Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

Making sense out of treating PF

Posted by Glenn X on 7/24/01 at hrmin (054117)

Borrowing from some leadership principles, I've taken a run at trying to better 'manage' my PF condition . . . to get it under firmer control and ultimately behind me. Shaping an overall strategy kept jumping out at me as a need, so I took a crack at one. What follows is this work in progress; my strategy for curing my chronic, 40 month, right-foot case of PF. I share it as a framework that might possibly be useful for others; not as a suggested course of treatment.

GOAL (1 to 3 years out, where I see myself):
Walk sufficiently to accomplish basic day-to-day work, social, and other life needs.
(I'll revisit and maybe expand this some day. But for now, this serves).

MISSION (What drives my day to day efforts re PF):
Discover the surest regimen of treatments to healing

BELIEFS (Enduring thoughts or treatments that I know work):
Retain personal responsibility for my recovery
Get educated in PF (heelspurs is far and away my best source for this. I log on daily.)
Rest my fascia -- To the extreme (I've not been obsessed enough about this)
Temper my expectations . . . it lessens my disappointments
Maintain a daily journal to track changes and progress or setbacks
Maintain a running one-page history of my condition, like 'Scott's History'
Remember that messages from my feet take 50 hours to reach my brain

TREATMENTS DOs and DON'Ts: (Treatments are transitory. They may elevate to a belief, they may sink to a 'never again,' or they may drop off my radar screen entirely. This is where most of my energy is focused, not so much in doing them but in learning about, testing, and modifying them [i.e. 'doctoring']. Treatments for me are also behavioral, meaning I can see and track me doing them):

DOs (in order of perceived value):
1. Wear shoes with firm arch support (Orthotics) always . . . Never barefoot
2. Stay on crutches until I can comfortably put weight on foot
3. Apply tape daily -- 2-Strip Method
4. Wear splint nightly
5. Maintain flexibility -- lower legs, entire body (Julie foot exercises 3 times daily)
6. Exercise all the muscles in my body I comfortably can (Gym 3 times a week)
7. Cool feet when they complain (icing)
8. Massage fascia, particularly in the morning
9. Limit carbs after lunch (Seems to temper swelling)
10. Crunch toes in the evening (towel grabbing)
11. Use thin socks

DON'Ts:
No weight-bearing stretches
No hard orthotics
No cortisone shots
No ultrasound
No pain meds or anti-inflammatories. They don't help me.
No to any activity I'll POSSIBLY regret later

QUESTIONS (I still don't know enough about):
Swelling, icing, flexibility, strengthening foot muscles, proper shoes, proper orthotics, safe flexibility routines, Yoga, ultrasound, medications, anti-inflammatories, tennis-ball rolls, edema, measuring flexibility, collagen, nutritional supplements . . .

BIGGEST WISH: Find a capable, dedicated health-care professional I can partner with

NEW IDEAS TO EXPLORE:
ACFAS flow chart for PF (apparently being presented in Chicago)
Stretch Hamstrings to get entire leg limber
Theraband stretching
Heel lifts
Birkenstocks
Leuko tape
Johnson's Foot Soap
Jade Balm
Acu-Flex
Thorlos
Vitamin C
ESWT
more . . .

How do I use this document?
Treating chronic PF is a fair amount of work; and generally, planning one's work, and working one's plan is a more likely path to accomplishment.
My own plan pours a lot of thoughts into one bucket, keeping me focused, helping me appreciate and track progress, bolstering my commitment, encouraging me . . . It also seems useful to review and edit with a health-care professional (though I haven't done this as yet).
This is also a dynamic document. A month ago it was different (3 current DOs and several curiosities weren't there); and a month from now it will be different again.

What does it need?
This is pretty left-brained. Doesn't feel very creative. Isn't allowing much for unconventional directions.

As always, input is welcomed.

Re: Making sense out of treating PF

ellen w on 7/24/01 at 10:31 (054119)

Great plan, Glenn. I do theraband exercises and hamstring stretches in bed in the morning, after doing Julie's exercises. Have been thinking of getting a large heating pad to warm up the back of legs before I do the hamstring stretches (based on one of the posts last week about heat aiding the stretch.) Is the Acu-Flex site still up and running? Haven't seen anything about them recently; thought the guy who made them was on an extended visit to Thailand. If at some point you feel like giving another NSAID a try, check out Mobic (it's an osteoarthritis drug that works similarly to Celebrex and Vioxx) --I've been finding it helpful. Though my 3-week prescription has run out as of today, and will spend the next 2 weeks evaluating whether I need to go back on it.
Good luck,
Ellen

Re: Making sense out of treating PF

Julie on 7/24/01 at 10:34 (054120)

It sounds extremely creative to me, Glenn. Well, I did say you are an inspiration to others, didn't I? You're committed to learning as much as you possibly can about all this - and I know you'll share your learnings with all of us. Wonderful. Really.

