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 from a few weeks to many 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.
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. these micro fractures, like all fractures, heal by having the two sides of the
broken bone produce more bone and, in effect, glue them selves together. After
the bone is "glued together" the body remodels the glued site until
it is indistinguishable from regular bone. A well healed fracture might not be
seen on an x-ray. I will attempt to explain with a admittedly belabored analogy.
Imagine that the room you are sitting in is the heel bone and the ceiling and walls are
made of thin plywood. This 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.
 This is a side view of a foot x-ray. The spur is the little projection that
goes from the bottom of the heel bone to the right. Contrary to popular opinion a heel
spur does not point down toward the ground.
By clicking this little picture you can get a nice view of the actual spur.
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.
For Extra
Credit: A Little Algebra
H + S + W + A +
F + B + P + L+ O = Excess Plantar Fascia Pulling = Heel Pain
Heel pain
is multifactorial. It often takes a combination of factors to make the heel hurt. Some of
the factors are:
Heel height: The
higher the heels the less the pain. Pumps or clogs for ladies and cowboy boots for men)
The worst shoes are cleats without heels like shoes for soccer, football, golf and
baseball.
Shoe types: The
more stable the shoe the less the pain. Athletic shoes are better than slippers. Slippers
are better than no shoes at all.
Weight: The
greater the force on the foot, the greater the pain.
Activity levels:
The more you are on your feet, the more the heels will hurt (especially the next morning
after days of great activity).
Floor or walking
surface: The pain is worse when walking on unforgiving surfaces like tile, marble,
hardwood floors and concrete. Walking on sand or grass eases the pain.
Body position of
the hip and legs: Hip motion, knock-knees, bowlegs all contribute to heel pain.
Pronation: The
amount the foot "pronates" or
flattens during the walking cycle.
Ligament
flexibility: Flexibility increases pronation that leads to greater heel pain.
Overuse:
Increasing even normal activities too much in too short a time can cause it.
Some of
the factors like activity levels shoe types you might be able to control. Others, like
ligament flexibility and joint motion, you have no control over. But do what you can to
decrease the factors you can control. If you work in a factory or at a cash register, try
a cushioned mat to stand on. Try newer shoes with more stability, preferably with a little
more heel height.
Fortunately
podiatrists have a lot of control over the "P" which stands for (sorry Professor
Higgins) Pronation. Many, if not most times, when we control the amount your foot pronates
we can reduce or eliminate you heel pain without the need to change jobs,
activities or even your weight. We do this with taping and orthotics. It is very
gratifying to see the smile on the face of patients who experience pain relief with their
taping and orthotics.
|
| 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 ¼" 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 plastic 12-ounce 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. Just roll your heel on the
bottle 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.
Night splints do
not have to be worn just in bed. If you are going to read a book or
watch a ball game or movie on television and are going to stay put for a couple of hours -
go ahead and wear your splint. Even 2 hours can be helpful.
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 at your very 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,
Voltaren, Lodine, 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 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.
Dr. Zapf, 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.
The entire foot area is shielded with drapes to prevent the patient from seeing anything (unless they
want to).
I spray the area of the heel with a skin refrigerant to pre-numb the skin.
I use a small 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 know the location of THE POCKET!. I call the pocket an area of loose tissue just above the insertion
site of the plantar fascia. By injecting a small quantity of a powerful cortisone
preparation into the pocket the pain can be minimal. Many patients have expresses some
disbelief with the lack of pain saying "Have you done it yet?" after the
injection is over.
I mix the cortisone with a fast-acting anesthetic Xylocaine (a
Novocain-like
anesthetic). The Xylocaine I use is not the typical multi-dose vial but single dose vials
that are MUCH more expensive. The advantage of a single dose vial is it is made without
the preservative methyl parabens. The
preservative mixes with the cortisone and causes it to clump in the syringe and needle.
Not only does the clumping inactivate the cortisone but other doctors have to use a larger
needle to pass the now inactivated clumps through. With my non-clump formula, I can use
the tiny 30 gauge needle to inject the cortisone. Ask your doctor if he or she can use a
30 gauge needle with their cortisone. I bet not.
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.
Are orthotics covered by insurance?
Most insurance companies cover 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.) Most insurance companies will cover
most of the fee leaving you to make up the balance.
How do I know if my insurance company pays for orthotics?
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 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
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. [Note for out-of-area readers: The Alzner is advertised heavily in my area of Los
Angeles with 30-minute infomercials played, near as I can tell, almost constantly on the
cable channels. In case any Alzner lawyers are reading this, I am basing my comments on
what I have heard and seen from patients who purchased an Alzner orthotic, and not direct
facts. If I mis-represent anything I will be more than happy to correct it in this web
site.] 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.
One scene shows a gentleman gain about 3" in height when he slips these magic devices
into his shoes. 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 may be 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, after all,
only an arch support - and not a custom made device adjusted to fit just your foot.
What about casts?
Placing the foot into either a removable walking cast or a fiberglass 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.
To
read more about the heel surgery click this line <---
An actual letter:
Dear
Dr. Zapf,
I cannot
believe how my right foot feels now. After my fall I started to feel a terrible pain in my
right heel area. This fall was in 1996 and I have had to live with this everyday until Dr.
Zapf operated on it [with the in-office plantar fasciotomy October 2000]. I now can walk
without pain in my right foot. This operation consisted of a small incision to the right
heel area and I was able to walk within days.
I would
recommend Dr. Zapf to anyone who needs this kind of foot surgery.
