Welcome to the Website of

Dr. Michael Zapf, DPM, MPH, FACFAS

Call: (818) 707-3668

 Thank you for visiting my website. I have been placing information and articles on this site for many years and have received millions of  hits during that time (and not that many of them were mine). I have designed it for people who like to read about their foot and ankle problems. Since I started the web site, I have added two associates to my practice, Dr. Darren Payne and Dr. Stephen Benson.  Since my site is filled with just my thoughts and opinions they are not, necessarily, shared by my colleagues. To see our less controversial (and less windy) practice web site, I offer you: www.ConejoFeet.com, the practice site for The Agoura Los Robles Podiatry Centers (ALRPC). The ALRPC practice site has a lot of material about our office, many of our policies and the registration forms to be filled out before your visit. I suggest all prospective patients visit www.ConejoFeet.com.

 I made the web site to give my patients the extra depth information that I donít always have time to cover in the office visit. Visitors who are not my patients are welcome to browse the information found here. I am from a generation that likes to read in depth about all sorts of things, including our ailments. This site is dedicated to all those who want more information that what can be contained in a series of bullet points. If you like this philosophy then let me know when you see me or if you ask a question.

Remember, this site is in no way intended to tell you how your own ailment or problem should be treated, only the approach I use when confronted with certain situations. Your problem may well be different from what you think it is and should always be evaluated by the appropriate professional, whether podiatrist, orthopedist or other authority. Please understand that I, nor anyone else, can offer you a proper diagnosis or treatment plan without seeing and feeling the problem at hand (foot?) Happy reading.

 Sincerely, Michael Zapf, DPM, MPH, FACFAS, FACFAOM

 P.S. All the information in this web site is © by me and it is mine alone. No picture and none of the articles can be used by anyone without permission from me, personally.

P.P.S. Comments about this web site or questions about your feet can be directed to me at zfootdoc (at) doctor (dot) com.

P.P.P.S.  I was going to offer a nice prize to the person who could send me a screen shot of being the 3 Millionth person to visit this web site. I am sorry I missed that opportunity. But wait until you see what I offer the 4 Millionth visitor.

 


11/12/2013News+FAQ

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Heel And Arch Pain

{Note - many of the illustrations and pictures in this monograph did not get printed on the web page. Please order a monograph from my office. Please include $1.00 for postage and handling. 

Heel Pain:

What You Should Know

By:

Michael Zapf, D.P.M.

Diplomate, American Board of Podiatric Surgery

Diplomate, American Board of Podiatric Orthopedics

Fellow, American College of Foot and Ankle Surgery

Fellow, American College of Foot and Ankle Orthopedics

Associate Professor, California College of Podiatric Medicine

Assistant Clinical Faculty, L. A. County / U.S.C. Medical Center

Selected Best Podiatrist by The Last Two Daily News Readers’ Polls

 

Revised 10-22-00

What causes heel pain?

There are many causes of heel pain including fractures, cysts and infections. By far the most common "foot cause" of heel pain is due to the pull of a ligament on the inside-bottom of the heel. The ligament goes by the medical name of the plantar fascia and the inflammation you feel is called plantar fasciitis. There may or may not be a heel spur involved. Heel spurs, themselves, are usually not painful. I have seen people with large heel spurs with no pain and other people with terrific heel pain without any spur whatsoever. The plantar fascia ligament gets pulled or stretched too tightly by a change or increase in activities, a sudden injury, using very bad (broken down) shoes on unforgiving surfaces, spending excess time on the feet or by being overweight.

What are the symptoms of heel pain?

The typical symptoms of heel pain are pain on the inside of the heel when you stand or walk after periods of rest or inactivity; especially pain with the first step in the morning. The pain lessens after walking for a while. Typically in the afternoon the heel hurts whether you rest or walk on it. The pain can vary from mild to debilitating and can last for years. The pain can be centered just under the heel or it can extend across the arch of the foot. The pain can appear to be cured, at times, only to return months or years later. You may have noted that shoes with a bit of an elevated heel or walking with your feet turned inward helps to relieve the pain. Plantar fasciitis is uncommon in anyone younger than 30 but not impossible.