Re: Making sense out of treating PF

Ed Davis, DPM on 7/24/01 at hrmin (054137)

Glenn:
Sounds like a great plan--it is individualized. There are a few areas where I believe the plan would not be applicable to others.

Ultrasound is a very successful modality for plantar fasciitis. It is a high frequency sound wave as opposed to the low frequency wave used in ECSWT. The actual effect on the plantar fascia may not be all that different. Perhaps you had a bad experience with ultrasound--please let me know. There are effective and not so effective ways of applying this this modality.

Most people do better with non-weight bearing stretches because they stretch with too much force when performing the exercises in a weight bearing fashion. A long slow gentle stretch works better than a short, hard stretch. It is possible to do stretching in a weight bearing fashion with the proper technique--I spend time with patients demonstrating technique.

Most of the studies done on orthotics demonstrate that 'rigid' orthotics are the gold standard for heel pain. Keep in mind that the word 'rigid' is
somewhat arbitrary in terms of the degree of hardness or flex in a device.
Most orthotics we make are 'semi-rigid.' A couple caveats... 1)A foot which is acutely inflamed may not tolerate a 'rigid' orthotic; the inflammatory process must be eased or resolved first. 2)The firmer the orthotic, the more PRECISE the prescription must be; softer devices are more forgiving. I wish I could say that all practitioners are providing devices made with a high degree of precision. I wish we had a device, like the one optometrists use to read the prescription off eyeglasses, that enables us to determine more precisely what is wrong with an orthotic device. There are some bad ones out there, unfortunately.
Ed

Re: Making sense out of treating PF

john h on 7/24/01 at 16:47 (054152)

glenn buddy you have to come from the corporate world or military world with 'mission statements' and 'goals' etc. i wish you were my neighbor as i think we could provide enough moral and informational support to get through this together. for now, however, i guess the information highway will have to do.

Re: Making sense out of treating PF

john h on 7/24/01 at 16:54 (054153)

dr davis: you are the authority but from a guy who was pushed into rigid orthotics on my first visit to the doctor ($400) i tend to respectfully disagree on 'hard orthotics'. i 'WAS' a runner if you can describe a guy my age as a runner. My gut instincts tell me the hard orthotics 'help' send me down the PF highway to hell. they may work wonders for some but for me they were not the gold standard but a factor in my long road to PF hell. i hope i do not offend you because we need all the professional input we can get on this board. just MHO from a guy from arkansas who brought you bill and hillary.

Re: Making sense out of treating PF

Nancy N on 7/24/01 at 16:59 (054155)

John--

I agree with you that there are probably exceptions to the rule--not sure if we are the exceptions or the rule, but I have to agree with you--my rigid orthotics did nothing except make me feel worse. They're now kept in a Ziploc bag for evidence that I tried them, but otherwise are useless unless I have some frost on my windshield in the morning.

Re: Dr. Davis

D.Thomas on 7/24/01 at 17:04 (054158)

Dr. Davis,

I use to have a full length orthotic that was 'semi-rigid' that worked pretty well until two years later my PF came back full force from increased activity. The pain is in the arches (Medial side) of both feet. I do have extremely high arches. Another doctor prescribed 'rigid' ¾ orthotics and I have had them for 6 weeks and I still have not gotten use to them.

I like your comment, 'A foot which is acutely inflamed may not tolerate a 'rigid' orthotic; the inflammatory process must be eased or resolved first'. I swear it feels ok sometimes and the next it feels terrible. I would say when it feels terrible is when I do feel inflammation and sore.

Any suggestions?

Re: Hey neighbor!

Glenn X on 7/24/01 at hrmin (054181)

John: Right on both counts, though Air Force time was long ago. Didn't think it was so transparent. I'm in Oregon. Think I saw you and Arkansas mentioned in the same message once. Years ago, I spent a month in Hot Springs one weekend. (Just kidding. Liked it a lot). I'll catch up with you on the soshe board and visit more.

Re: Second thought on hard orthotics

Glenn X on 7/24/01 at hrmin (054182)

I read the above and went right back to my hard orthotics, which suggests how rapidly a strategy can change.
I'd been using my more-giving orthotics for a month, but my feet haven't been adjusting well, particularly my good foot. What Dr. Davis said helped me take a more objective look at my progress. I don't think the rigids are a perfect fit (ball of foot sort of hangs off end), but I wore them so long (20 months) my foot broke into them. Also, the rigids have a shallower, smoother heel platform my foot likes better. My others have more of a cup for the heel and are lined with a cushiony material that squeezes my heel and aggravates.
Dr. Davis's remarks also make me rethink ultrasound. I was ultrasounded in my spot (the most identified pain spot in Scott's survey), 5-7 minutes in a PT's clinic. Three times a week for six weeks. They were also massaging me, stretching me, wobble-boarding me, and resisting foot moves for strengthening. Ended up being too much. I stopped the ultra-sound and then the other treatments. Maybe should have hung in their with the US. Always seem to be more variables than are manageable.
Thanks doc.

