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case studies

AUTHOR: Marc Mitnick DPM

REVIEWED BY: Podiatric Medical Review Board

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heel fracture

A 42 year old white male was wearing flip flops and as he was walking down his basement steps, his foot slid down the steps and hit the heel of his left foot on the next descending step. He went to the emergency room of the local hospital and had x-rays which failed to show any pathology including fracture. In the emergency room he was given crutches along with an immobilization wrapping around his foot and lower leg. He was told to stay off his foot. At that time he was also given a prescription for Percoset tablets for the pain.

One week later he presented to our office in a lot of pain. He had not been using his crutches and is in a line of work that requires a lot of walking.

During the exam it was noted that the majority of his pain was on the bottom of the heel, but further back from where the plantar fascial ligament attaches to the heel. In spite of the amount of pain he was experiencing, there was no overt sign of inflammation in the heel area; it was not red, hot, or swollen.

Between the time the patient was seen in the emergency room to the time he came to our office he had done a lot of research and spoke to a few people and was convinced he had plantarfaciitis. So convinced in fact that he pretty much dismissed my suggestion that I did not think it was plantarfasciitis.

In any event I applied a low-dye strapping which essentially attempts to force the fat in the heel area to stay on the bottom of the heel and not displace away from the bottom when the patient bears weight. In addition to the Percoset, I gave him a prescription for Mobic tablets which is an anti-inflammatory medication. I told him he needed to stay off his foot but he explained that his job required he walk and that since it was a new job he did not want to risk losing it.

I saw him back in a week and he was no better and perhaps even in more pain. Any doctor who treats the same medical condition over and over again has a certain level of expectation as to the progress the patient is making. In this case, there was no progress, so in spite of a normal x-ray in the emergency room, I suspected more than just a bone bruise.

mri heel fracture

We sent him for an MRI to rule out heel fracture or even a tear within the plantarfascial ligament and sure enough he sustained a fracture of his heel. Look at the yellow arrow on the MRI and you will notice a vertical crack in the heel bone.

Once I reported to the patient that he had a heel fracture, he started to take my advice seriously. He went non-weightbearing on crutches and was forced to do his job that way, which all of a sudden he seemed able to handle.

I am presenting this case because I think it is important for people to understand that not all pain is the same condition. Plantarfasciitis is a very popular diagnosis these days, but just because you have heel pain does not mean you have plantarfasciitis. If you are having heel pain that does not seem to respond to the more common treatment modalities available, then the problem has to be examined in more depth.

plantarfascial tear

A 57 year old women slipped in a parking lot and immediately began to experience pain in her left heel. Approximately one week later she appeared in our office complaining of pain on the bottom of the heel.

X-rays were negative for fracture. Because of the amount of pain she was in and due to the fact that there was a history of trauma, we put her in a walking boot along with a prescription for anti-inflammatory medication.

The patient was seen back in the office in four weeks and at that visit complained of ongoing pain which had not diminished much during the previous four weeks, although I am not sure she was wearing the walking boot as religiously as she had been instructed.

Since the degree of improvement proved to be marginal, an MRI was ordered. The following MRI reveals a small tear in the central slip of the plantarfascial ligament at its insertion into the heel.

plantarfascial tear on mri

The MRI also reveals bone marrow edema at the insertion of the plantarfascial ligament into the heel bone. This essentially indicates that there was stress to the calcaneus (heel bone) but not enough to create an out right fracture.

An incidental finding of osteochondritis dessicans was observed on the MRI. This a defect in bone, usually occurring in the talus bone which is the bone that makes up the floor of the ankle joint. This type of problem generally occurs from a twisting motion in the ankle sustained during trauma. In this particular instance, this problem was identified as a chronic problem and not associated with the patient's recent trauma.

osteochondritis dessicans of talus

metatarsal stress fracture

A 70 year old women was seen in the office complaining of pain in right forefoot. This patient has been a patient of mine for years. She is very athletic and naturally not overweight. There was no specific incident that initially caused her pain, but she related that the front of her foot only hurt her while she was on the treadmill and pretty much did not bother her otherwise.

