Hi guys,

I know that there are a few MDs who post on here so I have a semi-related hunting question for them:

I will head out for an unguided Caribou fly-in hunt in northern Quebec next month.

I have plantar fasciitis in my right heel just past the heel pad (I guess where the tendons/ligaments attach to the heel bone) that might act up on a hard, heavy backpack hunt. I have been taking anti-inflammatories (Nono-difenac SR 75 mgs) but they don't seem to be working- still walk with slight limp after a tough fishing trip on rocky terrain for a week.

Saw a General MD today and he gave me a prescription for:

1. Methylprednisolone Acetate Injectable Suspension USP 80mg/ml 1ml one time only via injection to affected area

The doctor mentioned that if my foot really acts up to point of high pain, to rest at base camp and do a self injection into the painful area of the heal. He explained that it is a type of corticosteroid to reduce inflammation.

My question comes from when I looked at the label and it mentioned to NOT inject into the Achilles tendon. Isn't this pretty close to the heel? I am concerned that it might do more harm than good.

Does this make any sense or should I seek a specialist (what type?)?

Thanks.

Note: not looking for a medical opinion, just some casual thoughts on this Remember that I am from Quebec, Canada so seeing a GP is my first step in a long process.

Go to a Specialist...

I have heel spurs in both feet...I have gotten Cortazone shots and they have worked for about 5 months, then after a while they don't work anymore and you just have to learn to live with the pain, but you sure do need specially fitted shoe inserts or the spurs will just get worse..

The most effective cure is a boot you were while sleeping that stretches the tendon back to normal, but it is a long drawn out process of several months...

In the meantime go to a specialist and get a shot that will last about 5 months, get the fitted inserts for your boots, that will get you through this hunt mostly pain free...

I´m an MD and I would not recommend self-injection if you don´t have medical training. The achilles tendon starts at your heel and ends at the calf so the risk of hitting it while injecting something in your heel/foot is minimal as long as you don´t get "buck fever". There is also the risk of "mainlining" which won´t kill you but it won´t help your foot either. In order for the injection to work you have to get the meds into the right spot, something that isn´t always easy to do in a clinical setting...

I find it a bit irresponsible of your doc to give you that kind of a prescription. Follow Ray´s advice.

don't do it. All you need to do is inject depo-medrol into a vein or into the nerve back there and you are going to be in alot of trouble. We do those in pain clinic all the time and they take 5 minutes. Go see someone.

CL

"Go with what Ray said."

My Plantar Fasciitis caused a heel spur or my heel spur caused the P.F. I don't know which comes first.

The best success I have had so far, is they are now taking the hypodermic needle and pricking the bone spur to make it bleed in order to cause scarring around it followed by the Cortozone shot. Last visit has been 7 months ago and I am still staying pretty active without pain. Insurance will not pay for surgery to remove the spur as they claim it will grow back.

It also took three tries to find the right shoe insert too. Good luck!

Fred

Thanks. I thought it was a bit unguided (excuse the pun) on the part of the MD. Quebec (mainly french speaking) has hired in a bunch of people to work here from Haiti (because they speak french & we have a need for qualified MDs)- this might be the result...

I assume that I might need a referral to a Doctor of Podiatric Medicine (DPM) or foot doctor?

Thanks again. I will not use that prescription- though he felt it would be unlikely that I'd need it, I have limited first aid trainnig and little medical background.

I do agree that telling the patient to self inject a heel spur out in the bush, "prn" at a remote hunting camp, smacks of malpractice.

I used to run indoor track, outdoor track, cross country, road races, marathons, and one !@#$%&! ultramarathon! I have dealt with plantar fascitis in myself and patients of mine.

Apparently I have an imperfect arch and slightly pronated heel on one side. I dealt with it by getting the custom inserts or "orthotics" for my shoes. A podiatrist made mine.

It depends, but sometimes you can do about as well with a heel cup and arch support OTC ala Dr. Scholls. Cupping up the fat pad of the heel in a plastic heel cup plus a cushioned insole/arch support will help.

Plantar fascitis starts the problem, with micro tears of the plantar fascia where it attaches to the calcaneus or heel bone on the plantar or "sole" side of the foot. This plantar fascia is the suspensory ligament of the arch of the foot. Due to over stress and structural imperfection like mine, the PF is trying to tear away from its attachment. Healing of these small partial tears repeatedly over time results in calcium buildup and the "heel spur" which may get to be like a bird's beak of bone spur.

