Thursday, January 17, 2019

My Plantar Fasciitis Story

As a serious runner of 15 years, I'd heard others talk about fights with plantar fasciitis (PF) but had been lucky to never deal with it myself. I didn't fully understand what it was or how it manifested itself when it came about.

Then, one fateful evening in October 2017, I went to play my weekly match of tennis with my dad but forgot my tennis shoes. I had worn some Vans casual shoes to work that day and figured one evening of relatively low-key tennis in those shoes should be just fine. We only played a couple sets of friendly tennis and all went well. The next day, however, I felt like I had a bruised right heel. This made sense--I ran around on a hard surface in some flat, no-cushion shoes for a couple hours. It seemed a no-brainer I had bruised my heel. No biggie, I'll just take a week off from running to let the bruise heal up and get back to normal.

Fast forward 15 months and I'm here laying on the couch recovering after undergoing a plantar fasciotomy surgery on January 15, 2019 hoping that within the next few months, I'll be able to get back to my pre-PF activity level. In the past 15 months I struggled with every conservative PF treatment I heard about trying to get this PF resolved without any success. Surgery was the final, last ditch option; one I had tried to avoid.

This blog post is my detail of the the last 15 months with a timeline of how I came to understand I had PF and how I tried to treat it conservatively.  If you're reading this because you're currently dealing with PF or considering surgery, I hope you find something helpful here.

October 2017 - December 2017: The Onset

As I mentioned in the introduction, I'm 100 percent sure when my PF began--after a night of playing tennis in poorly supportive and poorly cushioned work shoes. In hindsight, of course, this was stupid. But I had done similar things many times without issue and have never had PF before so it didn't even cross my mind. The day after playing that tennis match, my heel felt bruised. It wasn't bad, just there. Having never dealt with PF, or even really being aware of what it is, I was oblivious to the fact that I may have PF and thought it was just a bruised heel. For the next two months, I'd take a week or so off from running and try again hoping my heel wasn't bruised anymore. We went to Greece in November 2017 and I really wanted to run there to explore the countryside so I did run. It was running on loose limestone rocks so it wasn't very comfortable. A few weeks after returning from Greece I was talking to my friend Bill about my ongoing bruised heel issue. He had had PF a couple times in the past and suggested I may be dealing with PF. This was late December 2017 by this point. After doing some reading about PF I was quite sure that, yes, I had PF:
- Pain in the bottom of the heel: Check. 
- Pain is worst in the morning, first thing out of bed: Check
- Pain subsides throughout the day and often only hurts after exercise, not during: Check.

January 2018 - March 2018: Initial Treatments

I began reading as much as I could about PF and started the recommended stretches, including stretching my foot in bed in the morning before getting out of bed. I also went to a familiar face in Los Alamos, podiatrist Jeffrey Sauer. I had a long history with Dr. Sauer starting in 2004 when he surgically shortened the second toe on my right foot. In January 2016, Dr. Sauer surgically removed a neuroma from my right foot. He quickly came to the same conclusion as me about my heel pain--plantar fasciitis. He suggested continued stretching of my calves and foot and administered a steroid injection. I didn't feel any relief as a result of the steroid injection and, having had previously injections for my neuroma without any relief from them, I opted to not try any more injections. 

I tend to seek out second and even third opinions. Therefore, I made a visit to Dr. Joel Wilner, a podiatrist in Santa Fe, about my PF. He suggested more stretches and custom orthotic footbeds for my shoes. There in the office he had me step into foam molds which he would send off for the custom footbeds to be made. This all seemed reasonable and appropriate. Two weeks later I had the $250 custom footbeds and began using them in my work shoes and running shoes every day. 

By this time, I was in a daily routine of waking up, stretching my foot immediately out of bed and then stretching my foot on the stairs at home. I was also using a lacrosse massage ball directly on my plantar fascia to massage and work the fascia. I would also use a roller massage bar to massage my calf. This was my daily routine. I had also more or less stopped running and moved to mountain biking a lot more. We had a pathetic winter in terms of snowfall which allowed for plenty of mountain biking all winter, thankfully. I was glad to have something to do that didn't bother my PF yet kept me active and fit. That said, I did manage to run  the Run Through Time half marathon in Salida, CO in March which, of course, didn't help the PF. My PF wasn't getting worse but it wasn't getting better, either. I posted on Instagram about my half marathon run and ongoing PF issues and was happy to receive a number of other suggestions including a suggestion for acupuncture.