Her pain was limited to the area on top of her foot just behind her third toe. There was a minimal amount of swelling and a slight sign of erythema (redness). Palpation on the area resulted in discomfort.

Typically, in cases like this the diagnosis is usually one of either extensor tendonitis meaning an inflammation of the tendon that brings the toes upwards. Tendonitis is very common in people who are athletic but of course it can occur in anyone. The second possibility was that of a stress fracture. A stress fracture is usually a crack in the bone that occurs without any history of trauma. As the name implies, if a bone is overstressed it can fracture.

I started the patient on an anti-inflammatory agent, as well as advising rest and limiting ambulation to necessary tasks. She was sent for an x-ray which came back negative for any pathology. Thus, the working diagnosis became one of tendonitis.

In spite of the anti-inflammatory medication and rest, the foot did not improve over the next couple of weeks. Most doctors expect a predicted response when they initiate a treatment plan for any medical condition. If their expectations are not met, the doctor needs to go to Plan B.

metatarsal stress fracture

In this instance I sent the patient for an MRI essentially to get better detail of what might actually be going on with the right forefoot. The MRI came back as a stress fracture of the third metatarsal. If you look closely at the yellow arrows on the MRI you will see a crack in the bone at the tip of the inferior yellow arrow.

I bothered to include this case because I get a lot of people writing to me stating that they had sustained an injury, or perhaps had foot pain without any history of injury. They go on to state that they had an x-ray which did not show any sign of fracture, but they still continue to experience pain weeks after the first instance of pain.

In cases of stress fractures, sometimes the fracture will not show up initially on x-ray. It may take a second x-ray 10-14 days later to show signs of fracture. Even then the x-ray may still look normal. If this is the case and the pain continues, then an MRI or CT scan is indicated which will give better visualization of the bone. Additionally, if the pain is not related to bone, but perhaps soft tissue surrounding the bone, these tests will also give your doctor a better idea of the health of the surrounding tissue.

avascular necrosis of sesamoid bone

A 26 year old female presented to the office complaining of severe pain and swelling near the big toe joint of her left foot. She stated that she had stepped on a piece of glass a couple of days earlier, the area had bled a little bit, but she was unable to remove any glass. Twenty four hours earlier, she was in so much pain that she went to the Emergency Room of a local hospital where the foot was x-rayed.

The ER physician thought she might have fractured her lateral sesamoid based on the central point of pain and the fact that the x-ray was suggestive of a possible fracture. She was put on crutches, given a prescription for Naproxyn to reduce the inflammation, as well as a prescription for Clindaymycin since a possible infection secondary to stepping on glass, could not be ruled out.

When the patient presented to me the following day, even though she had been on crutches for 24 hours, the forefoot in the area of the big toe joint was very much swollen and very much tender to touch. There was even some erythema, although it did not look like true cellulitis, on the top of the foot between the first and second toes.

I was unable to find any sign of a previous focal point for a foreign body (glass) and so even though I had to keep it in the back of my mind, I did not think the pain and swelling (and redness) was from an infection. She also was not running a fever.

The most painful area of the swollen part of her foot appeared to be in the area of the fibular (lateral sesamoid bone). People in my specialty see a lot of sesamoiditis and there was way too much inflammation to be sesamoiditis. Plus, she had not done anything physically out of the ordinary over the last few days, other then yoga.

So, yes there was the possibility of a fractured sesamoid, but again there was no excessive activity the last few days. Plus, she also had some symptoms of turf toe as there was pain, to a lesser degree on palpation of the capsular ligament.

Since I did not have a definitive diagnosis and since there was so much pain, I ordered an MRI with contrast.

The report came back as avascular necrosis of the fibular (lateral sesamoid) which means the blood supply has been cut off to the sesamoid bone. If you look at the MRI film below, the yellow arrow clearly shows the tibial sesamoid (medial sesamoid), while the blue arrow shows a gray shadow representing the diseased fibular sesamoid bone.

avascular necrosis of sesamoid bone

Treatment consisted of taking her off the Clindamycin, to remain on crutches as much as possible. I also gave her a temporary orthotic with a cutout around the sesamoids, simply because she has a young child at home and there are instances where she is going to have to bear weight.