What is going on here?

The ligament forms the bottom of a triangle with the heel bone (called the calcaneus) and the metatarsals (the long bones of the foot). Force from above tends to make the foot elongate. The plantar fascia resists this force. If there is more force on the plantar fascia that it can handle one of two things can happen: either tiny plantar fascia fibers tear or it pulls too strongly on the heel bone. If the pull on the heel bone goes on a long time (at least 18 months) a spur can form on the heel bone (see photograph of a spur on an actual x-ray). This is the so-called heel spur. As I stated above, the heel spur is not the cause of the pain. Heel spurs are correlated with plantar fasciitis and it is more common to have a heel spur if you have plantar fasciitis.

Injury to the insertion of the plantar fascia begins a process of heel inflammation. Inflammation is characterized by swelling even though this is not so visible in plantar fasciitis. Some of the inflammatory fluids brought to an injured area stimulate pain nerves. This is nature’s way of getting us to slow down after an injury to allow the tissues to heal. If a pet dog or cat were to injure a similar ligament they would favor the injured leg. They would probably walk on three legs keeping the injured leg off the ground. Humans, being so much smarter, continue to walk on feet with plantar fasciitis.

Plantar fasciitis has long been recognized as the most common athletic injury for runners, aerobic dancers and tennis players.

What causes the spur?

For those interested in the inner workings of feet, the cause of the spur has been an intriguing question that does not have a clear answer. The best explanation I have heard is that the spur forms as a reaction to an accumulation of micro-fractures to the heel bone. I will attempt to explain with a belabored analogy.

Imagine that the room you are sitting in is the heel bone and the ceiling and walls are made of thin plywood. The bone (the room) gets its strength because there are thousands of pea-sized ping-pong balls crammed into the room. There are so many balls that not even one more can be placed inside the room. These balls, with thousands of walls and holes, represent the network of woven bone that makes up the insides of the heel bone. Now imagine that a truck rolls across the top piece of plywood. The plywood bows but does not break because the weight of the truck is bone by all of the balls. Some of the balls bend and bow under the weight of the truck. Some that used to be round are now rather oval in shape. Now imagine that you start putting weight in the bed of the truck. Eventually you would put so much weight on the plywood that one or more of the ping-pong balls would actually crack. This might not be the ball directly under the wheel but it could be one several dozen balls below the roof line. The one that breaks first depends on factors like how the forces were distributed throughout the room full of balls and the shape of the room, itself. In the foot the weakest point is about half an inch into the bone. The forces create a fracture of some of the tiny ping-pong ball like bone in the heel. Since the bone looks intact, we call these stress fractures that show up on an x-ray as a little curved white line. Stress fractures, like all fractures, heal by the body bringing in extra calcium to form a splint around the fracture. On a long bone, like those in your arms and legs, the bony splint is called a bone callus. In the heel this extra bone can form the spur. The spur is not the cause of the pain, but more a result of the plantar fascial pull on the heel bone.

When do you suspect that there might be a stress fracture?

I am very suspicious of stress fractures when pressing the heel of the foot from side to side with the palms of my hands causes pain (see diagram) or when there is little response to the most common treatments. When ice therapy, heel elevation and taping is minimally helpful I am quite suspicious of a stress fracture.

The first diagnostic test is a regular x-ray. Sometimes the stress fracture is seen and sometimes it is not. Equivocal cases that do not respond to the first line therapies probably need a bone scan to diagnose a stress fracture. A bone scan is performed at a hospital radiology department or at an independent radiology office. The procedure involves placing a little special dye in the arm that is mixed with a harmless (I hate to use this inflammatory next word) radioactive dye. The bone scan substance (Tc99 or Technetium, pronounced teck-nee-zee- um) will stick to any bone disturbance. The dye is washed out of the system quickly unless it stuck to an area of bone activity, like a stress fracture. If the radiologist sees a response like the one in the diagram he or she will report that the hot spot is "consistent with a stress fracture." Radiologists couch their words more than lawyers. Stress fractures might require being in a cast for 3 to 6 weeks to heal.

