Tiger Woods and You...

You or someone you know may have something in common with Tiger: plantar fasciitis. Tiger dropped out of the Masters golf tournament last weekend due to severe heel pain caused by plantar fasciitis. This all-too-common orthopedic condition afflicts a huge number of middle-aged Americans every year. The most common symptoms are heel pain when first getting out of bed, when barefoot or with prolonged walking, running or sports. Here are some key “Dos” and “Don’ts” when it comes to plantar fasciitis:

What To Do When You Have Plantar Fasciitis:

1) Seek medical attention early: We have many tools in the toolbox to treat this condition, but we first need to need to confirm the diagnosis, set-up a multi-faceted treatment plan, and guide you on your prognosis. Ultrasound, which can be done in our office, is by far the best imaging study to see the plantar fascia. This factors into our concept of PIO- Proactive Interventional Orthopedics.

2) Wear good footwear at ALL times: when in the house, in the yard, at the gym, at the pool, while shopping, going to that concert, socializing with friends and at church. Good footwear means very supportive, not too flexible, and not too cheap. Cheap unfortunately often means lower quality.

3) Consider inserts/orthotics for your shoes: over-the-counter can get the job done, but you’ll need some advice on how to choose these. A high-quality athletic shoe store or a visit to your sports medicine doctor can supply that information. However, custom orthotics prescribed by your physician may really be what you need. We are fortunate to have custom orthotic specialists that work directly with our practice.

4) Consider physical therapy as it’s beneficial for most patients: many cases of PF are related to biomechanical problems, meaning that your calves are too tight, your foot pronates or supinates, your foot muscles are weak or you are overweight. Physical therapy along with weight loss in some individuals can help correct these biomechanical problems.

5) Realize that 10-20% of cases of PF will need an advanced treatment: in our practice, our first-line innovative and advanced treatment for stubborn PF is a platelet-rich plasma injection. PRP uses your own blood and the concentrated growth factors we have produced to reduce inflammation and pain while stimulating a healing response. If this fails, then we move on to a minimally-invasive surgery called a percutaneous fasciotomy using the Tenex system.

What Not To Do When You Have Plantar Fasciitis:

1) Stretch the bottom of the foot: many cases of PF involve tears in the plantar fascia. Although stretching the calf can help, stretching the bottom of the foot often irritates the fascia and can inhibit the healing process.

2) Buy expensive orthotics that are rigid or produced by an “orthotics store”: in our experience, these tend to be very uncomfortable for patients and unsuccessful in treating patients’ symptoms. Stick with an orthotics specialist recommended by an orthopedic/sports medicine physician.

3) Have multiple steroid/cortisone injections: although offered by some orthopedic doctors and podiatrists, we rarely offer these injections for PF and essentially never do more than one. Steoid injections can contribute to further tearing and often impede healing. Some patients feel better in the short term with steroid injections, but are worse in the long term.

4) Run/Walk through the pain: unfortunately, PF will just not get better if you keep doing the things that are causing the problem. So, a period of complete rest or relative rest will be necessary for PF to improve. Relative rest can mean dialing down your walking/running frequency or distance to the point that you stay below your pain threshold.

5) Become impatient: recovery from PF is often in the range of months, not days or weeks. So, once a treatment plan is in place, you’ll have to be patient. We often construct a Plan A, Plan B and Plan C. Each plan has 2-4 treatment entities within it and we insitute these for 1-2 months, judge their success and then move on to the next plan if we are not seeing the expected results.

In summary, plantar fasciitis is a condition that requires methodical treatment under the care of an experienced physician. Don’t just trust the advice from your non-medical friend, Dr. Google or YouTube. We are always here to help!

F. Clarke Holmes, M.D.

Will My Heel Pain Ever Go Away? I Need Help!

In middle-age individuals, 90% of the time, heel pain is caused by plantar fasciitis. The plantar fascia is a soft-tissue band, technically a ligament, that supports the hindfoot and midfoot. It is quite prone to inflammation, degeneration and tearing. It is a stubborn problem to both endure and to treat, and commonly becomes a condition that last months to occasionally years. However, do not fear, we have solutions for you!

How Does it Present?

·       Heel pain, often sharp, with the first few steps out of bed and after a long day on your feet

·       Pain when rising from a seated position after prolonged sitting, such as in a car

·       In endurance athletes, pain during and after exercise

·       Tenderness on the bottom of the foot, specifically at the heel where the plantar fascia originates

Why Did I Get This?

