Why is There an Epidemic of Heel Pain?

Why does it seem like there is an epidemic of heel pain in the United States? Everyone I talk to has had plantar fasciitis or at least has heard of it. Many can even spell it correctly. (Isn't that scary!) Most people suffer for months and even years before they seek medical attention. Even those treated with traditional methods seem to take just about forever to get better. And there are more voodoo treatments available than Carter has liver pills. Why is that? Seems to me that there is a lot of money in heel pain!

So let's take a closer look.

What is plantar fasciitis? Simply stated, it is inflammation of the ligament that holds up your arch, also known as your plantar fascia.

What causes heel pain or plantar fasciitis? Most experts agree that plantar fasciitis is caused by too much stretching of the plantar fascia, usually because of excessive pronation or flattening of the arch of your foot while you walk. Some people just have excessive stretch because they have flat feet. Others have really high arches and their fascia is under a lot of stress in normal walking. Some are just too heavy. It can be triggered by an injury like simply falling off a curb, excessive stress by a new exercise program, poorly supporting shoes, and many other increases in stress like a new job or carrying heavy objects. There is even one theory that states that plantar fasciitis is caused by weakening of the muscles of our feet from wearing shoes all of our lives. Hmm...Will have to look at that a little closer in the biomechanics lab.

Why does it afflict so many people? Let's think...oh yeah...most of the United States is overweight. Most people choose absolutely awful shoes to wear due to their sense of fashion. Slaves to fashion usually have painful feet! And the flip flop phenomenon has accelerated the epidemic! Those that aren't fat and in poor shoes are usually crazy obsessive exercise-aholics.

Now that we know why it seems that everyone suffers from heel pain at some point in their lives, how can we treat it without breaking the bank? Let's start simple. Better, more supportive shoes are the key to success. Arch supports if the shoes aren't enough. You need to stop the stress that caused the arch to strain in the first place. Then treat the inflammation with over-the-counter anti-inflammatories, if you can tolerate them, and lots and lots of ice. Slow down. (That's tough for more people) And gently stretch the arch of your foot and your Achilles tendon.

When should you seek medical attention? If you have arch and heel pain for more than three or four weeks, and you have done the simple things to alleviate the pain; it's time to see your podiatrist. Not time to go to the shoe store and spend a bizillion dollars on off-the-shelf inserts and funky "proven to work" shoes. Not time to go to the pharmacy for hundreds of dollars worth of gadgets and creams. Time to see your podiatrist, who is the expert in heel pain.

How will your podiatrist treat your heel pain? Every case of plantar fasciitis is different, but some standards of care do exist for treatment protocols for heel pain.

First order of business: You need to rule out anything else by taking an x-ray to make sure it's not a stress fracture or tumor in your heel bone. A physical exam is also needed to assess why you have heel pain.

Then your podiatrist will usually assess your shoes and possible prescribe arch supports or orthotics if your need them. An injection or two of an anti-inflammatory into the heel is often used to break the pain cycle. Physical therapy is also often helpful. A night splint or brace is sometimes used. And if all else fails, you may be put in a cast to rest the area.

Contrary to popular belief, you do not have to suffer from plantar fasciitis forever. Most patients (>85%) will get better with aggressive conservative treatment. It is tedious and frustrating, but the diligence and consistency in the treatment protocol yields excellent results.

Here is the bottom line: if you seek the attention of your podiatrist early, you will get better faster and your treatment will not break the bank. Procrastinators will end up spending a lot more money and the chance of needing surgery to alleviate your pain goes way up!

Is Your Achilles Tendonitis Really Bursitis?

Did you know that there are more than 250,000 Achilles tendon injuries in the United States each year? Of these injuries, almost 25% require some kind of medical intervention to heal. A fully ruptured tendon requires surgery. Most other injuries can be treated conservatively and will resolve without surgery.

The most poorly understood Achilles tendon injury is actually not an injury of the tendon, but an inflammation of the bursa sac that separates the tendon insertion on the heel bone from the back of your ankle. The fluid in the bursa actually allows the tendon to move smoothly over the bone. When the bursa sac becomes irritated from frequent or abnormal movement, it becomes inflamed and bursitis can set in.