What is pronation and what does it have to do with my foot pain?

Our feet are the product of a Master designer. They have to do two very opposite things every walking step we take. First the foot hits the ground and pronates. In pronation the foot (the diagram shows the right foot) collapses and becomes very flexible. This flexibility allows the foot to adapt to changes in terrain. As the opposite foot swings by the planted foot the foot begins to supinate into a foot rigid enough to support push-off. A supinated foot is very stable and not prone to plantar fasciitis. A pronated foot elongates and allows for a potentially painful stretch of the plantar fascia. Some pronation and supination is normal in every walking step. Pronation beyond the normal amount is one of the most common causes of over-stretching of the plantar fascia and, thus, pronation.

What role does my weight have on heel pain?

Any force causing the foot to elongate, or flatten, can contribute to the pain of plantar fasciitis. This includes weight, which is implicated in as many as 70% of the cases of heel pain. Excess weight also seems to be the one common thread connecting those few people who end up having heel pain surgery. While difficult or impossible for many people to achieve, weight loss can help their foot pain considerably.

Plantar fasciitis is common in pregnancy because of weight gain and the presence of the hormone relaxin. Relaxin is produced in the latter stages of pregnancy to allow the pelvic ligaments to stretch. There is a ligament in the foot that also responds to this hormone and causes the foot to stretch putting strain on the plantar fascia. Usually pregnancy related plantar fasciitis goes away after birth, but not always.

What else could it be?

As stated above plantar fasciitis can mimic a heel stress fracture.

Another confusing diagnosis is tarsal tunnel syndrome. Fortunately it is much less common than plantar fasciitis. In tarsal tunnel there is a stress or force on the nerve that passes to the inside of the ankle. This produces pain in the distribution of the nerve across the bottom of the foot. Nerve pain is tingling, sharp, burning and radiating, quite different from that dull ache with first steps caused by the plantar fascia. Tarsal tunnel syndrome is the pedal equivalent of the more well-known carpal tunnel syndrome.

Still other possible causes of heel pain include arthritis, tendonitis of the ligaments on the inside of the ankle, radiating nerve pain from the back or hip, infection, AIDS and even fibromyalgia.

Is there anything I can do on my own to help my foot?

The plantar fascia ligament is relaxed as the heel is raised. Wearing shoes with an elevated heel can help reduce the pain. Women can easily wear a 1"-2" heel with many shoes. Men can wear cowboy boots. For flat shoes and athletic shoes a heel lift can be added. I would suggest not using more than ľ" at first.

A second at-home treatment is ice massage. I recommend doing this three times a day. My favorite method is to freeze a Coke bottle full of water (freeze it without the cap and place the cap on the bottle only after it is frozen). Three times a day place the bottle on its side and roll your heel on the depression near the bottom of the bottle. A good time to do this is when you are eating. Roll your heel under the table during your dining.

Many physical therapists, chiropractors and trainers believe stretching to be very helpful in treating plantar fasciitis. I find that in most cases stretching the plantar fascia makes the sore fascia even more painful. The exception is the use of a night splint. A night splint is placed on the back of the foot and ankle and extends from the toes to just below the knee. Worn from 2 to 8 hours at night the plantar fascia and Achilles tendon are stretched. The stretching of the plantar fascia reduces the pain of plantar fasciitis in most cases. Some very resistant cases of plantar fasciitis have been improved with a night splint. The draw back to a night splint is the awkwardness of its use, which causes many patients to abandon it. Overaggressive use of night splints can injure the Achilles’ tendon.

If you want to try stretching your calf muscle, use a book or two-by-four. Place the ball of your foot on the book and allow your heels to slowly stretch down to the floor keeping your knees straight. You should feel the stretch high up in the Achilles’ tendon. Hold this stretch for 30 seconds and repeat three times. Do not bounce as this stimulates stretch receptors and defeats the purpose. Alternate each repetition with the same maneuver but bending the knees slightly to feel the stretch closer to the ankle.

Sometimes strengthening the foot muscles helps heel pain. Try placing a towel on a smooth floor and pulling it toward you using only your toes. For a second exercise place your feet flat on the floor and raise the ball of your foot by pushing down with your toes (the so-called toe push-ups).