·       Age- middle-agers are prone to this, as they are very active, but their rate of tissue breakdown exceeds their body’s repair rate. This is why younger individuals do not typically get this problem. They have a faster healing rate.

·       Poor footwear- shoes that are flimsy, too old or generally unsupportive contribute

·       Weight- gaining weight or being overweight overloads the tissue at the lowest point of our body

·       Too much activity/overuse- runners, walkers, and athletes repetitively load the plantar fascia, and at times, are in a situation of overuse or too much, too soon

·       Poor biomechanics- tight or weak calf muscles, a high arch or flat foot or a foot that excessively pronates or supinates can all contribute

How Do I Treat It?

Patience is the key. Let’s repeat that….patience is the key. This condition often requires months of treatment. Recovery can be slow. The underlying risk factors listed above must be corrected. What works for one patient may not be the best treatment for another. Care must be individualized.

·       Rest- yes, this is a dirty, four-letter word for many patients. Plantar fasciitis will NOT improve as long as one continues to run, walk or exercise to the same degree. Sometimes, activity modification will work- fewer miles, less frequent high-impact exercise and/or trying something lower impact such as biking or swimming

·       Improve the footwear and minimize going barefoot- remember with shoes, you often get what you pay for. Don’t go cheap!

·       Physical Therapy- helps most patients, can be curative for those with mild cases. Will not get the job done by itself for moderate to severe cases.

·       Orthotics/Inserts- over-the-counter or custom. OTC ones are less expensive and worth a try for mild cases. Custom are more expensive but are more successful for most patients. Orthotics alone usually will not cure plantar fasciitis. Other treatments must be combined.

·       Anti-inflammatory medications- helpful in mild cases caught early. Not helpful in more severe cases or in patients that have had the problem for months or longer.

·       Cortisone injections- occasionally helpful, more often harmful. We rarely utilize these, as they don’t promote healing, only reduce inflammation and can increase the risk of further tearing of the fascia. NEVER get a series of 3 cortisone injections as recommended by some.

·       Orthobiologic injections- very helpful for most. These are meant to “heal the heel!” Platelet-rich plasma injections introduce numerous growth factors to the area to improve the tissue environment and thus, are typically successful in promoting healing of the fascia while reducing pain and improving function. These are game-changing injections and ones we have provided under ultrasound-guidance successfully now for many years.

·       Surgery- we favor a minimally-invasive procedure called the Tenex procedure. Tiny incision, local anesthesia only, no stitches required with minimal healthy tissue disruption. The “old-school” surgeries require larger incisions and involve “releasing”/cutting the fascia off the bone, are less successful, higher risk and have been abandoned by many orthopedic surgeons.

What to Avoid:

1)      Stretching the bottom of the foot. An example is when you pull the toes back towards you. Most cases of PF involve inflammation and/or tearing of the fascia. Stretching damaged or inflamed tissue is often counterproductive

2)      Pushing through the pain with exercise. If you have PF, you have to relatively rest, which may mean temporarily discontinuing running, walking, jumping, etc. or at least, reducing your distance or frequency of these activities.

3)      Skimping on shoes and/or orthotics. The old adage, “you get what you pay for…” applies here. Think of purchasing high-quality athletic and everyday shoes as well as orthotics (inserts) as an investment in your health and quality of life. At times, the more expensive orthotics are worth the extra cost.

In conclusion, heel pain affects a high percentage of middle-age individuals and can range from a nuisance problem to a disabling one. The key here is to seek care early and from someone who can customize a well-constructed treatment plan for you that has a variety of quality interventions. We are here to help!

Five Mistakes to Avoid with Plantar Fasciitis

Plantar Fasciitis is the most common cause of heel pain, most commonly seen in middle-age individuals. There are numerous treatment options, yet with our decades of experience in treating this problem, we’ve found many pitfalls, and thus, here’s a list of what NOT TO DO!

1)      Stretching the bottom of the foot. An example is when you pull the toes back towards you. Most cases of PF involve inflammation and/or tearing of the fascia. Stretching damaged or inflamed tissue is often counterproductive

2)      Pushing through the pain with exercise. If you have PF, you have to relatively rest, which may mean temporarily discontinuing running, walking, jumping, etc. or at least, reducing your distance or frequency of these activities.

