The treatment of plantar fasciitis is like building a pyramid.  The base has to be strong to support all higher levels.  In part one I talked about ice.  This is the beginning of relieving inflammation.  The next step is gently stretching these inflamed muscles.

Stretching:

Flexible strength is a big word in fitness.  What it means is that muscles that remain stretched are stronger than muscles that are always tight.  This is a huge part of avoiding injury, so stretching is key to keeping yourself healthy.  Since plantar fasciitis involves tight and over-worked muscles it makes sense that you need to stretch them in order to make the pain go away.  The actual muscles in your foot are difficult to stretch on their own, but if you stretch your calf muscles, you will actually help these foot muscles more than if you try to stretch your toes.

The stretch is known as a “runner’s stretch”.  The goal is to stretch your calf muscle more specifically known as the gastrocnemius muscle.  Stand about 2 feet away from a wall you are facing with your feet shoulders width apart.  Put your hands straight out in front of you at shoulder height and touch the wall.  If you can’t touch the wall you are too far away.  This is a one foot at a time stretch.  For argument sake, move your right foot back a little and your left foot forward a bit.  Now you are going to be stretching the right leg.  It is very important to make certain that the toes of your right foot are pointing straight at the wall.  If your foot turns away from your body (out), you can injure your foot.  Keep your right heel on the ground, right knee straight, and bend your left knee slightly as you slightly bend your elbows and lean into the wall.  You will feel stretch in your calf.  If you feel stretch any place other than your calf, STOP, reposition yourself as described above.  Hold the stretch for a count of 30 seconds then change feet.  Repeat the stretch 3 times per day.  That’s it, just 3 minutes per day.

To make that horrible morning pain go away you can use a frozen water bottle or small foam roller.  Place the bottle on the floor while you are seated.  Rest your arch on the bottle (wear a sock if using the frozen water bottle) and roll for 30 minutes.  Don’t push hard, just allow the weight of your leg to do the work.  Do this as close to going to bed as possible.

Pain in the heel of your foot can be frustrating.  As long as you keep moving the pain stays away, but when you stop for  while and try to get up again it feels like something just stuck you in the foot.  I can assure you that you are not alone.  This is the most common complaint I see at Desert Foot Surgeons.  The official diagnosis is called plantar fasciitis.  What this means is that the muscles in your foot become inflamed where they attach to your heel bone.  Why these muscles become inflamed involves tightness in your Achilles tendon, how your foot reacts when it hits the ground, a change in shoes, activities, or an injury.  Some people can have a heel spur, but the problem is still plantar fasciitis.

The treatment of plantar fasciitis is like building a pyramid.  You must first form a solid foundation at the base and then progress upward.  It’s the base of treatment I want to tell you about today.  The basic treatment of all plantar fasciitis includes three steps:  ice, stretching, and arch support.

Ice:

Remember what I always say to my patients at Desert Foot Surgeons, “You can’t heal until the inflammation is gone.”  I’ve discussed ice in many other posts on this site.  The general rule is apply the ice for 20 minutes and leave the ice off for 40 minutes.  As long as you stay with this basic rule you may repeat as many times as you want.  Some people need to have a sock on their foot in order to tolerate the ice, others do not.  That’s an individual decision and I would say that if in doubt wear a sock.  Ice can be applied in three forms:  the store bought gel pack, ice massage using a small paper cup filled with water and frozen, or a frozen water bottle.  In the case of heel pain the ice bag is placed on the ground and you put your heel on the bag for 20 minutes.  The ice massage gets the cold deeper.  You peel the top edge off the paper cup, turn the exposed ice toward your foot and use the paper cup in your hand to push the ice along the arch and heel of your foot for 20 minutes.  The frozen water bottle is best done before bed.  The bottle is placed on the floor, your put your foot on the bottle and roll through your arch for 20 minutes.