When should I see a professional?

When your personal efforts to improve your heel pain fail it’s time to see a podiatrist. A podiatrist can often make heel pain more comfortable after your first visit.

Who else treats heel pain?

Most internists and family practitioners will make a stab at treating heel pain. Usually this will consist of a course of an anti-inflammatory medication (DayPro, Relafen, Celebrex, Vioxx, etc). Some primary doctors will try an injection of cortisone. If you return to him or her two or three times with significant heel pain, you will probably get a referral to either a podiatrist or orthopedic surgeon, depending on their preference. More then half of my new patient visits with heel pain are sent to me by family practitioners, internists and even an orthopedist or two.

Podiatrists, orthopedic surgeons, chiropractors and physical therapists provide definitive treatment of heel pain. Each specialty has its own unique approaches to the problem.

Orthopedic surgeons frequently provide cortisone injections and anti-inflammatory medication. Most of them will provide you with a heel cup or over-the-counter arch supports. Podiatrists love using orthotics to treat your heel pain but some orthopedists have a bias against them. Many will tell you that they do not work. A couple of years ago a big heel pain study was published in a respected orthopedic surgery journal. The article concluded that over-the-counter arch supports costing $15-24 were every bit as good as the kind that podiatrists make for ten to 15 times that cost. Academic podiatrists pointed out many flaws with the article, not the least of which that was the lack of long term follow-up. Also, after a cortisone injection, even a Band-aid will seem to make the heel feel good. For some orthopedists, however, this was the article they needed to prove their pre-existing bias against orthotics. While some patients might only need an arch support for relief, every podiatrist has hundreds (or thousands) of patients who presented for heel pain after trying heel cups, arch supports, different shoes, anti-inflammatory medication and even cortisone injections first.

A bit of irony in the podiatrist-orthopedist debate on orthotics is the behavior of those orthopedists who specialize in the foot and ankle. There are not a lot of these guys out there but there are one or two per community. Some of the foot-and-ankle orthopedists make orthotics that are exactly like (and cost exactly the same as) those made by a podiatrist.

Chiropractors often manipulate the foot or the spine and the foot and will sometimes prescribe and make or dispense an orthotic. While some chiropractors make a functional orthotic based on a plaster impression of the foot, most orthotics made by chiropractors are so-called spine levelers. To a podiatrist these are very similar to a leather arch support insole with a few lumps of leather placed seemingly at random. Chiropractors usually do not make these in the office, but send to a supplier for them. Most chiropractors love these little things. Spine levelers are so prevalent in chiropractic that I need to give the vendors credit for market penetration. They were originally marketed to make adjustments last longer and they may do that. Many chiropractors use spine levelers for heel pain where, from my perspective, they are often ineffective. Unfortunately some insurance plans, like those for L. A . City Firefighters, pay for only one orthotic for the lifetime of the patient. If the chiropractor bills the insurance for a spine leveler, there is no money left in the insurance pot for a truly functional orthotic later on. Fortunately for heel pain patients, chiropractors are getting better training in foot biomechanics and they are making great strides at creating a better class of foot orthotic.

Physical therapists often use ultrasound, massage, stretching and other physical therapy methods as well as over-the-counter arch supports. Some physical therapists will make a custom orthotic.

Is my heel pain "chronic"?

Chronic heel pain has been present for more than three months or is accompanied by a heel spur. Even though heel spurs, by themselves, do not hurt, they do indicate that there is a biomechanical problem with the foot that needs to be addressed for long-term heel pain relief.

What can you do to get me out of pain?

At your very first visit I will examine your foot and come to some conclusion as to the cause of your pain. If the diagnosis is plantar fasciitis, I will apply tape to your foot as if you were a professional athlete. This orthopedic tape strapping will keep you from stretching your plantar fascia. It is not unusual for you to experience 40-80% or more pain relief with your very first step. I have had numerous patients who had seen numerous doctors for their heel pain but have not been out of pain until this strapping was applied. This miracle strapping is available in any podiatric office and is called a low-Dye after the inventor, Dr. Dye.