Achilles bursitis, also known as retrocalcaneal bursitis, is a common overuse injury in runners, hockey players, football player and many other athletes. Improper shoe gear and too much, too soon, too fast syndrome are usually the cause of this pain in the heel. It can also be seen in non-athletes who wear poor shoe gear or low cut shoes. Often it is seen in people with rigid, high arched feet.

Bursitis is a painful swelling that occurs in the back of the heel just deep to the Achilles tendon insertion on the heel bone. This inflammation makes it painful to squat, lunge or run uphill. Many shoes press on this area and make the pain worse. Even running on uneven or soft surfaces can increase the inflammation.

First line therapy for Achilles bursitis is rest, ice, heel lifts or heel cups and gentle stretching. Many patients require physical therapy and functional foot orthotics for complete relief of symptoms. Severe cases my even require a period of non-weight bearing casting or bracing prior to physical therapy in order to decrease the inflammation of the bursa. Chronic cases may even require more invasive therapy with extra corporeal shock wave therapy or injection of platelet rich plasma to jump start the healing process. Surgery is rarely needed unless bursitis is ignored for a significant period of time.

Long standing Achilles bursitis can cause significant difficulty in ankle movement and often a spur will form within the insertion of the tendon. Left untreated, this can eventually cause a rupture of the Achilles tendon at the insertion and lead to life long disability. If you are experiencing painful swelling in the back of your ankle, seek the help of your podiatrist early, so you can get back to running quickly and avoid any long term effects of this chronic inflammatory syndrome.

Will I Be Able to Run After Bunion Surgery?

Running After Bunion Surgery?

Great question! I hear this question at least several times a month from my active, athletic patients. Of course, my first response is always, “Are you able to run now?” This is not sarcasm, but a true fact finding mission. If you are unable to run before your surgery, due to the pain in your bunions, then if you can run afterwards - I am a hero! The same goes for the opposite. If you are running pain free before surgery, and really only want your bunions fixed due to the fact you think your feet are ugly, if you can’t run afterwards - you really don’t like me very much!

Let’s talk about this a little more in depth. A bunion is the result of undue stress on the big toe joint, which causes a protuberance of bone or tissue around that joint. Bunions can be very painful, inhibit normal walking, and make it difficult to fit into some shoes. Contrary to popular belief, bunions are aggravated, not caused, by tight shoes. They usually are due to inherited faulty foot mechanics which put abnormal pressure on the front of the foot. Pain is the primary reason patients seek medical attention for bunions. A majority of bunion surgeries are performed on women because they wear tight-fitting, high-heeled shoes that worsen the underlying foot problem and cause abnormal stress to the joint.

There’s good news for anyone considering bunion surgery. A survey in 2003 by the American College of Foot and Ankle Surgeons (ACFAS) had surgery performed by a foot and ankle surgeon to correct bunions within the past 6 to 24 months found more than 90 percent of patients who had the procedure say they experienced significant pain relief, increased their physical activity, and would recommend it to others.

Many runners who can benefit from the surgery avoid it and continue to endure pain because they have heard that surgery doesn’t work and is excessively painful. Their biggest fear is that they may not be able to ever run again! The truth, as evidenced by the survey results, is that advanced surgical techniques have allowed us to effectively correct bunion deformities with excellent outcomes in terms of pain relief and improved quality of life.

Ninety-six percent of the survey respondents identified pain relief as a desired outcome of the surgery, and 86 percent also said they hoped to improve their walking and increase their physical activity following surgery. On a scale of 1 to 10 with 10 representing “much pain,” the survey respondents averaged a score of 7 when assessing their pain before surgery, and the average score dropped to 2 when they assessed their pain six months after the operation. Ninety-two percent said they were able to increase their physical activities -- walking, golf, tennis, exercise -- and 90 percent said they would recommend bunion surgery to others.