April 2018 - June 2018: Trying More and More

Adding to my daily stretching routine, I went for eight acupuncture treatments, once a week for eight weeks, with Dr. Henry Ahlefelder at Acupuncture Los Alamos. The morning after the first treatment, I didn't feel my PF at all anymore. I thought I had found the panacea and was super excited and relieved. Unfortunately, a few days later it was feeling the same as it had before. I continued the treatments but only found temporary relief. Still, I feel this is a worthy treatment option worth exploring for those in the initial stages of PF. I also talked to a friend, a physical therapist, that had recently become certified in dry needling with electronic stimulation (estim.) She was wonderful and looking for a person to practice on while gaining more experience. I was a happy guinea pig and saw her for about eight weeks of estim with the needling being done in my calf and foot to help release tension. Again, I felt a temporary relief from these treatments but as it would turn out, it didn't help in the long run.

July 2018 - October 2018: 

I had skipped over the idea of using a night splint boot despite it being suggested in many places online and by others I had talked to. I finally got a night splint boot and began wearing it every night. I really wish I had started this long ago as it seemed to help the most. If I have one piece of advice for new sufferers of PF, get the night splint ASAP and use it habitually.  This felt like it offered the best treatment and I feel like if I had started with this immediately, along with the daily stretching, the PF would have subsided. By this time, though, my PF was so chronic it would feel better after a night in the splint but then just return pretty quickly. 

By now, I was a year into this PF ordeal and getting depressed and desperate. In July, I met up with a great group of ultrarunners near Salida, CO to do a training run for a 100 mile race I was registered for, the High Lonesome 100 in August 2018. During this training run, I ran a number of miles with the race director, Caleb, and he told me about his experience with PF and the extracorporeal shockwave treatments (ESWT) he had had success with. He said they were highly effective for him but had a catch--most insurance companies did not cover the cost of the treatment. I searched around discovered the podiatrist I had seen earlier in the year, Dr. Wilner, also did the shockwave treatment. I saw him again and signed up for four sessions of ESWT at a whopping $750 total cost. Long story short, the ESWT was not effective for me despite reportedly being effective for roughly 80 percent of patients. I was gutted and distraught. As you may have guessed, I did not end up running the High Lonesome 100 in August. We did travel to Scotland in mid-September where I ran the Ben Nevis 50k trail run race, however. I had signed up for this in January 2018 naively expecting to be over the plantar fasciitis. It was a slow, arduous race for me but an enjoyable experience nonetheless. 

I began questioning if I really had PF and thinking perhaps I had a fractured calcaneus. With that in mind, I made an appointment with my primary care physician to see if I could get an x-ray. He was very understanding and ordered the x-ray. Whilst sitting in the x-ray waiting room at the Los Alamos Medical Center, I saw an advert on a display there for a new podiatrist in the medical center, Dr. Marta Riniker. Fortuitous as the only podiatrist in town, Dr. Sauer, had retired in March 2018 shortly after I had seen him initially. Riniker suggested I get an MRI done so she could see just how significant the PF was. The MRI report showed "acute on chronic PF."  Dr. Riniker didn't push surgery but after hearing all that I had tried in the past year suggested surgery is likely the next best option. I concurred.

October 2018 - January 2019:

Having scheduled the endoscopic plantar fasciotomy surgery for January 8, 2019, I resolved to stopping running, stretching even more and taking it real easy in hopes I wouldn't actually have to follow through with the surgery. During this time, I did a good bit of internet research to see if I could find cases of active runners and climbers having this surgery done and what their outcome was. I didn't find much but a couple posts on reddit, including a private message exchange with another Reddit user that had been through this, was helpful. 

But, alas, January rolled around and I was no better or no worse so surgery it was. It was scheduled for January 8th but that morning the elevator that gets patients up and, more importantly, down after surgery broke. Due to safety concerns, all surgeries for that day were canceled. I was rescheduled for January 15, 2019. 

January 17, 2019: Two Days Post-Op

The surgery on January 15th went well, as I'm told. I was home in the early afternoon after the short, 20 minute surgery (prep time and recovery time accounted for the rest of the morning.) I've had no pain as a result of the surgery. None at all. I took two percocet that first evening thinking that once the nerve block in my foot wore off, it would hurt but it never did. So my last percocet was at 10pm the night of the surgery. Since then, I've been keeping it elevated and spending a lot of time on the couch. Nothing very exciting. Dr. Riniker called this morning to see how I was doing. She told me my fascia was the thickest she'd ever worked on and it took three passes to get it cut enough. Even then, she said it wasn't as much as she wanted but that it should help. I've been crutching around the house and have a walking boot (saved from my last foot surgery!) Riniker said I could put weight on it if necessary but ideally I should stay off the foot for two weeks while the stitches heal. 
She had hoped to do a single incision on the inside of my heel using a single tool that was both a camera and a saw that uses a single incision but apparently my insurance, BCBSNM, didn't approve that. Instead, she made two incisions--one on the inside of the heel and one on the outside of the heel-- to put the camera in one and the saw tool in the other. 