Re: TO: ED DAVIS DPM ~~~~ Re: ULTRASOUND

Necee on 7/24/01 at 22:23 (054186)

In your opinion, what is the proper way to apply Ultrasound? I have a heelspur and currently I'm taking this treatment. Your comments would be greatly appreciated.
Thanks,
Necee

Re: Making sense out of treating PF

Julie on 7/25/01 at 03:51 (054244)

Ellen, I think Alan closed down the site when he went off to Thailand. He must still be there, as the site is still non-operational and we haven't heard from him.

Your hamstring (and all other) muscles are probably warm enough to stretch from having been cozy inbed all night, but it certainly wouldn't hurt to try a heating pad. If you try it, please tell us what effect you experience.

Re: Hey neighbor!

john h on 7/25/01 at 08:52 (054257)

i spent 21 years in the air force a long time ago also glenn and later some time with GE in the corporate world. your post sounds like they were created at SAC Headqurters (no offense). What was your job in the Air Force? i suspect it was writting 'mission statements'!

Re: Making sense out of treating PF

ellen w on 7/25/01 at 09:27 (054260)

Hi Julie,
Thanks. If Dondi or Glenn don't want your Acu-Flex, I'd be happy to buy them from you.
ellen

Re: Acu-flex

Julie on 7/25/01 at 09:41 (054264)

Hi Ellen

Glenn hasn't mentioned being interested in Acu-Flex, has he? I'll wait a day or so for Dondi to reply to my e-mail, and if she doesn't want them, they're yours.

Do you mind putting your e-mail address on the thread so I can contact you?

Julie

Re: Acu-flex

ellen w on 7/25/01 at 11:41 (054276)

I thought Glenn had said part of his intended program was to use Acu-Flex, which is why I posted I thought the Acu-Flex site may not be operant. Anyway, my email is ewatson@netmail.hscbklyn.edu .
ellen

Re: Acu-flex

Glenn X on 7/25/01 at hrmin (054282)

Julie: I am curious about the Acu-Flex, though don't even know what they look like. I tried finding (Alan's) site with no response. Since learned he left the country. I went ahead and got the PFT. Just had 'em a few days and learning how best to use them. They clearly help me tone some foot and lower leg muscles that otherwise (being off my foot) have been very difficult to 'resist.' I understand the plantar fascia to be a muscle surrounded by fascia. Seems important to tone it (and other foot muscles) as part of recovery. Still looking for best way to do this muscle toning without injuring anything. Appreciate your thinking of me re the Acu-Flex you have. I'm covered by the PFTs for now but would like to hear from Dondi or Ellen, or whoever ends up with that device, how well it works for them.

Re: TO: ED DAVIS DPM ~~~~ Re: ULTRASOUND

Ed Davis, DPM on 7/25/01 at hrmin (054286)

Ultrasound probably causes some 'damage,' albiet in a beneficial way to tissues, helping to break down scar tissue and temporarily increase inflammation. The intensity (power) of the sound wave used and the amount of time applied is dependent on 1)the amount of pain and inflammation already present--it can really stir things up temporarily 2)the thickness of the plantar fascia. Initially, we generally start with less power and gradually increase it as acute inflammation subsides. We generally tape and ice the plantar fascia immediately after ultrasound in order to reduce strain on the fascia and reduce the inflammation. Eventually, as the pain and inflammation subsides we apply a fairly high dose of ultrasound in order to achieve the desired effect, often using a steroid cream as the coupling medium (the liquid that the sound waves must pass through to get to the tissues), a process often termed 'phonophoresis.'

It is not, in most cases, a 'stand alone' modality but must be coupled simultaneously with good biomechanical control and rest, that is, rest from the type of activities which strain the fascia but not cessation of all activities. There are four layers of musculature within the foot, which, for the most part, run parallel to the plantar fascia. The stronger those muscles become, the greater tension load they can take off the plantar fascia. Interferential stimulation, to an extent, but to a larger extent, Russian stimulation, can actually enlarge and strengthen those muscles. The term 'Russian stimulation' came about to describe a waveform used, years ago, by the Russians as a passive modality to strengthen muscles in their athletes. A study on plantar fascia in Russia showed a high cure rate for plantar fasciitis using only that waveform----I presume that adequate strengthening of the intrinsic musculature was achieved. This waveform, which causes a strong musculature contraction, can be used to 're-educate' weakened muscles in individuals with neuromuscular disease.
It is used sparingly as it can be painful, though.
Ed

Re: Dr. Davis

Ed Davis, DPM on 7/25/01 at hrmin (054287)

Sounds like you can only wear your orthotics intermittently but that is probably beeter than not wearing them at all. Perhaps you could obtain a soft prefabricated orthotic such as Superfeet ( http://www.superfeet.com ) that you could alternate with the rigid orthotics. Also, consider icing your foot at those times when acute inflammation occurs--if it occurs often or for long periods of time, consider a course of physical therapy.
Ed

Re: Second thought on hard orthotics

Ed Davis, DPM on 7/25/01 at hrmin (054289)

Sounds like you had a combination of PT modalities, some of which were well focused, but others not. There can be some logic behind some of the extraneous modalities but they can be counter-productive as in your experience.