Why do some surgeons still use pins that stick out of your foot?  A bunion is a “deformity”, which means bones have shifted out of position leaving you with a bump or lump behind your big toe.  In order to fix this deformity, bone must be shifted back into position to get rid of the prominence.  The way I shift bone back into position involves cutting the bone at some point, basically the same as saying I am breaking your bone to shift it back into the correct spot.  Broken bones heal fastest when held together using screws, staples, pins, etc.  There are a huge number of options, but just casting your foot is not one of them.

Now the question, would you want a pin sticking out of your skin?  Plain and simple…don’t give me a “maybe” or “if”…no “that depends”.  Would you want to see a pin sticking out of your foot when that first bandage is removed?  My answer would be NO!!  Things are not supposed to be sticking out of your foot.  Everything that belongs in your body is supposed to stay under your skin.

When devices to hold bones together, now called fixation, were first discovered there was no option.  A pin had to be used because it was the only form of fixation available.  But now medical science has advanced.  We have a variety of screws made out of space age metals like titanium, staples made out of nitinol or memometal, plates designed by computer to fit the bones precisely, pins and screws that absorb in your body over time.  It’s my job to make your foot look and feel better.  Why would I leave a pin sticking out of your foot when I have all these options?

At Desert Foot Surgeons, your surgery is done using the most up to date technology and techniques.  You won’t have a pin sticking out of your foot.  I want you to look and feel better as soon as you leave the operating room.  Cosmetic foot surgery is not magic, it just takes attention to detail.  There will be no surprises after your surgery since everything is carefully planned and reviewed with you long before you get to the hospital or surgery center.  This is our “personalized approach” to foot care.  Come to Desert Foot Surgeons and see the difference.

If you have heard me say this before than you also know that at Desert Foot Surgeons, I recommend using ice, stretching, and Biofreeze as methods to relieve inflammation.  There are pills I prescribe and shots I can give to relieve inflammation as well, but these can be scary to some people.  Let’s face it, there is a movement away from drugs because we are seeing that continued abuse of some of these medications affects your entire body.  Natural methods to relieve inflammation have been around since man first walked on two feet and anything that has stood the test of time that long has to have some merit.

One thing that makes Desert Foot Surgeons different is that I have always been athletic, working out nearly everyday of the week.  Because of this level of activity I get injured just like you.  I understand how hard it is to make inflammation go away with a busy work schedule, kids, and the various other demands on your life.  Still when you are in pain it means there is inflammation and you can’t heal until the inflammation is gone.  There are a ton of methods to relieve inflammation, and I have tried all of them.  Therapeutic massage, yoga, acupuncture, various relaxation methods (if you know me, you know I’m no good at these), you name it I have probably tried it.  I am always looking for massage therapists and yoga studios to recommend for my patients.

What makes me most excited about the new office location on 44th street and Camelback in Phoenix is the friendships I have made in such a short time with other business owners in the area.  I’m happy to tell you about a business I think will be a huge asset to patients at Desert Foot Surgeons.  I have found you a business that contains all of the things I recommend quite often.  Massage, yoga, spa services.

Spa Lamar is located at 5155 N. Scottsdale Road (480.945.7066).  Services at Spa Lamar include the usual spa services such as hair styling, manicures, and pedicures, plus services that I’ve never been able to find under one roof.  Heidi Lamar has been developing her spa for years and with recent expansions has been able to include a yoga studio and massage therapists in her spa among the pool and hot tub, steam room, and dry sauna.  The first Wednesday night of the month, if you bring a friend, you can enjoy live music and snacks to help with that relaxation that I find so difficult.  What’s best is with the pricey resort spas in the same area, Spa Lamar is truly priced for the locals.  You will not get this level of service at a comparable price anywhere in the area.

When you’re in pain don’t forget:  You Can’t Heal Until The Inflammation is Gone!