I kept her on Naproxyn and saw her a week later. At that visit the swelling was dramatically reduced, there was less pain on palpation and she was able to bear some weight on the foot. We will keep her on this regimen for four to six weeks, then re-evaluate her situation.

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I've been doing some aggressive research lately (it's how I found your incredible website) and realize now that my symptoms are not consistant with the diagnosis. Jennifer

Hunterville, NC
….after reviewing your amazing site (great for the avg. jill). So thank you very much!!!


I am really, really impressed with your plain-speak explanations for the various conditions.


This was an extremely helpful site. I have an appointment on the 18th and your info. Was right on target…..


A well organized site containing much information written in a manner that the average reader can comprehend.


Ontario, Canada
I found your website and articles most interesting.


Thank you for a quick response. I think your site is the best information site on foot pain and I have viewed many.


(location unknown)
I came to your website, via www.foot-pain explained .com which I think is also your website? I thought explanations for different types of problems were well addressed and thoughtfully stated for the patient in mind.


New York
You have an amazing and extremely informative site. I enjoyed looking through all of the data and stats.


Memphis, TN
Thanks again so much for the information in the article. Very interesting.


Great article. I have had plantar fasciitis since I was in high school……..

J. Simmons

(location unknown)
Dear Dr. Mitnick, The orthotics arrived four days ago and I slipped them into my shoes immediately. I was skeptical as to the usefulness of the item, they really didn't look very exotic. I have to say though, after using them for just four days, I have experienced grand relief from my foot pain. Even the very first day, I was able to do a lot of work while on my feet with at least a 75% reduction of pain. It has only gotten better every day, and I go nowhere without my shoes with the orthotics. I had been experiencing extreme heel and sole pain for about six months and had to take extended breaks off my feet many times a day as well as regular doses of Ibuprofen. Since getting the orthotics, my life has returned to normal and I feel good again. Just wanted to say thanks for the recommendation for a very effective item, I had no idea what a change this item could affect.

Yours truly,

J.C. Forbes

Thanks for the Response, you hit it on the head.


Redondo Beach, CA
Thank you for your time and expertise in answering my question…..


(location unknown)
First, thanks for putting together this website. Its the most informative site I have found dealing with foot problems. Last June I started having pain and swelling at …….


(location unknown)
First of all, thank you for having all this useful information available in one place. I've been through most of your website and based on my research, pain and evaluations I think I've narrowed things down quite a bit.

Pete M.

(location unknown)
Thank you for the best site I have found when researching foot pain.

Glenda B.

Madison, Alabama
Thanks for replying so quickly. I was a bit concerned. I think your website is great, and chock full of info.....


Denison, TX
Dr. Marc, Thank you so much for your reply which seemed to be right on. I have researched many sites but you put me on the right path to the possible answer. My foot pain may not rule the rest of my life after all! I believe I'll make a sign that reads, "THE END IS NEAR!" Thanks Very Much,


West lafayette, IN
Dear doubt you get positive comments re your site...May I please be added to the list of your admirers. In all of my years of web surfing I would say your site is right there with the very best. Thank you for taking the time to write the terrific info you provide and for putting things into laymen terms for us mere mortals. I pray you have much on going success and thank you again for a deed well done. As for me I did not find much help for my symptoms and will continue on my quest. Were you anywhere in the South I would make and appointment...Thanks again dear sir...m.e.

Michael E.

Tampa, Florida 33624
Hi. This is a great site! I'm a healthy middle aged woman who is in good health, but.....


Just a wee word of thanks for your wonderful website...It is a terrific service...Thank you for providing your knowledge and help...With highest regards, m ebeling

Michael D. Ebeling

Tampa, Florida 33624

Thanks for a most interesting website, which has helped a lot.



Dear Dr.Mitnick

I usually do my research on the Mayo clinic website. I think your website is the most informative site I have found when researching foot pain.

I thank you for putting together this incredible website.


Dragica W.


....I have been told that it is not hard enough to be cut off. Please help, I am not sure what to do now! THANKS FOR A WONDERFUL AND VERY HELPFUL SITE!


South Africa

You have an unusually clear, informative and well-written website for laypersons. Thank you for that.

Matthew W.