I've been sleeping just fine. The only discomfort I have is if I put pressure on the arch of my foot by standing on it. I haven't yet put full weight on my foot as I'm trying to be a "good patient" and not weight the foot at all. I'll continue to update this blog post as my recovery progresses....

January 21, 2019: Six Days Post-Op

For the past two days I've been hobbling around sans crutch while wearing my DeRoyal walking boot. If I stay on the ball of my foot, it's not uncomfortable. If I put direct pressure down on my heel/arch, it feels very "bruised" and uncomfortable. I did get out of the house for the first time this week with a knee scooter trip to the local grocery store. A friend of mine borrowed the knee scooter from a friend at work and it's great for a situation like this. 
Wild Friday night scootin' around the grocery store. Going so fast I caused flames!
Sleeping has still be quite good. I have woken up a couple times with discomfort on the outside edge of my foot around the middle of the arch. I think this is from my foot rotating out while I sleep thus causing pressure on the part of my foot where the bandage is bunched up. If I flop over to my left side, the discomfort dissipates. 
I peeled back the bandages yesterday to take a look at the stitches on the medial side of my foot and it looks great. I was pleasantly surprised. 
Taking a peek at the medial stitches. There's another incision on the lateral side but I haven't peeked at that yet.
Also, I can drive now! I'm used to driving in my soft snowboard boots so driving in the walking boot is a piece of cake. The training paid off!

January 22, 2019: One week post-op update

I had my one week post-op appointment today with Dr. Riniker. The incisions appear to be healing very well. It was my first time seeing both incisions as I had worked to be a good patient and not remove the dressing. The area around the incisions is bruised, as expected, but not unreasonably so. In another week I'll return to have the sutures removed. Functionally, I'm still hobbling around well in the walking boot and if I stay on the front of my foot, it's not uncomfortable. If I step on the heel, it's pretty tender but feeling a little bit better each day. Some photos:
Lateral incision, one week post-op

Medial incision, one week post-op

January 24, 2019: Nine days post-op

This morning I was able to put my pants on by putting all my weight on my affected foot instead of sitting down to get them on. Progress! It's still uncomfortable but not debilitatingly so. Walking around the walking boot is a lot more natural now. Sleeping has been completely normal.

January 25-27: Ten days to twelve days post-op

Ten days post-op my foot was feeling good enough I knew I could at least top-rope some climbing routes in the climbing gym while wearing the boot. I called the climbing gym and verified it's cool to climb in a walking boot and they were fully on board with it. After a couple of easy top rope routes on the vertical wall I was confident climbing wasn't going to bug my foot (the walking boot is so stiff I was virtually climbing one-footed anyway) so I went to the steeper lead wall for some leads. Turns out it was easier, in a sense, on the steep wall because the routes are generally less foot-intensive (at least in the 5.10 range I was climbing in.) I did a lot of pull-ups and pixie kick moves to make up for not being able to fully use my right foot. I was gassed but it was exactly what I wanted and felt great to be climbing again after a few weeks off. 
Ten days post-op, leading a steep, juggy route--perfect for 1.5 foot climbing
Around home on Saturday, I installed new blinds in every window in our house so I was on my foot a lot (in the boot) and it seemed not to be a problem. The incisions look to be healing great and each day I feel less discomfort (but still feeling discomfort) when I weight the foot, especially the middle/back of the arch area. Staying on the ball of my foot is quite comfortable but walking a full stride motion (heel on ground first, roll through length of foot and push off ball of foot to take next step) is definitely uncomfortable kinda like someone took a meat tenderizer to my arch and beat on it for an extended period of time.
Sunday, twelve days post-op we went climbing at the gym again and again had a great time. I'm finding it useful and good training to climb with mostly just one foot. It translates to more dynamic movement on the wall and certainly a lot more campus-like moves. It also means I climb slower and spend more time on a route shaking out and trying to recover--good training for my forearms. 
Medial incision eleven days post-op
The sutures were supposed to be removed Tuesday, 14 days post-op, but the appointment was rescheduled for Thursday, sixteen days post-op. So four more days!