Case of Carol S.: Carol was a 52-year-old woman, 5’-5" and 170 pounds. She worked as a librarian and could wear a variety of shoes to work. Her left heel hurt her for three years before she limped into my office. Prior to her visit with me she received a course of Lodine from her internist and a course of Voltaren from an orthopedic surgeon. In addition the orthopedist gave her a heel cup and three times injected her with cortisone. She continued to have heel pain, especially the first step in the morning. She tried two kinds of arch supports, changing shoes and chondroitin + glucosamine complex from her chiropractor. She saw me on referral from a fellow librarian. An x-ray of her foot revealed a 3-4 mm long heel spur but no other pathology. When I rubbed her foot I could reproduce the pain by touching the spot where the plantar fascia attaches to the foot on the inside of her heel. I made a diagnosis of plantar fasciitis and made my usual recommendations to avoid flat shoes, bare feet, sandals, slippers and socks without shoes. I told her to ice her heels three times a day and then I applied a low-Dye strapping to the left foot. She felt more immediate relief of pain then she did with her cortisone injections. I retaped her twice a week for three weeks. During this time I made a plaster impression of her feet and made a pair of functional orthotics. Wearing the orthotics kept her virtually pain free from that day to now

If the strapping works, then what?

If the strapping does work you will have a couple of choices. First you can be retaped every three or four days for a few weeks. This will allow the inflammation to diminish. If your problem is not chronic this may get you back into regular activities without pain. If the pain returns you may elect to try to do something with a little more staying power like an orthotic.

If the strapping does not relieve the pain, then what?

If the tape does not help you may well not have plantar fasciitis. At the next visit I will confirm the diagnosis. If it truly is plantar fasciitis I will suggest other courses of treatment. I might suggest a single cortisone injection and then retaping of your foot.

How does cortisone work and is there a danger to cortisone?

The cortisone that I use for injection is a synthetic version of one of the body’s own hormones produced by the adrenal gland. This is an important hormone and essential to a life able to cope with the stress of living. I inject a very small quantity of this hormone, mixed with local anesthesia, into the heel area. It produces a nearly universal reduction in pain anywhere from a few days to a few years. According to the most recent classic textbook of pharmacology, Goodman and Gillman, a single cortisone injection "is virtually without side effects." A cortisone injection will not change or create fat deposits and will not cause a weight gain. I am fairly liberal with the first cortisone injection to get patients out of their initial pain. I am more hesitant to give additional injections. I do not want the cortisone injections to allow patients freedom to do activities that are harmful to them. Since the cortisone injection will mask the pain, it is unwise to go straight back to activities that previously hurt.

Do cortisone injections hurt?

Cortisone injections into tight spaces like hips and shoulders do hurt. An injection into an area with a little room, like the knee, hurts much less. The heel is at a level between these two. I employ several techniques that lessen the pain of a heel injection of cortisone.

I spray the area of the heel with a skin refrigerant to pre-numb the skin.

I use a small needle (27 gauge). I use a preservative-free anesthetic that does not clump the cortisone in the syringe allowing me to use a smaller needle.

I use a small syringe (1 cc tuberculin – the kind used for diabetes) I find that the small pressure built up with this small syringe causes less painful tissue expansion.

I mix the cortisone with a fast-acting anesthetic Xylocaine (a Novocaine-like anesthetic).

Instead of pushing the medication into all the areas of the heel with the needle, I use gentle ultrasound to move the medication into all the nooks and crannies.

In Agoura, you can hold a giant Teddy Bear.

__________________________________________________________________________________

Note: I never realized how much I say the phrase gently-gently when I explain my technique for injections. A young patient from Calabasas told me that their family refers to me as Dr. Gently-Gently. I was actually quite proud. There are lots of worse things to say about your doctor. _________________________________________________________________________________

Are anti-inflammatory pills dangerous to take?