That being said, in most cases, we can treat the pain caused by bunions conservatively. In fact, we feel strongly that surgery should be a last resort. We surprise many bunion patients with our ability to help them avoid surgery when they have been told previously they have no choice but surgery. A custom foot orthotic to off weight the bunion in your shoes is often very helpful. Many patients run for years pain free in orthotics before they decide to have surgery. If you have tried all conservative treatment, however, and bunion pain is causing pain or limiting your activity, surgery as you can see, can be a very effective option.

If the pain in your bunions has caused you to decrease or eliminate running from your life, contact our office for alternatives. Do not let the pain in your bunions change your life!

Run Happy!

Huckabee Encourages Health Reform at APMA National Meeting

Huckabee encourages Heath Reform at the APMA National Meeting

Health care reform is on the tip of everyone’s tongue this week. The debates in Congress and the attempt to pass some kind of legislation that most Congress members have not even read, let alone understood, is the news leader. I was lucky enough this week to be present for Mike Huckabee’s keynote speech to the American Podiatric Medical Association in Toronto, Canada. The former governor from Arkansas inspired and encouraged the APMA to discuss more than health care reform but to think of revolutionary health reform in the United States as the answer to our health care woes.

What does he mean by health reform? He encouraged the physicians to stop thinking about fixing the health care system. The system isn’t broken. It is actually considered the best in the world. If you start discussing socialized medicine overseas, you will quickly realize that most wealthy foreigners would rather have surgery or cancer treatment in the US than in their own countries. We don’t need to fix the system; we just need to work on unhealthy American habits. The combination of obesity, lack of exercise and smoking, lead to most of our chronic health problems in the US. The system is overwhelmed by chronic disease! Why not come up with a system that encourages healthy living, therefore decreasing chronic disease and actually increasing productivity in the country?

Mike Huckabee knows a lot about unhealthy living and its consequences. Several years ago he was diagnosed with Type 2 diabetes and was told he was now in the last decade of his life. His physician outlined what death by diabetes looked like and encouraged him to take control of his future. He lost an incredible amount of weight, starting eating better, and even started running for exercise. Multiple marathons later, he is no longer a diabetic and is healthier than he has been in years. Mike Huckabee took control of his health and wants every American to experience this life-changing heath makeover.

Why do most Americans have unhealthy habits? Is it laziness? Is it hereditary? Is it social? Actually it is a combination of all of these things in most people. We need to encourage healthier lifestyles and teach our children the importance of healthy choices. Multiple studies have shown that regular exercise including around three hours of aerobic exercise and an hour of strength training each week leads to decreased depression, diabetes, heart disease and osteoporosis. This has been well documented, but most Americans are not listening.

How can we encourage healthier life styles and off load the currently overwhelmed health care system? How about an overhaul of the health insurance system with incentives for healthy choices? I do not believe in penalizing people for obesity or smoking, but how about incentive discounts for a healthy BMI, non-smoking and regular exercise? Just like when car insurance companies give discounts for safe driving records. We could even put an accumulative healthy point system with sliding scale premiums for regular checkup and prevention programs.

Think of what this type of system would look like. The current reforms of the health care system being discussed will lead to a two tier system where the wealthy will have the best care and the rest will be stuck with the socialist model which has been shown not to work in many, many other countries. If we focus more of health reform instead of care reform, we can decrease the load on the current system, decrease health care expenditures and actually have a healthier, happier, and more productive society. Political parties aside, call or write your representatives and let them know you are unhappy with this rushed consideration of the most important legislation in decades. Let us not quickly put in place a program doomed for disaster that will significantly decrease the standard of care in the American health care system. Let us uplift the health of the American people instead.

Book Signing at Borders Books in Colleyville

Dr Crane's next book signing is at Borders in Colleyville, July 14th from 6-8pm.

Come by and say "Hi!"

Ow Ming! Is Yao Ming's Basketball Career Over From a Foot Fracture?

Ow Ming!