January 31, 2019: Sixteen Days Post-op

I showered! I actually showered yesterday, fifteen days post-op and again today. I figured since the sutures were supposed to come out at 14 days post-op (and they looked great!), it was OK to shower before the official go-ahead on that. I had been taking baths with one leg out of the tub which, at 6'5", baths already suck bad for me and this was worse. So the shower felt great. I saw Dr. Rinker today and she was very happy with the healing and removed the sutures this morning. 
Medial incision moments before removal, 16 days post-op

Lateral incision moments before removal, 16 days post-op
My foot continues to feel a bit better each day but still pretty tender on the inside of the arch. I'm waling in a regular shoe now but feel like I'm really favoring the outside of my foot on each step--not good for biomechanics--to avoid the worst of the tender discomfort on the inside of the arch. From here, I'm allowed to walk on it and "do stuff" but if it hurts too much, don't "do stuff". As yet I cannot tell if my original PF pain/issue has been corrected. Too early to tell as I'm really avoiding stepping on my heel much still.

February 4, 2019: 20 Days Post-Op

I made a concerted effort to walk normally today, using my entire foot, not just cheating to the outside of the foot. It was a sore pain but bearable and I'm stoked to have full, normal use of my foot back. I walked up to the gym and did a 15 minute bike spin followed by a 5 minute row and some core workout. My first cardio in three weeks! It was no problem and I'll plan on doing more this week. Also, I should note, I've been sleeping with the night splint every night since the surgery. I'm still worried my PF won't actual get better and I figure better to be safe...
Medial incision 17 days post-op (shortly after sutures removed.)

Lateral incision 20 days post-op. 

February 7, 2019: 23 Days Post-op

I'm still wearing the night splint and doing my morning stretching of both legs/feet. Old habits die hard. I really don't want PF in my left foot so the daily stretching routine continues, perhaps indefinitely to be on the safe side. Stretching my right calf and foot doesn't hurt and feels good, actually. It does, however, hurt to massage the plantar fasica with the lacrosse ball so I'm not doing that yet. Yesterday I went on my longest outing since surgery, a 5k walk. The day before that I walked about two miles around the neighborhood focusing on good form and walking normally. I've noticed in the past 15 months, and certainly since surgery, I changed my walking pattern to compensate for the PF pain. I'm doing my best to correct that by consciously focusing on my stride and foot movement as I walk.
The past two nights I put on a regular climbing shoe and climbed on our home climbing wall. I had done some climbing the past two weekends inside a commercial climbing gym but was using first the walking boot and then a looser-fitting approach shoe. This week was the first time I used a standard climbing shoe. It doesn't hurt at all when I climb but is still uncomfortable when I drop off the wall down to the padded floor. Still, I'm encouraged...each day my foot is feeling a bit more healed.

February 11, 2019: 27 Days Post-Op (Not Out of the Woods Just Yet)

Just when I was thinking I was out of the woods, I noticed last night after showering that my lateral incision seemed a bit red and more painful. It's a hard incision for me to personally inspect because I'm just not that flexible. But I laid down and got a decent look at it. It was partly open and puffy. I gave it some good squeezing resulting in some pus coming out. I was bummed as I have been trying hard to keep it clean and covered as much as possible, especially after my infection issue three years ago after my neuroma surgery. Thinking back on it, I'm pretty sure this incision has been showing signs of infection for about a week but I didn't want to admit it. 
I went to visit Dr. Riniker today and she said not to worry too much about this--it's common on feet because, well, feet. I started a one-week course of Keflex (Cephalexin) antibiotics (same as three years ago!) 
As for functionality, the overall feeling is better each day (except the discomfort around the lateral incision due to infection.) I went mountain biking on Saturday out at White Ridge and it felt great to be getting in some decent cardio again. I climbed a bit outside Friday with Allison but used an approach shoe on my right foot. Sunday we went climbing again and I used a brand new climbing shoe sized up a full size and that felt reasonable. I feel like I don't feel the PF pain anymore which is quite amazing. Still hopeful. 
Lateral incision infected. Slightly macerated due to antibiotic ointment and band-aid 

February 20, 2019 - 36 Days Post-Op

I finished up my one-week course of antibiotics a few days ago. The infection in the lateral incision seems to have cleared. The incision site is still a bit tender when pushed on but less and less so each day. The medial incision has healed up really well. It looks and feels very good. Funny thing--I went to the store five days ago and was in a bit of a rush. Without thinking about it, I jogged from my car to the store's door before the realization hit me that I had just run for my first time since surgery and, more importantly, without any PF pain. Ho-lee-shit! That was an awesome feeling.
Last weekend we went hiking, bouldering and camping in Roy, NM for a few days. I was paranoid about the lateral incision (I was still on antibiotics) so I was sure to clean the site with an alcohol wipe and fresh band-aid frequently. The first day of bouldering and hiking had my ankle, and whole foot, feeling pretty weird. A deep discomfort inside my ankle. I was kinda freaking out thinking maybe the infection had spread to the joint. Thankfully, the next day it felt tons better and I suspect it was just a case of not using my foot/ankle in that manner in a month or so.
Bouldering in Roy, NM just shy of five weeks post-op. Note the two separate shoes...I've been using a sized-up shoe on my surgery foot for more comfort. 

