I have been dealing with pain in my left foot for over 3 1/2 years after casing a jump. I recently sent a letter detailing my case to a large list of foot and ankle doctors across the US and some international. My hope is that somebody out there will see my case and be able to help. I understand that this is not a place to ask for medical advice. However, I wanted to put this out here on the chance that somebody has gone through a similar situation themselves or has any info they think might help. I welcome anyone’s thoughts.
I have included the letter below.
Thanks a lot
My name is Nate Keyes. I am a 24-year-old who has been struggling with an injury to my left foot for 3 ½ years now. I have no other major health issues. After a long list of doctor’s visits and treatments with no improvement in pain or function, I write to you today with sincere hopes that you may be able to help me in any way possible.
To begin, I will provide a brief background of how I ended up in this situation. Prior to 2014, I was a highly active person who engaged in multiple sports and recreational activities. My favorite thing was skiing. I thought about it and did it all the time. I did a type of skiing that involved doing tricks on rails and jumps. In early 2014, I tore my left ACL skiing, and due to further complications, I was sidelined from most physical activity for a few years (2014-2017). I finally got back to skiing in February of 2017, only to then injure my foot skiing later that year. In June of 2017, I had just begun work at a summer ski camp near Mt. Hood, Oregon. During a normal day of skiing, I came up short on a jump, causing me to land from a height to flat vs. landing on the smooth downhill transition. I was probably around 15 feet in the air. I immediately felt pain in my left heel upon landing and figured I had at the least bruised my heel (I bruised the same heel the same way in 2011). Following an x-ray, there was no sign of a fracture. After a brief period of rest, despite continued pain, I began to ski and skateboard throughout the rest of the summer (about another 5 weeks). Unfortunately, the pain continued to linger and has lead me down a path of various diagnoses and treatments over the course of the past 3 ½ years.
In an effort to most accurately depict my case to you under the confines of a letter, I will refrain from going into depth on everything that has occurred since the date of injury. Instead, I will attempt to highlight (a) the diagnoses that doctors came to a conclusion on, (b) the pain and functional sensations that I most frequently feel, and (c) the treatment that I thought recently held the most promise. However, this information does not tell the whole story nor conclusively what could be wrong with my foot, and in result, following this information, I will include a timeline with the basic details of almost everything that has occurred from the date of injury up until present day. I will also attach copies of my MRI reports and foot diagrams that pinpoint specific areas of pain to this letter.
Whether it was a result of the initial impact or an inadequate rest period and overuse, the first main diagnosis came 5 months after the date of injury, when an initial MRI revealed a calcaneus stress fracture/stress reaction. *Note: The MRI report states that there was a calcaneus fracture, but after reviewing the MRI, the doctors I was seeing at the time believed it to be more characteristic of just a calcaneus stress fracture/stress reaction. Despite me following treatment guidelines and recurrent MRIs showing some improvement in the bone over the next year, I continued to be in pain. Before moving to the next phase of my case, it will help to explain how my pain presents. For the past 3 ½ years, the majority of my pain has stemmed from the base of my heel, where I immediately felt pain upon landing from the ski jump. For the most part, I always have at least some minor level of this pain, and then with weight-bearing is where it gets bad. I have pain with any weight-bearing activities, even standing and walking. It is best described as a dull, aching pain, and sometimes burning. At close to a year after the injury, I began to notice that the pain felt more specific. At the base of my heel, I started to notice what feels like, to the best of my description, some sort of soft tissue fibrotic nodule or knot of scar tissue. When I plant my foot and shift weight from side to side, I can clearly feel this piece of tissue snap/roll over and reproduce this pain. The worst of my pain stems from this localized area and then radiates throughout the whole base of my heel. I cannot ski, run, or do any aggressive physical activities of that nature due to the pain. I cannot stand or walk for extended periods of time due to the pain. I can do everyday life activities, such as standing and walking around the house and going to the grocery store, but even they are very painful. I also have pain with the non-weight-bearing exercise that is biking. In addition, I have experienced pain in the medial side and arch of my foot for the better part of the past 3 ½ years.
Now I will move on to the next phase of my case. As time went on and I did not receive any relief from any of the bone-related treatments, it was largely a result of the aforementioned pain sensations and the nature of my injury that some doctors and I believed that I may have done some damage to my heel fat pad and/or may have some measure of heel fat pad atrophy. I describe this as somewhat of an opinion diagnosis/cause of my pain because the imaging (MRI and ultrasound) I have received has only shown evidence of minimal edema in the heel fat pad. There have been some ultrasound measurements that show minor loss of the left heel fat pad compared to the right side, but it doesn’t seem to be as drastic or characteristic of most patients that present with heel fat pad atrophy and pain. Perhaps more telling is that, to the plain touch, there is a slightly noticeable difference in the compressibility of the left heel fat pad compared to the right side.