3)      Skimping on shoes and/or orthotics. The old adage, “you get what you pay for…” applies here. Think of purchasing high-quality athletic and everyday shoes as well as orthotics (inserts) as an investment in your health and quality of life. At times, the more expensive orthotics are worth the extra cost.

4)      Having multiple cortisone/steroid injections. It’s probably best to avoid steroid injections altogether for PF, yet a one-time steroid injection can occasionally be indicated for the patient that is miserable due to severe heel pain. Repetitive steroid injections often result in long-term worsening of this condition.

5)       Not being patient. PF resolves in 95% of individuals with the proper customized treatment, yet it often is a 6 to 12-month process. Don’t give up on certain treatments too soon, as most interventions work gradually over weeks to months, including footwear changes, night splints, relative rest, physical therapy, orthotics and orthobiologic/regenerative injections.

If you are struggling with plantar fasciitis, then we are here to help!

Clarke Holmes, M.D.

My Heel is Killing Me! What is This and How Do I Get Rid of It?

In middle-age individuals, 90% of the time, heel pain is caused by plantar fasciitis. The plantar fascia is a soft-tissue band, technically a ligament, that supports the hindfoot and midfoot. It is quite prone to inflammation, degeneration and tearing. Let’s quickly dive into this common cause of heel pain.

How Does it Present?

·       Heel pain, often sharp, with the first few steps out of bed and after a long day on your feet

·       Pain when rising from a seated position after prolonged sitting, such as in a car

·       In endurance athletes, pain during and after exercise

·       Tenderness on the bottom of the foot, specifically at the heel where the plantar fascia originates

Why Did I Get This?

·       Age- middle-agers are prone to this, as they are very active, but their rate of tissue breakdown exceeds their body’s repair rate. This is why younger individuals do not typically get this problem. They have a faster healing rate.

·       Poor footwear- shoes that are flimsy, too old or generally unsupportive contribute

·       Weight- gaining weight or being overweight overloads the tissue at the lowest point of our body

·       Too much activity/overuse- runners, walkers, and athletes repetitively load the plantar fascia, and at times, are in a situation of overuse or too much, too soon

·       Poor biomechanics- tight or weak calf muscles, a high arch or flat foot or a foot that excessively pronates or supinates can all contribute

How Do I Treat It?

Patience is the key. This condition may require a month or a year of treatment. Recovery can be slow. The underlying risk factors listed above must be corrected. What works for one patient may not be the best treatment for another. Care must be individualized.

·       Rest- yes, this is a dirty, four-letter word for many patients. Plantar fasciitis will NOT improve as long as one continues to run, walk or exercise to the same degree. Sometimes, activity modification will work- fewer miles, less frequent high-impact exercise and/or trying something lower impact such as biking or swimming

·       Improve the footwear and minimize going barefoot- remember with shoes, you often get what you pay for. Don’t go cheap!

·       Physical Therapy- helps most patients, can be curative for those with mild cases. Will not get the job done by itself for moderate to severe cases

·       Orthotics/Inserts- over-the-counter or custom. OTC ones are less expensive and worth a try for mild cases. Custom are more expensive but more beneficial for most patients. Orthotics alone will not cure plantar fasciitis. Other treatments must be combined

·       Anti-inflammatory medications- helpful in mild cases caught early. Not helpful in more severe cases or in patients that have had the problem for months or longer

·       Cortisone injections- occasionally helpful, occasionally harmful. We rarely utilize these, as they don’t promote healing, only reduce inflammation and can increase the risk of further tearing of the fascia. NEVER get a series of 3 cortisone injections as recommended by some.

·       Orthobiologic injections- very helpful for most. These are meant to “heal the heel!” Platelet-rich plasma injections introduce numerous growth factors to the area to promote tissue regeneration. These are game-changing injections and ones we have provided under ultrasound-guidance successfully now for many years.

·       Surgery- we favor a minimally-invasive procedure called the Tenex procedure. Tiny incision, local anesthesia only, no stitches required with minimal healthy tissue disruption. The “old-school” surgeries require larger incisions and involve “releasing”/cutting the fascia off the bone, are less successful, higher risk and have been abandoned by most orthopedic surgeons

In conclusion, heel pain affects a high percentage of middle-age Americans and can range from a nuisance problem to a disabling one. The key here is to seek care early and from someone who can customize a well-constructed treatment plan for you that has a variety of quality interventions. We are here to help!