’t bother with the Rest, Ice, Compression, Elevation.
2. I would not do foam rolling or stretching.
3. I would not do the splint thing.
4. I had multiple prolotherapy sessions for one Achilles (injections of dextrose and lidocaine). I would not do that again.
5. I had multiple sessions of shockwave therapy. I would not do that again.
6. I had a lot of trouble finding knowledgeable medical folks. Even the ones who understood the problem were recommending outdated rehab ideas (eccentric only exercises are outdated).
7. Important! If you do some rehab exercise for the tendon, it takes 24 hours to know if what you did was OK or too much.

Below are some of the better links to research and info…..

IMO the top clinical researcher on the planet for Achilles tendinopathies is Jill Cook in Australia.

She has a number of podcasts out there, though they are not specific to the Achilles tendon…

https://soundcloud.com/bmjpodcasts/bjsm-podcast-11-jillcook?in=bmjpodcasts/sets/bjsm-1

http://physioedge.com.au/pe-005-tendons-and-tendinopathy-with-jill-cook/
Transcript: http://bit.ly/2uEG1hw

A good Jill Cook article….

10 things not to do if you have lower limb tendon pain
http://semrc.blogs.latrobe.edu.au/10-things-not-to-do-if-you-have-lower-limb-tendon-pain/

Good Jill Cook YouTube Interview Video (educational, more researched based)
https://www.youtube.com/watch?v=B4oahujUyH0

A research article…..

Achilles tendinopathy: understanding the key concepts to improve clinical management
Article · August 2015 Jill Cook et al.
http://bit.ly/2ua10Xb

Isometrics reduce tendon pain
Ebonie Kendra Rio (a Jill Cook Ph.D. student)
http://www.bodyinmind.org/isometrics-tendon-pain/

Jill Cook also has a twitter page…..
https://twitter.com/ProfJillCook/with_replies

This is another research article that might also help (for midportion injuries).

A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation
Authors: Karin Grävare Silbernagel, PT, ATC, PhD1, Kay M. Crossley, BAppSc (Physio), PhD2

http://www.jospt.org/doi/full/10.2519/jospt.2015.5885?code=jospt-site

Treatment of Achilles tendinopathy with combined loading programs
http://bit.ly/2vFHn8N

A review of the continuum of tendon pathology
http://bit.ly/2ttMGf2

Helpful! Look at Figure 2 in the article to see how a tendon reacts to exercise and how long it takes to repair.
http://www.running-physio.com/tendinopathy1/

 

[Ian]

Bob you deleted your post and my post dinner reading assignment!!!!

Bummer.  I wanted to read through those links.

My Google fu WebMD self diagnosis leads me to believe I have achilies bursitis.  Pictures I’ve seen and symptoms ive read all seem to line up.

[BlackHatGuy]

Bob, sorry to see you deleted your post. There was a lot of good info in there.

[Nick Gatel]

Doug,

Have you recently changed shoes? Have you changed anything else, such as how you tie shoe laces? Any chance your shoes are too tight?

 

[Jerry Adams]

yeah, I looked at a couple of those and was going to go back and look some more but they’re gone

[BlackHatGuy]

My issue seems to have been temporary. Haven’t hiked in a bit, but I have jogged with no issues.

[BC Bob]

Pasted my post back in above (with more links!).

[Author]

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