A bunion is a bump or knob on the side of your foot at the base of the big toe.  Look at your foot.  Find your big toenail and work your way down toward your foot.  When you get past the area where your big toe meets your foot look for a bump.  If you see is a lump on the inside of your foot then you have a bunion.  Most often your big toe is leaning toward your second toe and in extreme cases can move under or over the second toe.  The word “bunion” is derived from Italian or Scandinavian, and refers to a knob or bump. 

The question remains, how did that knob get there?  The bunion is not a “growth” of bone, but rather a bone that is not in the right position.  The bone behind your big toe is your 1st metatarsal.  The bump is actually the 1st metatarsal that has moved away from the 2nd metatarsal.  Why does this happen?  Well, the true cause is still debated, but basically something has happened to your foot to cause the 1st metatarsal to move out from the line of your toe.  At a certain point the metatarsal has moved so far that you begin to see a bump and eventually your big toe moves toward the second toe.  The knob that is your first metatarsal can be painful, but most often the joint that is out of alignment is the true source of pain.

Shoes are not the cause!  Think about this…if your foot is unstable (pronated) and you wear a heel, you have just forced your foot to supinate or in other words become more stable.  If the shoe makes your foot more stable how could it cause the bunion?  Now in all honesty the narrow toe of a women’s dress shoe applies more pressure on the bunion and there is more weight on the ball of your foot when wearing heels so the bunion may become painful sooner because of the shoe.  Still it was not the shoe that caused, but rather it was the shoe that brought it to your attention.

At Desert Foot Surgeons a detailed exam of your bunion is performed to find the cause of your unstable foot.  Remember what I say, “It is easier to change your shoes than to change your foot”.  Still many times surgery is needed to correct the bunion.  Does this mean you can go back to heels with pointy toes?  The answer is maybe.  I can’t be more specific because everyone’s feet are different and your ability to heal differs from everyone else as well.  Desert Foot Surgeons has introduced “personalized foot care”, meaning we discuss your wants and desires related to what medical science says is the best treatment option and together we arrive at a plan to get you the best result possible.

Stop blaming your shoes for your bunion, it’s not their fault.  Actually the shoe has brought the problem to your attention sooner than a tennis shoe would have so you can get treatment earlier, which is always better.  See, shoes really are a girls best friend…or is that diamonds?  I’m a podiatrist, I get that mixed up sometimes.

This was a goal I had set intending it to take 8 weeks to achieve, but completed it in only 6.

What’s special about this?   I did it without injuring myself!

There was a day when I would get up early and hit the road running 26 or more miles a week.  I suffered through heel pain, stress fractures, back and hip pain, but kept on going making the same mistakes day in and day out.  When I became a podiatrist and started treating athletes at Geller Podiatry I started to see a lot of the mistakes I had made.

It may be due to the fact that I am a runner, but I like to think it is my attention to detail that allows me to work well with athletes.  At Geller Podiatry I examine your back down to your feet, sitting, standing, and walking.  I find a lot of patients complaining of foot problems when the real cause of their pain is coming from an alignment problem in the hip or knee, tight muscles around their low back, or that ever annoying iliotibial band (IT band).  You can’t get better if the problem is not identified and watching patients walk is when I find most of the problems others have missed.

I can’t fix problems above your ankle, but I have a team who I work with.  I will get you to a trusted orthopedic surgeon, chiropractor, physical therapist, or massage therapist to make your problem go away.  As more and more people take to running I am getting more involved in their training.  I can draw upon my personal experience as well as my medical knowledge to help you reach your goals.

Good luck in the upcoming race season and let me help you train.  At Geller Podiatry we offer video gait analysis, shoe analysis, custom foot orthoses, bracing, and even surgery if it is needed.

With great care your surgeon has explained the details of the surgical procedures, discussed with you the things that could go wrong since this is not a perfect world, and developed a game plan for recovering from surgery to achieve the best possible outcome.  At least at Geller Podiatry, this is how it is done.

A great deal of information gets exchanged, but ultimately the days or weeks leading up to your surgery are busy planning for the big day.  You need to schedule time off from work, someone to help with household chores, care for the kids and their needs.  I’ve already written about planning before surgery, but there are little things that can make a huge difference.

