Dr. Zapf News Page

A copy of my Clinical Guide to Wound Healing and a suggested diet to heal wounds can be found at �

My April article was on the new use of Shock Wave therapy for resistant heel spurs and plantar fasciitis. To read click here:�

My March article was about Operation Footprint, the club foot surgery in Honduras. To read click �

My January ACORN article was on the performance of three bunions in one week where not one of the three patients even needed to take so much as one pain pill. To read this article click here: �

For more information about my recent trips to Honduras to perform club foot surgery, please see �

The following letter was received on December 4, 2002 and concerns Neuromas. Kristen's letter is in light blue and my response is in dark blue.

Doctor Zapf,

I first wanted to tell you that I found more relative information on your web site than I've been able to find anywhere else, including from my doctor. Thank you very much.

I currently have an extremely painful neuroma in my right foot between my second and third toes. As you might have gathered from my page on neuromas, the area between the 2nd and 3rd toes is not a common location for a neuroma. They are usually between the 3rd and 4th toes. Yet this very morning I surgically removed one from a second interspace and it was even larger than the one pictured on my neuroma page. What I am getting at is that often pain and tenderness of a swollen 2nd metatarsophalangeal joint 9the joint where he toe meets the foot) is the responsible culprit and irritates the nerve. Make sure you do not have more pain just under the second metatarsal head (your doctor can locate this for you) than you do with palpation of the interspace.. I also have flat feet. My podiatrist is Dr. P. I really like her but I am very frustrated with my treatment. I have had cortisone injections fine, taken anti-inflammatory medication fine, again and had orthotics made I think orthotics help bunion pain very much. As a rule I do not make orthotics for pure neuroma patient. If the second metatarsophalangeal joint is involved, however, orthotics are the first line of treatment. My neuroma pain actually feels like it is getting worse - I'm in constant pain driving and walking in any type of shoe. I realize that surgery should be a last resort but I'm at the point where I just want the nerve cut out! Surgery in your circumstance, with as much pain as you are having, is not something to be afraid of. It can help you tremendously. Just don't ignore sclerosing, as well. A series of 8 weekly injections of 4% alcohol can often do the trick without surgery. Dr. P really advises against the surgery (she doesn't do the surgery herself, it's performed by an orthopedic surgeon) as she feels that there is a much greater chance of a stump neuroma occurring than previously thought. I have had 2 painful stump neuromas in 16 years of doing neuroma surgery. As long as you have tried the conservative methods, including sclerosing, the risks are well worth the procedure. In some of my research I found a few doctors who after removing the neuroma actually insert the cut ends of the nerve into the! surrounding muscle to prevent a stump neuroma from occurring. I haven't been able to find anyone locally who knows of that technique though.I have herd of that as well, but do not do it. I pull on the neuroma just before I cut it and snip the nerve as far back into the foot as I can. When I cut the nerve it snaps back into the mostly muscle tissue from whence it came. It is a similar technique but I do not cut a groove in he muscle and tuck the nerve into it. I was hoping that you might know or be able to recommend a podiatrist here in ____ that is as knowledgeable in neuromas as you appear to be. Honestly, nearly every podiatrist worth his or her scalpel blade can do a great job on a neuroma. I suspect that your podiatrist is just a bit more cautious than most, since she does not do the surgery herself. The surgery is really quite simple and has a 95+% success rate. Just visit the web site for the ACFAS (American College of Foot and Ankle Surgeons) [put it into a search engine like Google] and find one near you who is Board Certified. You will do just fine, especially if he or she can also offer the alcohol sclerosing injections as a last, last resort. I understand that I'm not a patient of yours (although I wish I could be) but any advice that you could give me would be greatly appreciated. Thank you in advance for your time. Sincerely, Kristen S. You are most welcome.

This letter may or may not be serious. I hope not. Maybe you will recognize this guy by the bandages on what is left of his hand or the "red stuff" on the cars he works on.