It is due to these two diagnoses, that the majority of my treatment was initially geared towards treating this as a bone issue and then as a heel fat pad issue. As you will see from the timeline below, there were a few alternative treatment routes as well. I have felt no relief from any of the treatment I have tried thus far. The treatment that I recently had the most hope for was a foot fat grafting procedure done by Dr. Beth Gusenoff, DPM and Dr. Jeffrey Gusenoff, MD at University of Pittsburgh Medical Center. The goal of this procedure was to harvest autologous fat from my stomach flanks, process it, and inject it into the heel fat pad in an effort to restore any lost fat and to break up the potential specific fibrotic nodule and/or any scar tissue in hopes that my body would regenerate healthy tissue in its place. The procedure went very smoothly. However, 1 year has passed and I have felt no improvements. I am still experiencing the same pain, sensations, and dysfunction in my foot.
In order to portray a more complete picture, I believe it is necessary to present a few pieces of additional information. I will explain my secondary pain sensations, which are not as painful and constant as my heel pain, but still bother me a good deal. These secondary pain sensations did not seem to develop immediately on the date of injury, but rather over the following months and years. As I briefly mentioned above, I have experienced pain in the medial side and arch of my foot for the better part of the past 3 ½ years. I noticed this pain in the immediate few months after the fall. It has been the worst and most longstanding secondary pain sensation. I did not go into depth on this above in an effort to more clearly illustrate the progression of my case for your understanding. However, because I believe it is a vital piece of the story, I will elaborate on it here. I consistently get a cramping pain in the medial side and arch of my foot when I contract my foot muscles to point/curl my toes, especially when pointing the big toe individually. Alongside that cramping pain, every time I curl my toes, I feel and hear a clicking in the medial side of the foot. One or more of the intrinsic foot muscles feel like they do not function properly. However, I have not been able to tell whether this pain and dysfunction is due to direct injury to the muscle(s) or some other reason. No evidence of muscle damage has been noted on imaging reports. I also get pain in the medial side and arch of my foot with walking and other weight-bearing activities. I honestly do not know the truth behind what is going on here, but I find it significant to note that in addition to my heel pain, I have consistently experienced the aforementioned sensations for almost all of the past 3 ½ years as well.
The following two sensations are by no means the focus of my pain, but they do present. The next sensation to develop (around 1 to 1 ½ years after the fall) is that I get pain at the lateral, anterior, and medial sides of my ankle, specifically with positions like sitting on my knees, and walking down/upstairs (weighted dorsiflexion). The last and most recent sensation to develop (within the last year) is that I have been getting pain in the big toe joint when pushing off/through the toes.
The final pieces of information are the past injuries that I have had along the same kinetic chain. As I previously mentioned, I tore my left ACL in 2014. I had it reconstructed, but despite a good initial recovery phase, I had continued pain in the knee, resulting weakness in the surrounding muscles, and additional surgeries, such that it took me 2-3 years to come back from this injury. I also have an old IT band injury on the left side. It is possible that these old injuries could be playing a role here.
I am not saying any of the above pieces of information are definitive routes to an answer, I am just trying to lay out all the information seeing that I have pursued a number of routes with no improvement.
Below is the timeline of events from the date of injury - present day:
Jun. ’17 – Injure left heel skiing by coming up short on a jump (land from height to flat)
Jun. ’17 – Get x-ray to rule out fracture and confirm with Dr. Adam Baker, MD (Seen at Adventist Health Northwest Orthopedic Specialists, Portland, OR. Now at Northwest Permanente Physicians and Surgeons, Clackamas, OR.)
Jul. ‘17 - Aug. ’17 – Start to ski and skateboard again for another 5 weeks despite pain
Aug. ’17 – Return to Salt Lake City, UT for school
Sept. ’17 – See foot/ankle orthopedic Dr. David Howe, MD (Comprehensive Orthopedics & Sports Medicine, Salt Lake City, UT) at the orthopedic clinic I was previously a patient of – orders another x-ray that rules out fracture, suspects that I am dealing with plantar fasciitis, writes a script for physical therapy, and recommends the use of over-the-counter orthotics and a strassburg sock
Sept. ’17 - Oct. ’17 – 8 weeks of physical therapy geared towards treating plantar fasciitis, that includes various exercises, stretching, ultrasound, electric stimulation, graston, and dry needling, alongside the daily use of the OTC orthotics and nightly use of the strassburg sock
Nov. ’17 – First MRI – reveals a calcaneus stress fracture/stress reaction. *Note: The MRI report states that there is a calcaneus fracture, but after reviewing the MRI, the doctors I was seeing at the time believe it to be more characteristic of just a calcaneus stress fracture/stress reaction.
