My Favorite Case Report
After being a PT for over 12 years now and seeing a wide array of patients, diseases, and dysfunctions, I can say that there are a few cases that have stuck with me since the beginning. Some were serious learning moments for me as a new PT as I learned to navigate what is clearly orthopedic and what is caused by the nervous system. Another aspect about treating that I had to learn what was being caused by organ dysfunction. Today, I'm going to tell you about one of my favorite cases where a woman came to me for heel pain and I, in turn, sent her to....a gynecologist.
This woman I had treated for a couple of years prior on and off for hip pain, neck pain and other common ailments that happens. She is a runner and was participating often in half and full marathons. Another factor to consider is that at the time she was perimenopausal age. For women this age or status, their hormones fluctuate a lot, menses are irregular and typically spotty for weeks at a time and/or gushing for several days. It's a miserable time. She never mentioned any hot flashes, period changes, or anything like that when she returned to me for left heel pain. From an orthopedic standpoint, I was thinking more overuse initially as she runs nearly every day, has high arches and is not the best at stretching (very common with my runners). What was interesting to me is that her heel pain was not only occurring with running, but even at rest and sleep. (Insert yellow to red flag here)
To rule out more of a musculoskeletal issue, I performed a more orthopedic approach to her heel pain. I performed foot and ankle mobilizations, looked at her in her running shoes to ensure that her arch and heel had appropriate support, and did a ton of myofascial release to improve left calf muscles mobility and flexibility.
No change after 3 sessions. At that time, it's time for me to look at other things. I know that embryologically the heel and uterus are formed from the same tube while the fetus is growing en utero. For men, it is the Achilles and prostate. I asked her further questions regarding her menstrual cycle and she informed me that her cycle was definitely irregular, very heavy when she did menstruate, and was experiencing bloating. She denied any pain in her lower abdomen, but she is one of those people that I could probably body slam and she would respond with, "yeah, that was a little uncomfortable." Pain is somewhat of a guideline, but not my North Star when I treat my patients and am determining their plan of care.
I turned my attention to her uterus, which felt full, enlarged and not as mobile as a a uterus should. I explained to her the connection between the heel and the uterus from an embryology standpoint and encouraged her to see her gynecologist to discuss her symptoms and consider a pelvic ultrasound to see what might be going on in there. She texted me a couple of weeks later and said that the pelvic ultrasound revealed some fibroids in her uterus and a large cyst on the one ovary she had remaining. She was being scheduled for a hysterectomy and removal of the remaining ovary/cyst. I told her to keep me posted and let me know if there was anything else I could do while she recovered.
About 6 weeks after her surgery, she contacted me and informed me that her recovery was going very well and....she no longer had left heel pain. Imagine that! I'm not saying that every heel pain moment is intrinsically linked to the uterus or prostate, but it is something that I always keep in mind when I am treating patients from 40 years old to 55 years old. This was a situation where there was not much physically for me to do or for her to exercise her pain away, but I was proud to help guide her when my efforts failed to help to get her the care she needed. Moments like this demonstrate to my patients that I truly do care about their pain/dysfunction and am willing to advocate for them to their medical providers.
Have a great week, folks!
Kathleen Neal, PT, DPT