Mansfield Ctr, CT

First, I'd like to thank you for all the information that you provide on your website and the opportunity to write to you.


Placentia, California

First, I want to let you know that you have the best web site I've found related to foot issues. (The only thing I had difficulty finding was the "ask a question" page.)


Unknown location

I received the orthotics Monday afternoon and began wearing them Tuesday. After two days I would say that I have noticed a huge improvement in the discomfort I have been experiencing. My foot feels better than it has in months.

Ric J.

Unknown location

I greatly admire someone like you who would donate and dedicate so much time and effort to helping strangers with no compensation. Truly, it is uncommonly kind. And your site is so intelligently arranged.

Ron R.

Pacific Grove, CA

I used to work for a podiatrist (front desk) back during summers in college years ago, so I know the benefits of good care. Again, I want to thank you for an EXCELLENT website. It was so great to get to your site (top of google search) and actually find all the answers I needed EASILY and QUICKLY! Clearly you put a ton of work into it and I really appreciate it.

All the best,


Alameda, California

By the way, millions of websites could use yours as a guideline on how to organize information and make the site user-friendly. Kudos to you!


Thank you for your very interesting and informative site!


Hi. I come to your site often looking for information. It is really informative and I appreciate it very much. I have RA and have been having considerable amount of foot pain...... Dee RN

Thanks very much for the wonderful informative site.


New Zealand

Thank You for my answer! I have been schedule for a bone density scan, allingment, and I am in the process of getting orthotics made, and checking out the natural remedies. Thank again! What a great web site!



Yes I want both pair of orthotics. You don't have an option of ordering 2 at one time so I had to place the order twice. Thanks. My husband likes these and wants to put them in all of his shoes. (referring to Superstep orthotics)

Cindy H.

I searched the internet everywhere for a clear description and illustration of my symptoms/problem. was where I ended my search with answers. If I lived in Jersey (left 30 years ago) and didn't live in Florida I would definetly make an appointment with Dr. Mitnick.

Thanks, Kathy

1st of all THANKS A LOT for your great site......


Thank you so much for your response. I will let you know how I am doing if you would like. Your website is awesome!


South Carolina
Hello! I want to thank you for such an informative website! I found you based on my ankle pain search and am happy to realize that there may be a relatively simple cause and solution....


unknown location

...Thanks for your fantastic service.


Arlington, VA

Thank you so very much, that would be much appreciated. I love those insoles, by the way. (referring to Superstep orthotics)

Kelly W.

San Clemente, CA

Dr Marc is fantastic...He seems to know exactly what you are feeling with the problems you are having. I wish he was in my home town so I could go to him with my problems!!!!!!!!!!!!!


location unknown

Great insights! Thanks Doc, you're the best.


location unknown

I have been experiencing foot pain of various sorts and am working to figure out what it is. I found this site and can only say BRAVO!! What an excellent site! The time it must have taken to put all this together must've been a daunting task! I am sure it has helped so many people. Thank you so very much for doing this.


location unknown

Dr. Mitnick, Thank you so much for your reply. I did let my physician know and they took an x-ray - all is well! Also, thank you for providing this wonderful site, it is very helpful with lots of useful information! I appreciate your gift of time! God bless.


Dr. Mitnick, Thank you, you were 100% correct. The pain finally brought me to the ER. I spent 8 days in the hospital. The Doppler you spoke of was able to show that there was no pulse in that foot. This was an arterial clot that split and traveled throughout my leg. My leg was almost amputated. I am in rough shape but have all my parts intact!! You certainly know what you are talking about. Thank you for taking the time to answer. Yours Truly!


Staying at home after hallux surgery I spend quite a lot of time seaching info useful for avoiding problems which might come back. Today I found your site and I am .... delighted it happened. It's one of the best site I found last days.



Thanks for taking time to read and answer so many questions. It is truly a public service!


Seattle, WA

I just wanted to say that I am very greatful for this website!!


location unknown

Also, and importantly, just want to praise this web site. Thorough and thoughtfully presented, it certainly must be of considerable assistance to anyone with a foot problem. Terrific -- and very interesting.I trust the address comes up easily for those seeking information.


