Medial calcaneal pain

Hi Dr. Brady,

UPDATED the case:

Patient is 45, runner, logs between 3-8 miles per run, trains at least 3x/wk.

CC: pain at R fibular region, “ITB area” and R medial calcaneal pain (pin-pointed) to one spot (when pushing on the bone)

Hx: denies hitting it on anything, 3-6 mos duration of pain, runner who logs in appx 15 miles a week, was prescribed some inserts for his shoes and somehow customized the heel part by the running store to keep him neutral.

*Someone from the shoe store decided he needed a lift on the lateral calcaneal portion only despite having a pronated foot.

Exam results:

Dorsiflexion 3” with mild/moderate tension

FHL R with moderate tension, no pain

FDL R with moderate tension, no pain

Soleus had adhesion on it w/ mild/mod tenderness

Tib Post had adhesion w mild “tightness” as described by pt.

PK Test – unable to perform especially on the R lower extremity, L lower extremity was also positive, does not complain of any pain on any of these movements

Lockout Test ( 2 legged ) – negative

Lockout Test (1 legged) – positive RLE

Lunge test appears like he does land on his heel first and leaves from it as well. The only thing I noticed was instability when coming up (he wobbles).

Tinel’s to RLE negative for tingling/numbness

Heel Tap Test was positive on the medial side of the upper R calcaneus

Squeeze Test was positive on the medial side of the upper R calcaneus

Results thus far after 6 visits:

Improved dorsiflexion to 5” but FHL still has tension but less, no pain

FDL able move and lift toe w ease

Soleus less adhesion and less pain 3/10

Patient reports that the ITB region is pain free BUT the medial calcaneal heel pain is pin-pointed and when I told him to get rid of the heel lift it appears that pain is worse in the morning and stiff. He also stated that he has to lift his entire leg to walk and avoid loading the heel in the a.m.

Here’s what I think I can do:

1) assess the foot (plantar fascia and surrounding muscles)

2) check SLR if the sciatic nerve is involved

3) could the medial plantar nerve be involved?

4) refer to podiatrist? Advanced imaging?