I have been doing a lot of research lately about warts since i have a few on my hands that i desperately wish to rid of. I have very small ones growing under 2 fingernail tips and then 4 on my fingers themselves. The doctors have froze them before but with no luck. I have heard that the wart virus sometimes goes undetected by the immune system and needs to be identified by damaging the wart so your body will recognize this. I read that a lot of horse owners have crushed the warts of their horses with pliers with great success of killing the wart. Have you ever heard of this technique on humans? I know it sounds dreadfully painful but I am willing to handle it if it will work. I am down to my last straw with them and want a do-it-yourself remedy since all the doctors around me can't fix the problem. I have tried cutting them out but did not know what I was doing and it was a very bloody experience that failed horribly. I read on you website that you say warts prefer the body temperature of 98.6 and that excess heat can kill them. Would the hotter the temperature kill them faster? Such as maybe a cigarette lighter? I am not worried about scarring since i am a mechanic and my hands are roughed up pretty good already. I just want them gone and am willing to try anything short of shooting them off. Thanks for any help you can give me.

Dear Dr. Zapf,
My 11 year old son has been diagnosed with severs disease. After much research on the web, your site was very comforting, you explain the condition very well. I thank you. My son is not athletic, has been walking on his toes for 2-3 months now and the pain in his heels have reduced him to crying. The doctor I am using has given us heel lifts and a regimen of Advil 3x per day. This is not working well at all. I have also advised the doctor that in the last year my sons shoe size has remained the same. Is there anything else I can do to help my son, he hardly goes out anymore because he's embarrassed to cry in front of his friends when the pain becomes UN bearable.
Thank you for your time
Joanne R.

As you read elsewhere on my web site Sever's is a short time limited pain that kids get in the back of the heel (s). In the back of the heel bone (calcaneus) is a growth-plate like structure that is quite vulnerable to injury or trauma. The plate will close in a year or two but until then just running or jumping will aggravate it. First aid steps include the following: 1) elevate the heel with heel lifts and the corollary to that 2) avoid flat shoes (especially cleats) without heel lifts, bare feet, socks only and slippers or sandals without heels - even for the hour or so before going to bed, 3) ice massage of the heels three times a day (before school ,after school and before bed) and 4) avoidance of activities which aggravate the condition (running, P.E., soccer, etc). You can also have your local foot doctor apply a tape strapping to the foot (called a 'low-Dye") to see if orthotics can help. Orthotics are custom made devices that fit into the shoes and keep the foot from moving into positions that stretch one of the ligaments that pu8ll on the heel plate. If these fail, I recommend using oral anti-inflammatory medication for a time. If that fails you can try either a night splint (see that section on my monograph A Patient's Guide to Heel Pain) or a plaster, fiberglass or removable walking cast. Take heart, this only lasts for a short time.

My son was diagnosed with this about a week and a half ago. The growth plate even had a fracture in it. My son is 11. The doctor did not want to cast it. Do you think this is the proper thing to have done? Just curious. An 11 year old is not very easy to keep down for the month he is supposed to stay off his feet.

Kim

Dear Kim, What sometimes looks like a "fracture" of the growth plate is sometimes not a fracture. Ask you doctor to compare the pictures in radiology text books on Sever's with your son's x-rays. They are often "normal variants". As you see from the letter above there are many ways to treat Sever's and you need to do whatever it takes for your son to be comfortable.

Dr. Zapf

I wrote recently about foot pain which was found to be from bilateral Morton's neuromas. I know you mostly answer questions for your patients, but I'm going to try to bug you again because I am miles away in Tennessee and trust your advice most. You have me curious about the sclerosing injections, but I have only found one podiatrist here who does them, and not many patients here want them. I doubt he uses all of your methods for easing the injection pain, but I am still thinking of trying this. If it weren't eight weeks of injections, I would be tempted to fly out to your office! Do Morton's neuromas ever resolve without injections or surgery? What do you feel is the success rate of the alcohol injections? Do you try cortisone first? Do you advise still being careful with athletic activities and shoes after injections and surgery? I know you are busy, but it is so scary out here where I can't be your patient.