Deep heel cups on an orthotic can provide better control and attempt to bring the fat pad under the heel bone directly beneath the point of contact in order to enhance shock absorbtion. Unfortunately, if the deep heel cup is not shaped properly, you will have a painful squeezing sensation. In all likelihood, there was insufficient plaster expansion placed around the margins of the heel on the positive cast used to form the orthotic, resulting in the up-slope of the heel cup placing excess pressure on the margins of your heel. Do you still have the postive casts your orthotics were made from?
ED

Re: TO: ED DAVIS DPM ~~~~ Re: ULTRASOUND

Mary AnnS on 7/25/01 at 18:09 (054296)

Dr. Davis, I am wondering if ultra sound would help me. I have no PF pain after using the Jade Balm but my foot doensn't feel normal. I wear orthotics and have a flat arch. My foot gets a swollen feling after being on my feet and my heel feels thick. while I am at work it seems to get worse and I ice and it feels some better, In the am it is ok . Thanks,

Re: Second thought on hard orthotics

Glenn X on 7/25/01 at hrmin (054303)

Deeper heel cup orthotics were made fall of '98. Wore 'em 10 months with increasing comfort, then really re-injured fascia on business trip. (Realize now lack of flexibility was big reason for this). In meantime HMO bellied up, saw a different DPM who prescribed the more rigid orthotics which I began wearing in Sept 99. I'm able to tolerate them, but my good foot is complaining more and more. Probably lurching about on crutches doesn't help.
I'll check to see if I can catch up with earlier positive casts. I wonder though if orthotics change the shape of one's foot after a time. I used to be characterized as having flat feet. Now am described with a 'high arch,' (though I've seen higher).

Re: Second thought on hard orthotics

Ed Davis, DPM on 7/25/01 at hrmin (054307)

Orthotics can cause change in the shape of peoples feet to a small extent in adults but to a significant extent in ages 3 to 7 y.o. (My practice is about 25% pediatric foot problems).

Uh-oh, HMO--dirty word. Please don't shed any tears for your HMO that went belly up; the CEO probably left with severance pay in the seven figure range. My big beef with HMO's is that they hand out care in small parcels. That often works okay for small problems but makes it very difficult to provide the necessary level of care to deal with chronic or more difficult problems.

Two things that need to be looked at for you: your orthotics may not be up to snuff and the flexibility issue. Lack of ankle dorsiflexion is the probable the culprit behind a lot of re-injuries and difficult cases. Everything can be done perfectly but a tight achilles and calf muscle (tight achilles gastrosoleus complex) can spoil the best treatment. It needs to be addressed. I have a local therapist who has also been an athletic trainor for 8 years and is a whiz at helping patients gain better ankle dorsiflexion. The other thing that works are night splints. I like the Nice and Stretch mentioned on this site. It is the most comfortable of all the devices I have checked. Patients using adjustable night splints need to start with very light tension on the straps and SLOWLY increase the tension. Long gentle stretching beats short hard stretching. I perform an achilles tendon lenghthening procedure along with about 50% of the plantar fascial releases I do. I do not do a lot of such procedures since most patients get better with conservative care, but when I finally have to do the surgery, my 'cure' rate is about 70%, with 20% better but not cured and about 10% not helped.

Re: TO: ED DAVIS DPM ~~~~ Re: ULTRASOUND

Ed Davis, DPM on 7/25/01 at 21:29 (054308)

MaryAnnS:
Ultrasound may be helpful for you but only as part of a complete treatment plan. Success in this area generally involves the combination of several things working in harmony (excuse the cliche).
Ed

Re: Acu-flex

Julie on 7/26/01 at 00:44 (054329)

Hi Ellen

Dondi has declined, and Glenn (whose intention to explore Acu-Flex I had somehow overlooked: sorry!) now has the PFT, so my Acu-Flex is yours if you want it. I'll e-mail you.

All the best, Julie

Re: Acu-flex

Julie on 7/26/01 at 01:10 (054331)

Hi Glenn

I'm sure you'll get benefit from the PFT. The principle it works on, of relaxing the sets of muscles that we normally overwork, so as to strengthen their weak antagonists, is a sound one. And I'm sure you'll use it consistently, as I did not. And I hope you'll tell us how you get on with them - treatment reports add to the store of knowledge, and help others.

I'm just not an 'equipment person'! As I've just told Ellen in an e-mail, I have over the years enthusiastically bought, briefly used, and shamefacedly sold, an exercise bike, a rowing machine, and a rebounder (mini-trampoline). So I really should have known myself better.