Nov. ’17 – Upon review of the MRI report, Dr. David Howe, MD refers me to the other foot/ankle orthopedic in their practice Dr. Joshua Hunter, MD (Comprehensive Orthopedics & Sports Medicine, Salt Lake City, UT) for another opinion
Dec. ’17 - Feb. ’18 – 9-10 weeks of non-weight-bearing and taking vitamin D as prescribed by Dr. Joshua Hunter, MD
Mar. ’18 – Cortisone shot into the area of heel pain administered by Dr. Joshua Hunter, MD
Apr. ’18 – Second MRI – minor improvement in the stress reaction/bone edema signal
Apr. ’18 – Get second opinion from Dr. Florian Nickisch, MD (University of Utah Orthopaedic Center, Salt Lake City, UT)
Jul. ’18 - Dec. ’18 – Wear Orthofix bone stimulator for 3 hours/day as prescribed by Dr. Joshua Hunter, MD
Jul. ’18 - Oct. ’18 – Wear custom molded orthotics with heel cup in left orthotic per recommendation of Dr. Florian Nickisch, MD and confirmation with Dr. Joshua Hunter, MD
Dec. ’18 – Move back home to the east coast to try to devote more time to figuring this out
Dec. ’18 - Jan. ’19 – See a number of orthopedic/podiatric doctors – Dr. Amanda Fantry, MD (Advanced Orthopedics, Bloomfield, CT), Dr. Kurt Rode, DPM (West Hartford Podiatry Associates, West Hartford, CT), Dr. Robert Waskowitz, MD (Orthopedic Associates of Hartford, Newington, CT), Dr. Rock Positano, DPM, (Hospital for Special Surgery, New York City, NY), Dr. Raymond Walls, MD (Seen at Yale New Haven Hospital, New Haven, CT. Now at NYU Langone, New York City, NY.), Dr. Thomas McDonald, MD (Seen at New England Orthopedic Surgeons, Springfield, MA. Now at Orthopedic Associates of Hartford, Hartford, CT.)
Dec. ’18 - Feb. ’19 – Multiple x-rays, a diagnostic ultrasound, and a third and fourth MRI – the consensus from the majority of doctors is that there is only minor signal of injury, and it is nothing that should be causing pain of this magnitude, or for this long
Jan. ’19 - Feb. ’19 – 4 treatment sessions (1/week) of a form of shockwave therapy called Extracorporeal Pulse Activation Technology (EPAT) administered directly to the base of the heel by the office of Dr. Rock Positano, DPM
Apr. ’19 – See regenerative medicine specialist Dr. Paul Tortland, DO (Valley Sports Physicians & Orthopedic Medicine, Glastonbury, CT) – administers 2 separate diagnostic injections: one into the heel fat pad and one to the posterior tibial nerve
Apr. ’19 – MRI of the lumbar spine – normal findings
May ’19 – Try a couple myofascial release sessions
Jul. ’19 – Placenta tissue matrix injection into the heel fat pad administered under ultrasound guidance by Dr. Paul Tortland, DO
Jul. ’19 - Aug. ’19 – 4 weeks of non-weight-bearing following injection
Sept. ’19 – Try some massage therapy sessions
Oct. ’19 – Try a few acupuncture sessions (with moxibustion)
Oct. ’19 - Nov. ’19 – See naturopath to get food sensitivity testing done and alter diet for one month
Oct. ’19 - Nov. ’19 – See chiropractor for 2-3 adjustments/week for 8 weeks
Feb. ’20 – Foot fat grafting procedure performed by Dr. Beth Gusenoff, DPM and Dr. Jeffrey Gusenoff, MD (University of Pittsburgh Medical Center, Pittsburgh, PA) – the team harvests fat from my stomach flanks, processes it, and injects it into my heel fat pad in an effort to restore any lost fat and to break up the potential specific fibrotic nodule and/or any scar tissue in hopes that my body would regenerate healthy tissue in its place
Feb. ’20 - Apr. ’20 – 8 weeks of non-weight-bearing following procedure alongside range of motion exercises and stretches
Apr. ’20 - Jun. ’20 – Start to move forward with post-procedure at home rehab regimen, but only end up progressing to a certain activity level as pain does not improve
Oct. ’20 – See Dr. Michael Aronow, MD (Orthopedic Associates of Hartford, Hartford, CT) – orders a full rheumatology blood workup that comes back with normal findings
Nov. ’20 - Jan. ’21 – Try another round of shockwave therapy, this time through the office of Dr. Adam Tenforde, MD (Spaulding Outpatient Center, Cambridge, MA) and in conjunction with physical therapy – 5 treatment sessions of shockwave administered to the base of the heel, plantar aspect of the foot, subtalar joint/medial aspect of the foot, and calf during each session, alongside 8 weeks of a foot core strengthening physical therapy program
In addition to these treatments, at various times throughout the past 3 ½ years, I have tried a number of different heel cups/inserts, footwear, taping methods, and stretches/exercises.
If you have made it this far, I thank you for your time and willingness to listen. I have come to a point where I believe I need to rely on the chance that someone out there hears my story and can help me. Whether that person is a doctor who can treat me, a doctor who points me in the direction of another doctor who may be able to help, someone who has gone through a similar situation themselves or knows someone who has, or just someone who can provide an outside perspective and might have a new idea to try, I openly welcome anyone’s help. Maybe that person is you. Regardless, I am so grateful that you have taken the time to read this letter and offer what you are able to.
*MRI reports are attached in chronological order
**This thread was edited on Mar 18th 2021 at 1:12:37pm