What is the biggest obstacle to healing your hammertoe surgery?  After thousands of hammertoes treated at Geller Podiatry the one thing that differs between easy and difficult recovery from surgery is swelling.  Remember what I always say, “You can’t start to heal until inflammation is gone”.  Well one of the key signs of inflammation is swelling.

Toes are small.  There isn’t much room for them to swell.  Increased pressure on nerves causes more pain.  Increased pressure on your circulation to the toe makes healing take longer.   Patients who control swelling from day 1 always have a faster recovery.

The key to controlling swelling:  “RICE”

Rest, Ice, Compression, Elevation

Rest:

The way I discuss surgery with my patients always involves this statement: “No matter how minor you think this surgery is going to be, you need to treat it like it is major surgery”.  If you think you are going to pick up where you left off one or two days after surgery, think again!  Your daily routine will have to wait for your recovery, that’s why we plan before your operation.  First of all rest involves lying down, not just sitting.  you will be prescribed a boot to wear on your foot.  This boot is also part of rest.  The area of surgery will be protected or rested while wearing the boot.  Do not remove the boot until you are told that this is OK.

Ice:

In all of my years of experience I would have to say that ice is possibly the most under-rated anti-inflammatory in the world.  There are some simple rules you need to follow when using ice: 1.  do not put ice directly on your skin; 2. ice is applied for 20 minutes and then left completely off for 40 minutes.  Ice is usually applied to the ankle or behind your knee.  My patients tell me that behind the knee is the easiest and if it’s easy you are more likely to do it.  Put a washcloth over the ice pack and then rest your knee on the ice.  If you leave the ice on for more than 20 minutes or without protecting your skin you could develop a cold injury or frostbite.

Compression:

Keeping snug bandages on your foot help to prevent swelling.  There is a difference between snug and tight.  The appropriate amount of compression is still comfortable.  If your compression is applied too tight you will notice things like the toe changing color, usually blue, but white can also occur.  Numbness and tingling can occur when the bandages are too tight.  If these are noticed call your surgeon and loosen the bandage.  The layer of bandage that supplies the compression is always the outer most layer.  If you need to loosen compression only touch this outermost layer, nothing beneath it without your doctor’s permission.

Elevation:

This is the easiest part, but the one most people fail to do.  Elevation of a foot means getting your foot above your heart.  Remember that the heart is in your chest, so you have to lie down and get your foot up on pillows or the arm of a couch.  A helpful hint is to keep your knee bent slightly for comfort.

A Geller Podiatry, our team spends a tremendous amount of time with you planning for your surgery.  These simple steps are what we see as making the biggest difference between what patients consider an easy recovery vs. a difficult recovery.  Rest, ice, compression, and elevation (RICE) is an old standard because it works.  Don’t underestimate the power of RICE.  I hope you have a wonderful surgical experience when you decide to have your hammertoe surgically corrected.

A recent vacation found me running barefoot on the beach.  After a crisp-paced warm up mile on the packed sand splashing as the waves rolled in, my feet began to ache.  Knowing what I know, I quickly altered my running style, which helped until the way back.  By the time I turned and headed back people were enjoying the surf so I was forced onto the soft sand.  Another mile and my legs and feet were cooked.  I reached a level of fatigue I rarely achieve at home.

What is it about running barefoot?

In the media, people seem to be all for it or completely opposed.  There doesn’t seem to be any middle ground.  At Desert Foot Surgeons, it is my job to educate you so that you can make the choice that best fits your needs.  Maybe you want to run barefoot and maybe not.  Let’s talk about it and see what you decide.