I cannot
believe it! It's so great now.
Diane S. Camarillo, CA
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.
------------------ ------------------
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NOTE: THIS IS AN E-MAIL I RECEIVED ABOUT EPF:
Hi Dr. Zapf,
I read with interest that you are now performing a new procedure, much
simpler than the EPF [PRESUMABLY HE IS REFERRING TO THE OSSATRON THERAPY].
I wish I had heard about this procedure before I
had the EPF about 1.5 years ago. My foot is no better now, than it
was
before the scope surgery. Just wondering if you think there is
anything inherently wrong with the scope procedure? Why am I hearing
about so many people that were not helped? I was under the impression
the EPF helped at least 80% of the people that had it. It sure doesn't
seem like that to me. If you have the time, I sure would like your
thoughts on the EPF procedure, do you really think it helps 80% of the
people who have it?
Regards
Name withheld by request
Lunenburg, MA
Dear Withheld:
Personally I have not felt the need to
perform EPF procedures. I am comfortable being able to cut the plantar fascia
with my pinhole incision. The EPF people will tell me that I am missing out on
being able to visualize the plantar fascia. I am not convinced. My success is
also very high and my patients can avoid the need to use an operating room
(mine is done in the office) or pay the overhead of expensive equipment (my
little procedure takes just 4 simple instruments.
Now to the success factor. If a proper
diagnosis of plantar fasciitis has been made almost everybody is better with
non-surgical treatments as I describe in this monograph. The few that aren’t
get put into a special category that needs a surgical approach (less than 5
per hundred). I trust that your doctor has made the proper diagnosis and that
he or she only does a few surgeries per year. (An aside: If he or she
performs dozens of heel surgeries in a year I would personally mistrust his or
her diagnostic and treatment acumen.) These few resistant
patients are the ones that qualify
for the Ossatron therapy or for plantar fascial surgery.
Considering that these are resistant
patients, I think that expecting 80% success is probably about right.
That, of course, leaves 20% still hurting. This is where the Ossatron (or
other Extra Corporeal Shockwave Therapy machines) shine. This technique offers
hope for the, heretofore, hopeless.
When the Ossatron, or other form of
ESWT, comes you your area, you should be one of the first to sign up. What
have you got to lose? The procedure is described below.
What If I Do Not Want Anybody Cutting On My
Heel?
Great News
Great News! A Shocking New Way To Treat Heel Pain: ESWT
In February of 2001 I was one of the first podiatrists (or doctors
of any kind for that matter) certified
to provide shock wave therapy for patients with heel pain. High power shock
waves, produced by a 20,000-volt spark plug and focused on the heel can result
in significant pain relief when all other treatments have failed. The
treatment, called extra corporeal shockwave therapy (ESWT) has been available
for 10 years in Europe but was only recently approved in the United States.
The FDA approved the procedure in early 2001 for use on resistant heel pain.
The only FDA approved ESWT machine in California is located in a local surgery
center. My certification means that I am able to offer it to patients for
relief of heel pain.
A link to this machine is found here: -->
As a recap to the foregoing monograph, heel pain is a common foot problem
and is a frequent cause of visits to my office. The pain can range from the
mild annoyance of a "stone bruise" to a cause of missing work.
Classically the pain is felt on the bottom of the heel with the first in the
morning or after other periods of being off of the foot. In the first few
months of heel pain the discomfort eases off after a few steps. In advanced
cases the pain can persist throughout the day. Sometimes a heel spur can be
seen on an x-ray. Heel pain with an actual spur on the x-ray is often more
resistant to treatment.
Most of the time the pain can be successfully treated by over the counter
anti-inflammatory medications, heel lifts, stretching and shoes with some arch
support. More resistant cases can be helped with prescription strength in-shoe
arch supports called an orthotic. Sometimes a prescription anti-inflammatory
medications or an injection of a cortisone medication are prescribed.
Fortunately more than 90% of all heel pain patients are improved with these
non-surgical therapies.
Unfortunately, non-surgical methods fail about 10 times out of a hundred.
One or two of these people will choose to just live with their pain rather
than face surgery. In the past the others had to choose from a variety of
traditional surgeries. The surgery for heel pain involved cutting of the
ligament involved, called the plantar fascia, removal of the heel spur or
both. Finally, there is an alternative to traditional surgery: shock wave
therapy.
Extra Corporeal Shock Wave is patterned after the shock wave therapy
machines that have been used for 15 years to break up kidney stones. In the
foot, ESWT is usually performed under light sedation and local anesthesia.
During the treatment the device is aimed at the heel and 2000 shocks are
directed at the painful area. Afterwards the heel is sore for a few days and
sometimes the heel is "black and blue" for a few days more. In most
studies a majority of patients are happy with the procedure and back to
regular activates with less pain in 2 to 4 weeks. In one double blind study
with patients at seven different sites, the most common side effect from the
procedure was temporary pain and numbness occurring in 15 of 273 patients.
Success was reported by 62% of the patients after one treatment. When the
"failures" were subjected to a second treatment the success rate was
an astounding 90.5%. The success of this study led to the FDA approval of this
particular machine for heel pain.
ESWT is great news for anyone who has heel pain despite six months of
conservative, non-surgical, care and for anyone who has heel pain despite
having surgery. With this technique you may be able to finally "Wave
Good-bye" to resistant heel pain.
Flow Sheet for Typical Heel Pain Treatment
[To see this great flow
sheet you will have to get a copy of the monograph. It did not translate well to the web
page Sorry]
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