The most common anti-inflammatory medications are called "NSAIDs" (pronounced anne-seds) or non-steroidal anti-inflammatory drugs. These include the physician favorites of Naprosyn, Indomethacin, Relafen, DayPro, Ibuprofen and Lodine. You can use a prescription strength amount of over-the-counter Advil or Motrin (Ibuprofen) by taking 800mg three or four times a day. Short-term use of anti-inflammatory medications is not harmful as long as they are taken with meals. Chronic use has hazards involved and requires, at a minimum, kidney function tests every other month and an assessment of the effect of the medication on the intestines. It is safer to treat heel pain mechanically, if at all possible.

Until 1999 all anti-inflammatory medicines had bad effects on the stomach and intestine. Frequently they caused bleeding and sometimes even ulcerations. Fortunately, new anti-inflammatories have come on the market that do not cause stomach or intestinal bleeding and do not change the way your blood clots. The first two are Celebrex and Vioxx. They have made oral therapy for inflammatory problems immensely safer (and the manufactures immensely richer). Unfortunately their increased cost have made many insurance companies balk at approving these new anti-inflammatory medications.

How do you treat heel pain "mechanically?"

I, like most podiatrists, believe that faulty foot function is at the "foot" of heel pain. I prove this over and over when I stop the pain at the first visit with the low-Dye strapping. I challenge my patients to duplicate the effect of this taping with any over-the-counter devices they can find. They cannot. Then I construct a pair of orthotics to be worn in their shoes. Orthotics are successful so often that I am shocked when they do not eliminate the pain. Functional orthotics keep the plantar fascia from stretching and pulling on the heel.

How do I get my own pair of foot orthotics?

Podiatrists can order orthotics made by any of a dozen commercial laboratories or they can make them themselves. I use four different laboratories depending on the nature of the problem and the kind of orthotics you need. I will personally take plaster cast impressions of your feet in the office. I then send the cast to an orthotic lab, along with a prescription that I write especially for your feet. Some devices are a thin graphite material originally developed to give strength to aircraft wings. Other orthotics (like the one pictured) are made of a thicker polypropylene. The exact material and composition is different from person to person depending on their job and recreation needs.

If the low-Dye taping reduces your pain, then you are a candidate for orthotics. The evaluation, measurement and casting for orthotics can be made as early as the second visit.

Do orthotics really work?

Absolutely orthotics work. I have countless patients who wear them and successfully treated their heel pain. As a side effect they realign the knee and slow the progression of developmental foot deformities like bunions.

David P. says "I had heel pain for a long time and the tape helped right away and gave immediate relief. I got orthotics and broke them in gradually; they worked perfect. I could wear them full time after a four or five days. My arch feels good and I am not having any pain. I am happy with them.

Will they fit in my shoes?

Great question. For guys it is a slam dunk. Our running shoes and dress shoes are the same basic shape and size. A pair made for running will fit in dress shoes and vice versa. Ladies (and, Jackie, this is not a political comment) are more difficult.. A device made for running and walking shoes will most likely not fit into a dress shoe. Fortunately wearing a shoe with a bit of an elevated shoe can relieve some of the pain. If the elevated shoe can be worn at work and a running shoe at night and weekends, your problem can be solved. Not infrequently a second pair will be needed for work. Sometimes, when a dress pair is required for the office, insurances can be persuaded to (help) pay for a second pair.

Are orthotics covered by insurance?

Most insurance companies cover some or most of the cost of the orthotics. A few, like Motion Picture Health & Welfare and Retail Clerks, are very enlightened and cover the entire cost of orthotics. A select few, like New York Life and Medicare, do not pay anything toward your orthotics. (This probably explains why Medicare patients, as a whole, get more cortisone injections and surgery for their heel pain.)

How do I know if my insurance company pays for orthotics?

Another good question. The easiest way to find out is to call them. They will respond quicker to your request than ours because you are the one(s) paying for the policy. We will be happy to provide you with a list of codes we use to bill for orthotics and our current fees. Just ask at the front office for these numbers.

What if my insurance company does not cover orthotics, what will it cost me?

My case fee for a basic pair of functional orthotics was $430 for more than seven years. In the last year, in response to the demands of managed care, I have lowered it to $350. This fee covers the time I take to measure your legs, ankle and foot, make a plaster cast of your feet, the devices themselves and most of the follow-up visits to make sure they are working. The lack of insurance coverage should not be taken as a statement that the insurance company does not believe they are useful. Rather they choose to not cover functional orthotics as a cost savings measure.