Some people with monster heel spurs become pain free eventually. There is nothing wrong with getting the steroid injections a time or two (by a practiced hand), but you gotta get on the ball with the orthotics for structural correction, and pavement pounding stress reduction.

Mine quit hurting, but I still wear the orthotics most of the time. I also don't run marathons anymore due to fears of hip arthritis, etc.

If I don't go out and do those 10 to 20 mile training runs daily, I am pain free, and can jog 3 or 4 miles per day with impunity. No more stress fractures, shin splints, or plantar fascitis.

I'm a neurosurgeon, so I more often inject necks and backs rather than feet.

Go to a podiatrist, and have him inject you 2 to 3 days before you leave...plenty of time in case there is a problem.

The positive effects of a steroid injection persist for for more than a week, more like several weeks.

Also, try Celebrex (200 mg one time dose per day)...sometimes it gives better results than Relefen.

Garrett

quote:

Originally posted by N. Garrett:
I'm a neurosurgeon, so I more often inject necks and backs rather than feet.

Go to a podiatrist, and have him inject you 2 to 3 days before you leave...plenty of time in case there is a problem.

The positive effects of a steroid injection persist for for more than a week, more like several weeks.

Also, try Celebrex (200 mg one time dose per day)...sometimes it gives better results than Relefen.

Garrett

This is good advice. I am certified by the American Board of Family Medicine. I remove ingrown toenails and inject heel spurs, and I was trained to do it by a podiatrist in a two week podiatry rotation. I particularly love to split and yank off toenails. It ain't rocket science nor neurosurgery.

Actually, the injection itself may aggravate the problem for a day or two until the steroid can have its soothing anti-inflammatory effect for a few weeks.

That is why it would be stupid for the quack to tell you to give yourself an injection in fly camp.

The injection should also have a local anesthetic mixed with the steroid to numb the spot for a couple of hours after it is pumped full of juice.

BTW, if you let the steroid leak out into the plantar fat pad, you may get necrosis and atrophy of the normal plantar fat pad that cushions the heel. If you do, it is gone forever. Injecting into the plantar surface (sole of heel) is more likely to do this. The medial approach from the side of the heel is preferred, with the tip of the needle ABOVE the fat pad.

What needle approach did the Haitian Duck recommend?

I have both plantar fascitis and Giant heel spurs that look like "claws of death" in an xray. In addition, I'm heavy (290 lbs). Several years back, I went to a foot guy and he did something called a Gibney wrap on my foot, Let me tell you, I was in agony and could hardly walk. Every morning when i got out of bed, the heel and achilles were so sore and stiff, it was enough to wish myself dead. Since the Gibney wrap and some exercises, I've been fine since 1999. I use cheap Dr Scholls insoles in my hikers, and then I insert a Dr Scholls arch support. Both of these come to less than $10 at Walmart. The arch support fas a good arch in it that flexes and wears well. I went to my foot guy again this week for a different injury and he was interested in the arch supports. He'd been sending people to Dick's Sporting Goods for another kind of support for $20, but was impressed with my $7 ones. The above regimen has worked for me and is fairly simple to do along with some tendon stretching exercises. Plantar Fascitis can be managed without cortizone injections and anti-inflamatories, especially since I can't use them due to another medical condition. I've included a link on the Gibney wrap. http://www.nismat.org/traincor/pl_fasciitis.html

I am an orthopaedic surgeon and did a subspecialty fellowship in foot and ankle surgery. I agree with RIP in that I would not inject your own plantar fascia unless you are very skilled and experienced. Believe me, there are real potential side affects to steroid injections for plantar fasciitis and I’m referred patients not infrequently suffering from these complications. As RIP said fat pad atrophy is the most common and once gone you never grow a new plantar heel pad and the pain can become much worse in the long run.

A more rare cause of chronic heel pain is called distal tarsal tunnel syndrome which primarily involves one of the small branches off a main nerve adjacent to the origin of the plantar fascia on the heel. If you have this and inject the area with steroid there is a risk for more scarring to form around the nerve causing exacerbation of the nerve pain.

Overuse of steroid can also predispose the fascia to rupture acutely which is usually remarkably painful for most patients.

It is not at all wrong to use steroids as part of an overall treatment program, I just feel you need to know what you’re doing and understand the potential risks. The mainstay of initial treatment should be very aggressive stretching of the Achilles tendon and simple soft heel pads for your shoes. As Ray suggested a night splint to keep the fascia stretched when sleeping is also very helpful for some, especially when one has severe pain in the heel when getting out of bed in the morning. I literally see 3-10 new patients a week with plantar fasciitis and actually do very few injections as most get better with the above initial steps.