I'm starting to allow myself to feel some optimism that I might be over this PF chapter and it feels great. Ironically, it didn't really snow in the past five weeks while I was recovering. Then, just as I felt I was ready to try snowboarding again, we received a big dump of 12" new snow up at the little bird. What better way to go give 'er. And I was stoked! I managed five earned laps in the morning. My foot felt slightly uncomfortable towards the end but mostly a feeling of, "hey, what are you doing to me now after five weeks of taking it easy!?" Not a bad pain to have.  At six week post-op, next Tuesday, I plan to do my first run post-op. Excited to see how that goes. 
All smiles. Back in the game exactly five weeks post-op!
Now, of course, some incision photos:
Lateral incision, just a bit more than five weeks post-op. This is the incision that has been infected. Still red and a bit tender but better.

Medial incision, just a bit more than five weeks post-op. Nearly all healed.

Saturday March 2, 2019 - Six and Half Weeks Post-Op

I cried a little bit this week. Tears of joy. I did my first run in 2.5 months and first run since PF surgery on Monday, Feb. 25 and felt NO PF PAIN. It was an easy, flat four miler but being able to run without modifying my stride to avoid PF pain was amazing. It has been so long since I could say that. Damn. But let me back up to last weekend first. I finally felt confident enough to go for a long day in boots on a splitboard tour. I hike up a lap at Pajarito Mountain in the early morning, then splitboarded a couple laps on Rabbit Mountain and ended the day with a nice 1,200' run on Cerro Grande. A wonderful tour de Jemez after the solid storm Friday night. This was especially rewarding since it had been at least four years since we were able to ski Rabbit Mountain. During the day I had a couple of very brief, sharp pains in my arch but nothing disconcerting. 

Jemez Mountains Snowboarding - Feb 23, 2019 from Jason Halladay on Vimeo.

Since my run Monday, I did two more runs, spaced two days apart including an eight miler Friday. My foot felt a bit sore after each run but nothing lasting and nothing like the PF pain I had. I think it is just getting used to being run on again. Otherwise, I'm thinking about my foot less and less each day which is a great sign it's nearly normal again.
I'm not claiming success yet (nor ready to actually believe it) but I'm certainly encouraged. Here are a couple photos of the incisions at 6.5 weeks post-op. The medial incision looks great and resembles a healing blister. The lateral incision, the one that was infected for 10 days or so, is healing up very well and now has a small scab on it. Homestretch!
Medial incision almost completely healed. 6.5 weeks post-op

Lateral incision finally looking much better with just a small scab. 6.5 weeks post-op

Tuesday, May 7, 2019 - Sixteen Weeks Post-Op

I had my last podiatrist appointment related to this issue yesterday and I'm happy to report all is quite good. I'm very pleased I went ahead with the surgery. I have been running 20 to 30 miles per week for the past six weeks or so and I no longer have much noticeable PF pain. I do still feel a small bit of soreness in the heel area after a long run or hike with a heavy backpack but it's a different discomfort than the PF pain was. It's likely still the tissue and scar tissue breaking up and healing up. It doesn't really bother me. The incision scars are already very subtle and I must look pretty hard to see them.

Tuesday, June 4, 2019 - 4.5 Months Post-Op

I've been running more and more and enjoying running without constantly feeling/thinking about my PF issue. It's still not totally pain free as my heel does ache a bit after a long or intense run but it's considerably better than it has been in the past 18 months. The discomfort I feel is generally one of more of a widespread ache versus the pinpoint pain feeling of the PF. The discomfort did increase in the past couple of weeks as I ran more so I've gone back to sleeping with the night splint. The night splint is still helping. If you didn't catch it earlier in the post, USE A NIGHT SPLINT! Seriously, though, for me it has gotten results.

Wednesday, January 15, 2020 - One year Post-Op

A year has flown by. I'm happy to report my surgery was a complete success and I've had no issues with PF, or anything else, with my foot since the surgery. I had a great year of running and logged ove 1,200 miles including a finish of the UTMB PTL run with my best friend, Bill, in late August. I'm looking forward to starting the year off uninjured and being able to run a full year hopefully injury free. 

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