Re: Making sense out of treating PF

Ed Davis, DPM on 7/26/01 at hrmin (054367)

John:
There are appropriate and not appropriate uses for all modalities. Sounds like you had a bad experience but don't let that make up your mind about something that can benefit a lot of people. A poor prescription can harm more than help. I hope you have been able to resolve your problem since.
Ed

Re: Making sense out of treating PF

john h on 7/26/01 at 16:29 (054390)

dr davis: you are correct! perhaps a lot of people have been helped with hard orthotics and you are in a position to know. all of us post about things that we have experienced and of course each of us represent just our own thoughts and experience. we all throw our experieces out there for others to see and make their own judgement on. that is sort of what the board is about. i will say that i do not know or have any scientific evidence that hard orthotics are either good or bad. i did think enough of them to pay $400. I also purchased some custom $300 soft orthotics and they did not help. I am currently wearing $400 custom semi rigid orthotics and the jury is still out. i had to pay for all these because my insurance would not cover the cost. i did not intend to discourage anyone from trying any kind of orthotics although looking at my post i probably did.

Re: Acu-flex

Lisa C. on 7/27/01 at 00:19 (054423)

Hi Julie,
I don't want your poor Acu-Flex to get rejected again, so just put my name on the top of the waiting list. I too have bought a treadmill, nordic track & lifecycle which received the same treatment as your equipment. THIS one I might use. Famous last words, huh?

Re: Acu-flex

Julie on 7/27/01 at 02:01 (054430)

Hi Lisa

Thanks for thinking of my poor Acu-Flex! Ellen says she would like it, and I'm just packing it up for her. I wish we could track Alan down. There must be others like yourself who would like his device. I know Scott was contemplating adding it to the products board, but I don't think anything happened about that before Alan left.

Come to think of it I must have Alan'spostal address somewhere. If I can find it I'll drop him a note and tell him we're looking for him.

If you manage to get a pair, I'm sure you will use them.

Re: Acu-flex

john h on 7/27/01 at 09:44 (054469)

dr z did have som Acu-Flex for sale that he got from allen.

Re: Making sense out of treating PF

ellen w on 7/24/01 at 10:31 (054119)

Great plan, Glenn. I do theraband exercises and hamstring stretches in bed in the morning, after doing Julie's exercises. Have been thinking of getting a large heating pad to warm up the back of legs before I do the hamstring stretches (based on one of the posts last week about heat aiding the stretch.) Is the Acu-Flex site still up and running? Haven't seen anything about them recently; thought the guy who made them was on an extended visit to Thailand. If at some point you feel like giving another NSAID a try, check out Mobic (it's an osteoarthritis drug that works similarly to Celebrex and Vioxx) --I've been finding it helpful. Though my 3-week prescription has run out as of today, and will spend the next 2 weeks evaluating whether I need to go back on it.
Good luck,
Ellen

Re: Making sense out of treating PF

Julie on 7/24/01 at 10:34 (054120)

It sounds extremely creative to me, Glenn. Well, I did say you are an inspiration to others, didn't I? You're committed to learning as much as you possibly can about all this - and I know you'll share your learnings with all of us. Wonderful. Really.

Re: Making sense out of treating PF

Ed Davis, DPM on 7/24/01 at hrmin (054137)

Glenn:
Sounds like a great plan--it is individualized. There are a few areas where I believe the plan would not be applicable to others.

Ultrasound is a very successful modality for plantar fasciitis. It is a high frequency sound wave as opposed to the low frequency wave used in ECSWT. The actual effect on the plantar fascia may not be all that different. Perhaps you had a bad experience with ultrasound--please let me know. There are effective and not so effective ways of applying this this modality.

Most people do better with non-weight bearing stretches because they stretch with too much force when performing the exercises in a weight bearing fashion. A long slow gentle stretch works better than a short, hard stretch. It is possible to do stretching in a weight bearing fashion with the proper technique--I spend time with patients demonstrating technique.

Most of the studies done on orthotics demonstrate that 'rigid' orthotics are the gold standard for heel pain. Keep in mind that the word 'rigid' is
somewhat arbitrary in terms of the degree of hardness or flex in a device.
Most orthotics we make are 'semi-rigid.' A couple caveats... 1)A foot which is acutely inflamed may not tolerate a 'rigid' orthotic; the inflammatory process must be eased or resolved first. 2)The firmer the orthotic, the more PRECISE the prescription must be; softer devices are more forgiving. I wish I could say that all practitioners are providing devices made with a high degree of precision. I wish we had a device, like the one optometrists use to read the prescription off eyeglasses, that enables us to determine more precisely what is wrong with an orthotic device. There are some bad ones out there, unfortunately.
Ed

Re: Making sense out of treating PF

john h on 7/24/01 at 16:47 (054152)

glenn buddy you have to come from the corporate world or military world with 'mission statements' and 'goals' etc. i wish you were my neighbor as i think we could provide enough moral and informational support to get through this together. for now, however, i guess the information highway will have to do.