First of all, what are the benefits of running barefoot?  I will warn you that this is all theory!  No scientific evidence exists to date supporting these theories.  Running barefoot is said to increase the muscle strength of small (intrinsic) muscles in your foot.  By doing so it is thought that your foot will become more stable with the added strength thus help prevent injury and possibly even deformities such as bunions, hammertoes, and plantar fasciitis.  A study has shown that collegiate female track athletes who trained barefoot suffered fewer injuries.  Similar high level athletes have shown the same results such as volleyball players.

Here’s the catch with running barefoot…

There is a level of genetics involved in becoming a collegiate level athlete.  Of course there are your 5’6” guys who can dunk a basketball and a 5’9” football player who runs a 4 second 40, but for the rest of us we are not fortunate enough to have the same gifts as these people.  I’m not saying hard work and excellent coaching can’t make someone a collegiate athlete, I’m trying to keep the topic real.  A collegiate level track athlete has been coached for years and puts in significant miles with this coach.  These athletes know how to alter there stride length, change posture, modify their arm swing, go from heel strike to toe strike for different reasons.  Even in the famous book, “Born to Run” by Christopher McDougal, he was coached before he could accumulate any distance running barefoot.  So that leaves one question:  do you have a coach?

I’m not going to tell you that running barefoot is good or bad for you, that’s not my job.  My job at Desert Foot Surgeons is to examine your feet sitting, standing, walking, and even running.  With that information I can help you achieve your goals, but it might take some work.  If you want to run barefoot we are going to have to work on some things. Stretching programs, strengthening, balance and running in shoes with or without orthoses might be the first few steps before you ever step out there barefoot.  You might need help from a coach or trainer.  I can get you to the right people.  I don’t want you to be injured and the number of stress fractures in my practice has tripled this past year solely due to barefoot running.  To review injuries while training review my previous blog about marathon training.

This is the first thing a lot of patients say to me.  Pain in the toes or ball of the foot is very common, but making the right diagnosis is harder than you might think.  This part of the foot has only one muscle running from outside (little toe side) to inside (big toe side), but there are 7 tendons surrounding each joint, bones, joint capsule, ligaments, nerves, and fat.  Every step you take transfers weight across the ball of your foot as you move forward.  The 3 bones on the inside of your foot move as a unit and the two on the outside are another unit.  Each bone also has motion of it’s own besides the motion of the toe on the metatarsal bone.

Enough of the anatomy lesson, let’s get to the point.  A neuroma is a pinched nerve.  Plain and simple, there is nothing more to it.  The nerve lies in the space between your metatarsals (those are the bones in the ball of your foot) and divides to send a smaller nerve into each side of the two toes in front of it. The nerve gets pinched against a ligament running sideways from one metatarsal to the other.  Easiest way to think of it, the nerve is constantly irritated by pinching against this ligament.  That causes inflammation and then scar.  The longer this keeps happening the scar gets bigger and bigger until there is a lump.  Sometimes you can feel this lump “click” as it rubs against the  ligament,  ouch!!  If your toes are bent upward the nerve is more likely to rub against the ligament so pain is usually worse in heels, going down stairs (you land straight onto the ball of your foot), or hiking up hill.  Why does the nerve get pinched?  There are two reasons.  First, if you have toes that are buckled, bent, sitting on the top of your foot, the nerve is always pressed up against the ligament.  Second, there is abnormal motion between your metatarsal heads (that means an unstable foot).

Treatment for neuroma is: 1.  Relieve inflammation, 2.  Stabilize your foot so the pinching stops, 3.  If all else fails surgery.