Sorry this is so long, but it’s such a common problem I couldn’t help but throw in my two cents. Go see a specialist.

Tony

A classic story with a nice taping/strapping technique to create an artificial arch and prevent that PF from pulling on its attachment at the calcaneus. Thanks for sharing. That's a wrap! Seems that might help the athlete get through a sprint.

fergdog,
I would love to turf the heel spurs to you.

RIP, I know, I should have kept my mouth shut!

Tony

Just so you'll hear it again (general surgeon this time): get thyself to a specialist. Podiatrist, or Orthopedist (especially if specialized in foot and ankle).

I feel better now about paying my insurance premiums for private healthcare.

RIP: Yanking toenails is fun! I work parttime at a military base and do these "operations" (Ha!) weekly. After pulling the ingrown we usually treat the infected areas for 40sec:s with phenol, this way we can maximise the effect of antibiotic treatment witjout having to deal with microabscesses. Neutralising with saline after the treatment is of course important. Do you use this stateside?

I've got a big heel spur from a stress fracture, and subsequent achilles problems. One thing I've found over the years is that cowboy boots or any boot with a pronounced heel is bad on your heels and may aggravate achilles and/or pf problems. I haven't worn a boot with much of a heel in 10 or 11 years, and i've been pain free for at least 5.

quote:

Originally posted by cewe:
RIP: Yanking toenails is fun! I work parttime at a military base and do these "operations" (Ha!) weekly. After pulling the ingrown we usually treat the infected areas for 40sec:s with phenol, this way we can maximise the effect of antibiotic treatment witjout having to deal with microabscesses. Neutralising with saline after the treatment is of course important. Do you use this stateside?

cewe,
Yes, 30% phenol is used if I have to do the toenail a second time, down the road. I usually let them try to grow back a normal toenail the first time around, learn to trim it square, and manage it correctly: no tight shoes, use a tuft of cotton crammed under the ingrowing corner at first sign of tenderness, to get it elevated out of the fold, hot soaks, etc.

The second time around, for the recurrence, the phenol destroys the nail matrix so that it will not grow back in that one-third border (lateral or medial) that was the problem the first time around too.

I use alcohol to neutralize and rinse out the phenol, then saline.

Of course getting the toe numb is the most important part! A properly anesthetized big toe looks like a little turnip right after the injection, before the Xylocaine is resorbed.

A tourniquet during the procedure is good too, as well as proper instruments: periosteal elevator, nail divider, beaver blade, scrapers and hemostats, and we are happy.

We Generalists can handle over 90% of everything that walks in the door. What we can't handle, we "turf" to a specialist.

The specialists have it easy in some ways, in their comfy, limited specialties: Travel Medicine, Allergy, Dermatology. Look Ma! No emergencies! Bankers hours!

Of course there are specialties that can be brutal, like Trauma Surgery, Neurosurgery, Obstetrics, where the 99% boredom/1% terror balance gets skewed the other way considerably.

Now, how about a specialist to tell me how he uses a laser instead of phenol, and gets to charge more.

RIP: The anestesia can be a pain, I often have to reinject Lidocain and last week I had a recruit who just wouldn´t relax so I ended up doing it ala Mengele. I truly think the toe was totally numb!

Seems the guys brain also might have been.

GP work is nice, doing this and that and when I was in family med I sometimes treated three generations from the same family.

That´s the best compliment one can get, people bringinmg their babies and grandma.

Have you ever thought of working in Africa? The RSA has quite a complicated process for foreigners looking to work in their country. Strange as they seem to need people.

Maybe we could get an AR MD pool going?

This is a great post!!!

You Doc's have given some excellent advice

It's a shame that the current state of affairs isn't conductive to the Doctor/Patient relationship.

A dear friend, Benjamin Sherman, MD, finished a book titled "My Patients, My Life" about his early career just before his death last June. It's a quick read, and he really does a great job relating the triumphs, losses, & difficulties of a general surgeon just starting out on his own. Those were the days, your family doc could actually work on you! Or even work on a jaguar dog.

"Notice: I'm not trying to sell books here"

Here's a link for some excerpts:

http://www2.xlibris.com/bookstore/bookdisplay.asp?bookid=27619

Ben was the finest person and I feel fortunate to have called him my friend.

Minkman