Re: Making sense out of treating PF

john h on 7/24/01 at 16:54 (054153)

dr davis: you are the authority but from a guy who was pushed into rigid orthotics on my first visit to the doctor ($400) i tend to respectfully disagree on 'hard orthotics'. i 'WAS' a runner if you can describe a guy my age as a runner. My gut instincts tell me the hard orthotics 'help' send me down the PF highway to hell. they may work wonders for some but for me they were not the gold standard but a factor in my long road to PF hell. i hope i do not offend you because we need all the professional input we can get on this board. just MHO from a guy from arkansas who brought you bill and hillary.

Re: Making sense out of treating PF

Nancy N on 7/24/01 at 16:59 (054155)

John--

I agree with you that there are probably exceptions to the rule--not sure if we are the exceptions or the rule, but I have to agree with you--my rigid orthotics did nothing except make me feel worse. They're now kept in a Ziploc bag for evidence that I tried them, but otherwise are useless unless I have some frost on my windshield in the morning.

Re: Dr. Davis

D.Thomas on 7/24/01 at 17:04 (054158)

Dr. Davis,

I use to have a full length orthotic that was 'semi-rigid' that worked pretty well until two years later my PF came back full force from increased activity. The pain is in the arches (Medial side) of both feet. I do have extremely high arches. Another doctor prescribed 'rigid' ¾ orthotics and I have had them for 6 weeks and I still have not gotten use to them.

I like your comment, 'A foot which is acutely inflamed may not tolerate a 'rigid' orthotic; the inflammatory process must be eased or resolved first'. I swear it feels ok sometimes and the next it feels terrible. I would say when it feels terrible is when I do feel inflammation and sore.

Any suggestions?

Re: Hey neighbor!

Glenn X on 7/24/01 at hrmin (054181)

John: Right on both counts, though Air Force time was long ago. Didn't think it was so transparent. I'm in Oregon. Think I saw you and Arkansas mentioned in the same message once. Years ago, I spent a month in Hot Springs one weekend. (Just kidding. Liked it a lot). I'll catch up with you on the soshe board and visit more.

Re: Second thought on hard orthotics

Glenn X on 7/24/01 at hrmin (054182)

I read the above and went right back to my hard orthotics, which suggests how rapidly a strategy can change.
I'd been using my more-giving orthotics for a month, but my feet haven't been adjusting well, particularly my good foot. What Dr. Davis said helped me take a more objective look at my progress. I don't think the rigids are a perfect fit (ball of foot sort of hangs off end), but I wore them so long (20 months) my foot broke into them. Also, the rigids have a shallower, smoother heel platform my foot likes better. My others have more of a cup for the heel and are lined with a cushiony material that squeezes my heel and aggravates.
Dr. Davis's remarks also make me rethink ultrasound. I was ultrasounded in my spot (the most identified pain spot in Scott's survey), 5-7 minutes in a PT's clinic. Three times a week for six weeks. They were also massaging me, stretching me, wobble-boarding me, and resisting foot moves for strengthening. Ended up being too much. I stopped the ultra-sound and then the other treatments. Maybe should have hung in their with the US. Always seem to be more variables than are manageable.
Thanks doc.

Re: TO: ED DAVIS DPM ~~~~ Re: ULTRASOUND

Necee on 7/24/01 at 22:23 (054186)

In your opinion, what is the proper way to apply Ultrasound? I have a heelspur and currently I'm taking this treatment. Your comments would be greatly appreciated.
Thanks,
Necee

Re: Making sense out of treating PF

Julie on 7/25/01 at 03:51 (054244)

Ellen, I think Alan closed down the site when he went off to Thailand. He must still be there, as the site is still non-operational and we haven't heard from him.

Your hamstring (and all other) muscles are probably warm enough to stretch from having been cozy inbed all night, but it certainly wouldn't hurt to try a heating pad. If you try it, please tell us what effect you experience.

Re: Hey neighbor!

john h on 7/25/01 at 08:52 (054257)

i spent 21 years in the air force a long time ago also glenn and later some time with GE in the corporate world. your post sounds like they were created at SAC Headqurters (no offense). What was your job in the Air Force? i suspect it was writting 'mission statements'!

Re: Making sense out of treating PF

ellen w on 7/25/01 at 09:27 (054260)

Hi Julie,
Thanks. If Dondi or Glenn don't want your Acu-Flex, I'd be happy to buy them from you.
ellen

Re: Acu-flex

Julie on 7/25/01 at 09:41 (054264)

Hi Ellen

Glenn hasn't mentioned being interested in Acu-Flex, has he? I'll wait a day or so for Dondi to reply to my e-mail, and if she doesn't want them, they're yours.

Do you mind putting your e-mail address on the thread so I can contact you?