1. Every article on this website talks about relieving inflammation.  Do you remember why?  That’s right, because, at Desert Foot Surgeons, I always say, you can’t heal until the inflammation is gone.  Ibuprofen, Naproxen, Celebrex and other pills can be prescribed to fight the inflammation.  Steroid injections can be given if the lump is really big or your pain is just that bad.  The steroid can shrink the scar a little bit. Note:  Sclerosing injections are different from steroid injections.  These use a chemical to destroy the nerve leaving you numb in that area.  Before considering a sclerosing injection seek a second opinion to make sure the diagnosis is correct.
2. The underlying problem causing the pinched nerve is your unstable foot.  Arch supports are a good place to start, but if your foot is hard to control expect me to suggest custom molded foot orthotics.
3. Surgery for neuroma is something that I find controversial.  I have surgically removed very few neuromas throughout my career, while colleagues of mine seem to remove a few each week.  Why do so many doctors surgically remove neuromas?  In my opinion it’s because the orthotics are not made correctly or the diagnosis is wrong.  Remember I’m the doctor seeing the patients who have failed treatment by other physicians, or were deemed too difficult or too sick to treat.  Be cautious when considering surgery for a neuroma.  With that said, surgery consists of either removing the nerve that is damaged by scar or cutting the ligament that the nerve rubs against.  If you’re the type of person who has toes that are buckled, than the treatment is to straighten the toes and not touch the nerve.

So there you have it.  Morton’s neuroma is a pinched nerve in the ball of your foot as the result of you having an unstable foot.  If you relieve inflammation and stabilize your foot using orthotics the pain goes away.  At Desert Foot Surgeons, I have not needed to surgically remove neuromas.  Before you have surgery I would suggest you get another opinion.  The diagnosis might not be correct.  Think about all of the things in that area of your foot.  I will discuss other problems in the ball of the foot in later articles.

I’m not saying off the shelf inserts do not have their place.  I prescribe off the shelf arch supports for many of my patients.  These are not made to anyone’s foot in particular, and the materials used in construction are less expensive.  For these reasons off the shelf inserts might not work for you.  For one thing they don’t last very long because the materials are weaker and lose their shape sooner.  It is not made to your foot so might not work for your problem depending what that is.  Do some people get better using off the shelf arch supports?  That depends on what’s wrong.  At Desert Foot Surgeons, I exam your feet sitting, standing and walking.  If your foot is easy to control, than an off the shelf insert might help.

Custom orthotics are an art form.  First, I take a mold of your foot using plaster.  It is very important to hold your foot “just right” to capture the true shape of your foot.  The mold is then sent to a laboratory where it is scanned into a computer.  The lab now has a model of your foot.  The technician has to be an artist as well, which is why I only use one lab to make my patient’s orthotics.

Unfortunately art alone won’t make your foot stable.  The science is called biomechanics and takes many years to learn.  The clerk at a shoe store does not have training in biomechanics.  Remember at Desert Foot Surgeons, I examine you walking, standing, and sitting.  I take what I learned during your exam and write a prescription so the orthotic will control your foot.  Based on my prescription, adjustments in the computer image of your foot are made and the orthotic constructed to make your foot stable.

Not everyone treats you like I do at Desert Foot Surgeons.  For one thing, some molds are taken from pushing your foot into a box, onto an image scanner, or standing on a platform.  The problem with these methods is that any pressure on the sole of your foot causes the muscles to spread out and the foot to change shape.  Hence, the orthotic will not match your foot.  A tracing, thermal print, or pressure map of your foot cannot be used to make a custom orthotic because there is no model of your foot.  Standing won’t help, because I am trying to control the way you stand not accept any deformities or imbalances in your foot.

Don’t be fooled:

Have you seen any infomercials where they are selling arch supports?  They always show you how much more stable the person is in the arch support by pushing their arms down.  Here’s the trick.  You can try it at home:

Unfortunately this is not because your friend is now stable standing on the piece of paper.  This is a physiologic principle called “muscle memory”.  The first time you push your friends arms down, their muscles don’t know what to expect.  The second time the muscles remember what is going to happen and respond more appropriately making it harder to move the arms down.  Notice in the infomercials how they never test their product first, because there is no muscle memory.

I love when art and science come together to make something beautiful.  Custom foot orthotics might not look beautiful to you, but being able to create a piece of plastic that can stabilize your foot and relieve pain is pretty beautiful to me.  Let me show you how I combine art and science to fix your feet at Desert Foot Surgeons.