Why do you keep referring to your orthotics as FUNCTIONAL?

From the podiatric point of view orthotics are either functional or accommodative. Accommodative orthotics, often called soft orthotics, are designed just to pad you foot and give it a cushier landing. Arch supports, spine levelers and just about anything made of leather or rubber fit into this category. A functional orthotic changes the way your foot functions. It will hold your foot in a pre-designed position. A functional orthotic is made from a plaster or computer impression of your foot, not just measuring the size or having you step into a foam box. Originally accommodative orthotics were made of leather and were designed for patients who needed a more cushioned insole in their shoes. Insurance companies that do cover orthotics require that they be functional to be eligible for coverage.

My doctor says I should have soft orthotics. Do you agree?

The only way I can realign your feet is with an orthotic strong enough to keep your feet from moving into abnormal positions. Usually this can only be done with a rigid orthotic. Soft orthotics may seem comfortable the first few steps but like a soft mattress, it starts causing problems after a few hours. Firm mattresses and rigid orthotics are best.

What if I have orthotics from my chiropractor, physical therapist or another podiatrist?

Some orthotics from chiropractors, physical therapists and even other podiatrists are excellent and some are not. I will give you my opinion about any specific pair when I examine you, your feet and your orthotics. If the low-Dye taping stops your pain and I feel I can make a big improvement with a newer pair, I will tell you. If, like L. A. Firefighters, you are only eligible for one pair in your lifetime, we have a problem. Either you will have to pay for the second pair from me yourself or you can go back to the person who made your current orthotics and tell him or her that they are not working. They should either adjust the discomfort you are getting from your orthotics or they can refund the insurance company the cost of the orthotics and we can begin again. If they are not willing to adjust your orthotics again and again until they are comfortable, or offer you a refund, they should never have made them in the first place.

What about Alzner orthotics?

A few years ago patients were bringing in a flat metal orthotic with small suction cups on the bottom imported from Germany called Feathersprings. They purchased them by mail order from ads placed in major magazines. The company must have stopped importing them because I have not seen an ad for them in nearly 10 years. The new media-orthotic is the Alzner. The clever Alzner infomercial makes it seem like the device can cure anything in the lower extremity, the back and even put a smile on your face as you walk to work. Patients that have them report that they are not very comfortable. They were told that it could take from 60 to 90 days to get used to them. Since they come with only a 30-day guarantee they did not have enough time to evaluate them before the guarantee period expired. The Alznner device is a pre-made accommodative device that comes in a dozen sizes designed to fit the average foot. If your foot is not average and does not correspond exactly to one of the sizes, you are out of luck. If they do fit, you can compare their effect on the heel pain against the low-Dye strapping. If the Alzner is comfortable and feels as pain free as the taping, you have a winner. It is, alas, only an arch support - and not that good of one at that.

What about casts?

Placing the foot into either a removable or a fiberglass walking cast for 4 to 6 weeks gives the plantar fascia a chance to rest. It is not a bad treatment to consider when you are running out of non-surgical options.

Any other options?

A final non-surgical treatment for heel spur / plantar fasciitis syndrome is the use of a pre-made or office made night splint. This is a boot like device that fits across the bottom of the foot and up the back of the leg. With elastic straps you can bend the brace and the foot toward the leg. It provides a long slow gentle stretch of the Achilles’ tendon and the plantar fascia. The stretch should be held for three or four hours, which it is ideal to do as you fall off to sleep.

Do heel spurs need surgery?

Heel spurs are not the cause of the pain and do not need to be removed. The cause of heel pain is the pull of the plantar fascia. If all conservative options have been exhausted you might need a heel surgery. I have introduced into the Conejo Valley a procedure that involves only a micro-incision. Through this little incision I place a thin blade and cut the plantar fascia with minimal trauma to the foot. The incision is closed with a single suture that is removed in three or four days. Patients can walk the same day. The success rate for this office procedure is over 90%.

Dr. Zapf, what makes your plantar fasciotomy so special?