Julie

Re: Acu-flex

ellen w on 7/25/01 at 11:41 (054276)

I thought Glenn had said part of his intended program was to use Acu-Flex, which is why I posted I thought the Acu-Flex site may not be operant. Anyway, my email is ewatson@netmail.hscbklyn.edu .
ellen

Re: Acu-flex

Glenn X on 7/25/01 at hrmin (054282)

Julie: I am curious about the Acu-Flex, though don't even know what they look like. I tried finding (Alan's) site with no response. Since learned he left the country. I went ahead and got the PFT. Just had 'em a few days and learning how best to use them. They clearly help me tone some foot and lower leg muscles that otherwise (being off my foot) have been very difficult to 'resist.' I understand the plantar fascia to be a muscle surrounded by fascia. Seems important to tone it (and other foot muscles) as part of recovery. Still looking for best way to do this muscle toning without injuring anything. Appreciate your thinking of me re the Acu-Flex you have. I'm covered by the PFTs for now but would like to hear from Dondi or Ellen, or whoever ends up with that device, how well it works for them.

Re: TO: ED DAVIS DPM ~~~~ Re: ULTRASOUND

Ed Davis, DPM on 7/25/01 at hrmin (054286)

Ultrasound probably causes some 'damage,' albiet in a beneficial way to tissues, helping to break down scar tissue and temporarily increase inflammation. The intensity (power) of the sound wave used and the amount of time applied is dependent on 1)the amount of pain and inflammation already present--it can really stir things up temporarily 2)the thickness of the plantar fascia. Initially, we generally start with less power and gradually increase it as acute inflammation subsides. We generally tape and ice the plantar fascia immediately after ultrasound in order to reduce strain on the fascia and reduce the inflammation. Eventually, as the pain and inflammation subsides we apply a fairly high dose of ultrasound in order to achieve the desired effect, often using a steroid cream as the coupling medium (the liquid that the sound waves must pass through to get to the tissues), a process often termed 'phonophoresis.'

It is not, in most cases, a 'stand alone' modality but must be coupled simultaneously with good biomechanical control and rest, that is, rest from the type of activities which strain the fascia but not cessation of all activities. There are four layers of musculature within the foot, which, for the most part, run parallel to the plantar fascia. The stronger those muscles become, the greater tension load they can take off the plantar fascia. Interferential stimulation, to an extent, but to a larger extent, Russian stimulation, can actually enlarge and strengthen those muscles. The term 'Russian stimulation' came about to describe a waveform used, years ago, by the Russians as a passive modality to strengthen muscles in their athletes. A study on plantar fascia in Russia showed a high cure rate for plantar fasciitis using only that waveform----I presume that adequate strengthening of the intrinsic musculature was achieved. This waveform, which causes a strong musculature contraction, can be used to 're-educate' weakened muscles in individuals with neuromuscular disease.
It is used sparingly as it can be painful, though.
Ed

Re: Dr. Davis

Ed Davis, DPM on 7/25/01 at hrmin (054287)

Sounds like you can only wear your orthotics intermittently but that is probably beeter than not wearing them at all. Perhaps you could obtain a soft prefabricated orthotic such as Superfeet ( http://www.superfeet.com ) that you could alternate with the rigid orthotics. Also, consider icing your foot at those times when acute inflammation occurs--if it occurs often or for long periods of time, consider a course of physical therapy.
Ed

Re: Second thought on hard orthotics

Ed Davis, DPM on 7/25/01 at hrmin (054289)

Sounds like you had a combination of PT modalities, some of which were well focused, but others not. There can be some logic behind some of the extraneous modalities but they can be counter-productive as in your experience.

Deep heel cups on an orthotic can provide better control and attempt to bring the fat pad under the heel bone directly beneath the point of contact in order to enhance shock absorbtion. Unfortunately, if the deep heel cup is not shaped properly, you will have a painful squeezing sensation. In all likelihood, there was insufficient plaster expansion placed around the margins of the heel on the positive cast used to form the orthotic, resulting in the up-slope of the heel cup placing excess pressure on the margins of your heel. Do you still have the postive casts your orthotics were made from?
ED

Re: TO: ED DAVIS DPM ~~~~ Re: ULTRASOUND

Mary AnnS on 7/25/01 at 18:09 (054296)

Dr. Davis, I am wondering if ultra sound would help me. I have no PF pain after using the Jade Balm but my foot doensn't feel normal. I wear orthotics and have a flat arch. My foot gets a swollen feling after being on my feet and my heel feels thick. while I am at work it seems to get worse and I ice and it feels some better, In the am it is ok . Thanks,

Re: Second thought on hard orthotics

Glenn X on 7/25/01 at hrmin (054303)

Deeper heel cup orthotics were made fall of '98. Wore 'em 10 months with increasing comfort, then really re-injured fascia on business trip. (Realize now lack of flexibility was big reason for this). In meantime HMO bellied up, saw a different DPM who prescribed the more rigid orthotics which I began wearing in Sept 99. I'm able to tolerate them, but my good foot is complaining more and more. Probably lurching about on crutches doesn't help.
I'll check to see if I can catch up with earlier positive casts. I wonder though if orthotics change the shape of one's foot after a time. I used to be characterized as having flat feet. Now am described with a 'high arch,' (though I've seen higher).