New Jersey

Thanks so much for answering my question. You've been more help to me than my own Dr. has been lately. Thanks again....I hope to be able to walk without pain someday.


location unknown

Wow, that is exactly the information needed!!! thank you thank you thank you!!! I appreciate this help so very much from Marc Mitnick DPM. Excellent information and help to improve One's life.


location unknown

Thanks so much for this website Dr. Marc! It is so nice that you have this ask the doctor feature..I'm sure I'ts been helpful for alot of people. I will try what you suggested and see if it helps...thanks again!


Evansville, IA

Dear Marc

I just want to say thank you for the quick response and the good info. I find it amazing and a super nice thing that you do here by answering medical questions at no charge.

Russ W.

location unknown

Your website is full of a lot of helpful information, and I am very impressed with the time in which you responded to my post. Thank you again for your time and consideration in your response.


location unknown

Thank you very much for the information, I will consider it. Excellent web site.


San Diego, CA

Dr. Mitnick, Just want to say thank you so very much for your quick response and very informative reply! After reading what you had to say, I called the doctor's office and was able to get in and see him the same day as my injury. Toe was x-rayed and luckily, it is not broken or fractured. Very badly bruised and will probably lose the toe nail. And although my toe and toe nail are still very black and blue and very sore, they ARE both starting to feel a little better. So again, thank you! I am so very happy that I came across your website. The service you provide is outstanding and immeasurable!


Albany, NY

Thank you so much for all of your advice. In searching the web for people dealing with this same issue i can tell you that you are a Knight In shining Armor! If I lived in Jersey I would gladly be your Spokesperson. Hopefully next time you hear from me it will be good news. God Bless,

Jill S.

location unknown



Whichita, KS

thanks again, this site is very helpful.


Boston, MA

Like others have stated...This site is amazing and I am so thankful that it was created.

....Keep up what your doing. Your a life saver.



Thanks again for the information provided on your site. It's easy for non-medical folk to understand your writing, and helps provide better communication between patient and doctor.



Wonderful advice

by: Anonymous

This is the best site for foot problem info.

Thank you for this information. This description fits my pain and inflammation behind my 2nd toe perfectly.

by: Max

location unknown
Again, I really appreciate that you responded to my inquiry, and that your mention of Parkinson's helped me to find my way to a diagnosis of this difficult to diagnose disease. Most patients see on average 16 doctors before they are diagnosed. I hope that you can help other people that ask for your expertise in the future.

Barb D.

I just wanted to say that I am very greatful for this website!! I have had a fusion in my rt foot and am finally getting a little bit better......


location unknown
Again, Thank you from the bottom of my heart for taking the time to answer my question....your an angel!


Thank you for your response. You have provided some great insight (to my question)....


location unknown
Thank-you so very much for responding so quickly and in such detail to my question!! I will give my surgeon a call today!! This website is terrific!!!! Thank-you again!


North Carolina
Many Thanks Dr Marc!
Thank you for your response. It sounds like a good plan to me. He did not cut the wart out first ...


location unknown

Thanks again doc for having this website and we STILL need qualified Podiatrists in beautiful sunny Tampa Bay (Bradenton) Florida.

Bessie Mae

Dear Dr. Mitnick, Thank you so very much for taking your time to answer my question. You have greatly relieved my anxiety related to the continual tingly I feel in my feet. I will share your response with my podiatrist next week. God bless you for having this question and answer page on your website! Most gratefully,

Lynne T.

location unknown
Your webpage is excellent, I commend you on sharing your knowledge to the public.


New Jersey

Thank you. you were more detailed than what others have told me they finally called from the last xrays and my son is now in a cast for 2 weeks he did have a fracture that was not noticeable.

a mom

location unknown

I have read your website and I have to admit that I am amazed at all the information that is on here. I have learned more than the three years I have been going to several doctors that I have seen!!


Lenoir, NC

Thank you so much Doc for a quick and thorough response!


Bellevue, WA

I cannot thank you enough for your response, opinion, and suggestions! I want you to know how much it means to me, and I'm sure everyone else who has ever asked you a question! I feel like you're a lifesaver and have empowered me to take a stronger role and stand up for myself and my feet!


location unknown

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