My surgery is done in the office with only local anesthesia. Through a tiny incision about one third of the plantar fascia is cut using a small blade. The single stitch needed for the incision is removed in three days and regular shoe wearing can begin. Patients return to work or school in 3-5 days and are back to regular activities in 3 to 5 weeks. Everyone heals at a different rate depending on weight, age and activity levels. The procedure is 90% successful in getting patients back to regular activities with minimal or no pain. Complications of the surgery include the possibility of pain on the outside of the foot. It is the possibility of this complication that most reputable doctors will try conservative methods to treat heel pain for many months before resorting to surgery.

Who should do heel spur surgery?

Some criteria to use to select your foot surgeon are the number of heel pain patients he or she sees, their hospital staff privileges and their Board Certification.

Number per year: There are many intricacies in treating heel pain and the best results are done by people who treat heel pain patients week in and week out. Many doctors only see them occasionally. Ask your doctor (or his or her office staff) how many heel pain patients the doctor sees each week or each month. As a rule of thumb, you can expect a better result if your doctor sees 10 new heel pain patients a month.

Active Hospital Privileges: Hospitals have categories depending on how many procedures the surgeon does per year. Less active doctors are on courtesy, provisional or consulting status. Busy surgeons are classified as ACTIVE. A quick way to determine if your surgeon is reasonably active is to call your local hospital (Los Robles Medical Center is 805-497-2727) and ask to speak to the Medical Staff Office. Ask if the surgeon in question is on staff and is in the ACTIVE staff category.

Board Certification: Board Certification, at least in podiatry, requires the surgeon to be in practice for a number of years and have 75 surgeries reviewed by a board of experts. This qualifies him or her to take a two-day written exam followed by a two-day oral exam. If they pass they are Board Certified. Because this process is so onerous many podiatrists could not meet these conditions. These doctors have created a number of alternative boards. Despite how impressive some of the other boards sound, in podiatry there is ONLY ONE surgery board approved by the American Podiatric Medical Association: The American Board of Podiatric Surgery (or ABPS). Podiatrists certified by this board are allowed to join the American College of Foot and Ankle Surgeons and are then allowed to proclaim that they are Fellows of the American College of Foot an Ankle Surgeons and use the initials FACFAS on their letterhead.

The second approved board is actually more relevant to heel pain. Being certified by the American Board of Podiatric Orthopedics (ABPO) means you have achieved a status in the non-surgical Board of our profession. The case, written and oral examination requirements are exactly like the surgical board. Being certified by the ABPO makes you eligible to become a Fellow of the American College of Foot and Ankle Orthopedics and Primary Care Medicine.

Yes, I am one of the few podiatrists who is both ABPS and ABPO Certified and a member of both the American College of Foot and Ankle Surgeons and the American College of Foot and Ankle Orthopedics and Primary Care Medicine. I have the right to put all this after my name: Michael Zapf, D.P.M., M.P.H., F.A.C.F.A.S., F.A.C.F.A.O.M.

What about endoscopic plantar fasciotomy?

Endoscopic plantar fasciotomy (EPF) uses an arthroscope to visualize the plantar fascia with a television camera while it is being cut. This is an elegant procedure. Unfortunately the equipment to perform EPF is expensive and thus the charges for the surgery are correspondingly greater. A word of caution; many people who practice endoscopic plantar fasciotomy do dozens of procedures a year. Most podiatrists only need to do one or two heel surgeries a year. Some podiatrists who do EPF seem to be overusing the procedure and doing more surgeries than are called for. I have a brochure that details why my "mini-surgery" for heel pain is less traumatic and costly than EPF. You can request a copy by calling my office.

 

Flow Sheet for Typical Heel Pain Treatment

[Sorry this great flow sheet did not get converted to HTML. If you want to have one you will need to request a copy of this monograph using the form below.]

 

For a copy of the complete illustrated monograph, please send a request in writing and include $1 for postage and handling. I need the following information

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Copyright © 2000 Michael A. Zapf, D.P.M., F.A.C.F.A.S., F.A.C.F.AOA.M.
Last modified: November 12, 2013