Dear Kathryn, Sclerosing injections using a 30-gauge needle and a 1CC syringe should not hurt much at all no matter who does them. I encourage you to let your local doctor give them a try. He or she can even call me for any advice if desired. Morton's neuromas can frequently become quiescent, especially after a cortisone injection or two. I encourage my patients to try one or two cortisone injections first for just this reason. If the neuroma were to come back - we cal always sclerose it later. I find that the alcohol injections relieve enough of the neuroma pain that more than 90% of my patients never opt for the traditional surgery. I do not advise any special precautions after surgery or alcohol injections. Successful treatment for neuromas should allow you to do everything your "sole" desires. Good Luck,... Dr. Michael Zapf

Hi Dr. unfortunately my Dr. never game me the alternative and he perform a neurectomy. I have developed a stump neuroma and the pain is worse than before. I have pain in my entire foot know. I was wondering if I still have a chance of getting better and being free of this problem. I have another neuroma in my left foot and a stump on the right and I cannot do anything that involves walking. This problem have taken over my life. I will thank you for any information or advise you could provide.
Jennifer from Los Angeles.

Dear Jennifer, Every once in a while, perhaps 1 in 50 neuroma surgeries results in a terribly painful stump neuroma. Unfortunately for you that "1 in 50" is 100%. This rare but problematic side effect is why I encourage patients to try sclerosing injections before undergoing traditional surgery. I know that 8 visits to the doctor seems like a lot of time but, in retrospect, wouldn't you rather have taken the time then than have the pain now? I have had some success getting rid of stump neuroma pain with sclerosing injections. Your job is to find a local doctor who will be willing to work with you and try to inject this one (and the other foot, for that matter) with the alcohol solution. ... Dr. Michael Zapf

My question is I love to go barefooted and I haven't been able to find any cream or lotions for my dry skin and especially my feet. I have type 2 diabetes and my feet are really dry to the point of cracking and I have corns as well as warts what do I do?

I received a comment from Breanne H. of Texan on the use of Tagamet for warts. �

My first letter of 2002 is from Monica from England and concerns her mother. To read the letter and my answer please see .�

To begin with: I am a man (age: 36) living in Holland and just discovered your website. My story is the following: I bruised my left foot very badly about 4,5 months ago due to a heavy fall in my own home. First I went to the First Aid (they did nothing because my foot was swollen), after 2 weeks my own doctor examined my foot (the bunion was already visible) but didn't do anything, after almost 2 months I finally got "permission" for an X-Ray (nothing broken, no furthermore comment), after 2,5 months I went to a second doctor (my complaints were growing : pain in my left hip, muscles hurting, stiffness in my left leg that feels like missing a shock absorber) who finally for the first time diagnosed a Hallux Valgus. I'll had to go to an orthopedist (waiting list: 6 weeks) who "prescribed" me (within 5 minutes) standard (!) orthopedic soles under my shoes (which I'm still waiting for). In the mean time I developed also a beginning of a callus. I'll have a few burning questions for you because I'm getting a bit desperate:
- Are there similar podiatric clinics in Europe like yours ?, I cannot find them in Holland and I don't trust a surgeon who operates a foot once a month or so. - Is it possible (as a Dutch citizen) to undergo an operation in your clinic? (my health insurance will never pay for this of course, but money doesn't matter to me, I want to do everything to get my ambulant capacities back).
Hope to hear from you soon :),
Sincerely, R van der W (once a walker by heart...........)

I received a question about ingrown nails from Amber. Look for the answer here: -->

I discovered I did not write anything on Neuromas. Follow this link to see what I spent the early morning hours writing on this nervous topic. -->

Dear Dr. Zapf,
I found your information on pre-dislocation syndrome on the Internet,
and am very grateful for your explanation of the condition. I would greatly
appreciate if you could answer a few questions. For the past 19 months, I
have been trying to get help for this problem. I have had injections, which
only seemed to aggravate the condition. I have tried total rest, a walking
cast, orthotics, physical therapy, ice, various metatarsal pads. Still, my
second toe is lifting, and my big toe is moving over to the left,
underneath the second toe. I have been advised at this point to have
surgery: flexor tendon transfer, to stabilize the second MTP joint, and an
Akin procedure to get the big toe out of the way. Do you have any thoughts
on this as an appropriate solution? Any thoughts on other possibilities
that may have been overlooked? Thank you so much for your time.