Re: Second thought on hard orthotics

Ed Davis, DPM on 7/25/01 at hrmin (054307)

Orthotics can cause change in the shape of peoples feet to a small extent in adults but to a significant extent in ages 3 to 7 y.o. (My practice is about 25% pediatric foot problems).

Uh-oh, HMO--dirty word. Please don't shed any tears for your HMO that went belly up; the CEO probably left with severance pay in the seven figure range. My big beef with HMO's is that they hand out care in small parcels. That often works okay for small problems but makes it very difficult to provide the necessary level of care to deal with chronic or more difficult problems.

Two things that need to be looked at for you: your orthotics may not be up to snuff and the flexibility issue. Lack of ankle dorsiflexion is the probable the culprit behind a lot of re-injuries and difficult cases. Everything can be done perfectly but a tight achilles and calf muscle (tight achilles gastrosoleus complex) can spoil the best treatment. It needs to be addressed. I have a local therapist who has also been an athletic trainor for 8 years and is a whiz at helping patients gain better ankle dorsiflexion. The other thing that works are night splints. I like the Nice and Stretch mentioned on this site. It is the most comfortable of all the devices I have checked. Patients using adjustable night splints need to start with very light tension on the straps and SLOWLY increase the tension. Long gentle stretching beats short hard stretching. I perform an achilles tendon lenghthening procedure along with about 50% of the plantar fascial releases I do. I do not do a lot of such procedures since most patients get better with conservative care, but when I finally have to do the surgery, my 'cure' rate is about 70%, with 20% better but not cured and about 10% not helped.

Re: TO: ED DAVIS DPM ~~~~ Re: ULTRASOUND

Ed Davis, DPM on 7/25/01 at 21:29 (054308)

MaryAnnS:
Ultrasound may be helpful for you but only as part of a complete treatment plan. Success in this area generally involves the combination of several things working in harmony (excuse the cliche).
Ed

Re: Acu-flex

Julie on 7/26/01 at 00:44 (054329)

Hi Ellen

Dondi has declined, and Glenn (whose intention to explore Acu-Flex I had somehow overlooked: sorry!) now has the PFT, so my Acu-Flex is yours if you want it. I'll e-mail you.

All the best, Julie

Re: Acu-flex

Julie on 7/26/01 at 01:10 (054331)

Hi Glenn

I'm sure you'll get benefit from the PFT. The principle it works on, of relaxing the sets of muscles that we normally overwork, so as to strengthen their weak antagonists, is a sound one. And I'm sure you'll use it consistently, as I did not. And I hope you'll tell us how you get on with them - treatment reports add to the store of knowledge, and help others.

I'm just not an 'equipment person'! As I've just told Ellen in an e-mail, I have over the years enthusiastically bought, briefly used, and shamefacedly sold, an exercise bike, a rowing machine, and a rebounder (mini-trampoline). So I really should have known myself better.

Re: Making sense out of treating PF

Ed Davis, DPM on 7/26/01 at hrmin (054367)

John:
There are appropriate and not appropriate uses for all modalities. Sounds like you had a bad experience but don't let that make up your mind about something that can benefit a lot of people. A poor prescription can harm more than help. I hope you have been able to resolve your problem since.
Ed

Re: Making sense out of treating PF

john h on 7/26/01 at 16:29 (054390)

dr davis: you are correct! perhaps a lot of people have been helped with hard orthotics and you are in a position to know. all of us post about things that we have experienced and of course each of us represent just our own thoughts and experience. we all throw our experieces out there for others to see and make their own judgement on. that is sort of what the board is about. i will say that i do not know or have any scientific evidence that hard orthotics are either good or bad. i did think enough of them to pay $400. I also purchased some custom $300 soft orthotics and they did not help. I am currently wearing $400 custom semi rigid orthotics and the jury is still out. i had to pay for all these because my insurance would not cover the cost. i did not intend to discourage anyone from trying any kind of orthotics although looking at my post i probably did.

Re: Acu-flex

Lisa C. on 7/27/01 at 00:19 (054423)

Hi Julie,
I don't want your poor Acu-Flex to get rejected again, so just put my name on the top of the waiting list. I too have bought a treadmill, nordic track & lifecycle which received the same treatment as your equipment. THIS one I might use. Famous last words, huh?

Re: Acu-flex

Julie on 7/27/01 at 02:01 (054430)

Hi Lisa

Thanks for thinking of my poor Acu-Flex! Ellen says she would like it, and I'm just packing it up for her. I wish we could track Alan down. There must be others like yourself who would like his device. I know Scott was contemplating adding it to the products board, but I don't think anything happened about that before Alan left.

Come to think of it I must have Alan'spostal address somewhere. If I can find it I'll drop him a note and tell him we're looking for him.

If you manage to get a pair, I'm sure you will use them.

Re: Acu-flex

john h on 7/27/01 at 09:44 (054469)

dr z did have som Acu-Flex for sale that he got from allen.