I received the following letter after Dave visited the web page talking about heel pain.

Dr. Zapf: Just happened on your web page. Your article on flat feet--my
feet look just like your pilots, right down to the bulge on the side.
They have looked like that since I was 9 years old and started getting
leg pains. My legs and feet hurt so badly I became very inactive and
gained over fifty pounds. Converse gym shoes were terrible. But I
discovered a pair of old cowboy boots in the basement. They were
wonderful and I wore them to the chagrin of my parents who said the high
heels would ruin my feet. However, I went off to school, the Navy etc.
and didn't wear boots for almost 20 years. When I was nearly 40 my wife
came home with a pair of boots much like the old ones. I went nuts and
had to have a pair. After wearing them about three months I realized my
feet and legs didn't hurt. A number of A-B tests proved it was the
boots. A resulting trip to a pedorthist confirmed that heels were for
me. Now at age 61 my leg pain is gone and so are the calluses and corns
on my feet. I am also able to walk four to six miles a day in good
walking shoes, all I have to do is wear my heeled boots otherwise. Your
article is the first one I have seen which verifies my experience, over
20 years worth, everyone else says I'm nuts. Dave

What is the biggest QUACK device in all of podiatry and how is it related to the weinermobile? Visit -->

Question: We are away from home and I think I have a soft corn on the inside of the big toe, I wear an orthotic for a foot problem and don't think it breaths as I recently got 3 bad toe nails all within 6 mo. The other foot I do not wear an orthotic and that foot is fine. I will be at this address for another week and half or 2 weeks. Thanks.

Answer: Regarding the soft corn on your big toe, try getting a toe separator from your local drug store (or podiatrist) to prevent the big toe and the second toe from coming together. Regarding your bad toe nails, I do not think the orthotics are to blame. Athlete's foot fungus is ubiquitous and is just waiting for the right environment to spring up. It is unlikely that the orthotic changed the environment of your feet. It is possible that the orthotic wearing results in your being in shoes more of the time which could, in turn, increase the humidity in your shoes which, again, in turn, set you up for a fungus infection. My suggestions are the following: see someone about your nails and get a professional opinion on the presence of fungus, 2) change the environment in your shoes by wearing a sock that 'wicks' moisture from your feet and 3) spraying your feet each morning with an anti-perspirant spray (not merely a deodorant spray) that keeps your feet from sweating. In my opinion over the counter anti-fungus therapies work only anecdotally and not in real life. You can try a prescription level anti-fungal nail medicine like PENLAC. I would avoid any oral anti-fungal medicine until a professional has assured you that there is fungus in your nail.

I hope this helps. And what are you doing wearing only one orthotic? They come in pairs, usually.

I answered a question to Minh To, a high school student regarding the life of a podiatrist, I answered it on this web page for all to see. Feedback welcome. To see the answers go to -->

CRAMPING: The Alabama Sports Medicine Institute reports that mustard ingestion is useful for treating acute muscle spasms in athletes. The athletes ingest a packet of mustard, washed down by water, every 2 minutes until the cramps are gone.. It is believed that the vinegar in the mustard does the trick. Let me know if you try it.

I added a page on the reasons why my injections are thought of as being so very gentle.

I updated the page on warts and created a new page with great close up pictures of a wart surgery .

Michael A. Zapf, DPM, MPH, FACFAS, FACFAOM, LMI*

Send mail to (zfootdoc at doctor dot com) with questions or comments about this web site.
Copyright � 2000 Michael A. Zapf, D.P.M., F.A.C.F.A.S., F.A.C.F.AOA.M.
Last modified: February 24, 2008

Michael A. Zapf, DPM, MPH, FACFAS, FACFAOM, LMI*

Send mail to (zfootdoc at doctor dot com) with questions or comments about this web site. Copyright � 2000 Michael A. Zapf, D.P.M., F.A.C.F.A.S., F.A.C.F.AOA.M. Last modified: February 24, 2008

Send mail to (zfootdoc at doctor dot com) with questions or comments about this web site.
Copyright � 2000 Michael A. Zapf, D.P.M., F.A.C.F.A.S., F.A.C.F.AOA.M.
Last modified: February 24, 2008