Houston Rocket's Yao Ming's career may be over due to a non-healing foot fracture. He was sidelined during the playoffs on May 8th with a hairline fracture of his navicular. As of today, this has not healed properly. The nature of his non-union and his prognosis is being kept quiet by the team physicians, but it is evident that there is a problem. Most stress fractures heal completely in 6 to 8 weeks. This is not the 7 foot 6 inch center's first fracture. He has been out portions of the last three seasons with stress fractures in his leg and foot. Perhaps his lanky frame just can' handle the stress of the NBA? Why is it that some fractures don't heal?

Looking at his present injury, stress fractures of the navicular (the cornerstone of your arch) are often slow to heal due to three factors, blood supply to the bone itself, underestimating the extent of the initial fracture so delaying aggressive treatment and too much abnormal stress on the healing bone. Other medical issues can delay bone healing like lack of Vitamin D, poor calcium uptake and many other systemic problems like diabetes, hypothyroidism and peripheral vascular disease. Many of these fractures are actually missed due to lack of specific x-ray findings. Many fractures are actually misdiagnosed for months. Plain film x-rays are often read as normal so the fracture is missed until symptoms increase. Early symptoms can be diffuse and non-specific so the index of suspicion is also low. A bone scan, MRI or CT scan can identify the specific fracture. CT scan is often the most helpful in identifying the extent of the fracture and guiding treatment. For a non-displaced stress fracture, cast immobilization is the first line therapy. Studies have shown that non-weight bearing immobilization in a cast for at least 6 weeks is usually around 80-86% successful. For those that do not heal this way, surgical fixation of the fracture can be helpful and a bone graft may be needed for long standing non-unions. New technologies like electronic and ultrasonic bone stimulators and injectable platelet rich plasma can help even the most stubborn fractures.

Follow up care for a navicular fracture often includes physical therapy and custom foot orthotics. Abnormal biomechanics of the foot often are one of the causes of these fractures, so biomechanical control is crucial to distribute the abnormal stress so an athlete can return to sports and have a lower risk of recurrence.

Yao Ming has had multiple stress fractures during his career increasing the likelihood of traumatic arthritis from avascular necrosis (not enough blood supply to heal so the bone crumbles) in his foot causing him to retire. The next few months will tell the tale for this multi-million dollar All Star. Can he heal his fracture and return to sport? The Rocket's fans are praying for divine intervention to cure their dominant center.

Train Smarter In the Summer Heat!

I declared myself heat tolerant this weekend in my recent Twitter. I did a 3 hour bike ride in 99 plus heat at 5pm in the Texas heat and could still spit when I was done! That’s a success in my book! It definitely took 2 full weeks of suffering in the heat and a good hydration plan to finally feel like my body had made the transition to feeling relatively comfortable in the soaring Texas summer heat.

Dehydration, heat stroke and hyponatremia are your biggest worries while training in the summertime. Whether you are in Texas or Rhode Island, when the temperature soars over 90 degrees, heat illness can seriously hamper your endurance training. Most of us have an “A” race on the calendar in the fall and require a lot of base training in the summer. No way around those long runs and even longer bike rides in the heat. The average triathlete can sweat up to one liter of fluid an hour while training and sweat contains about 3 grams of salt per liter. How can we conquer the heat? Preparation and constant hydration! Diligence is the key! Always stay one step ahead of the hydration curve. Remember that heat illness really can kill you and hyponatremia has taken out more than one healthy marathon runner and triathlete!

Here are some simple tips that will help you train safely in the heat:
1. Hydrate all day long. Drink water throughout the entire day. Most people actually start their training runs already dehydrated. Especially when the temperature reaches triple digits, it is important to always have that water bottle near by.
2. Prepare for your longer training runs and rides. This means dropping water bottles along the route before you start or making the route circle around many times so you can stop and pick up more water at your starting point.
3. Drink a mixture of sports drink and water. Definitely mix it up. I always have a bottle of each on my bike.
4. Consider salt tablets if you are running or biking more than 2 hours. Unless you can carry salty pretzels on your run, salt tablets are a must if you are sweating heavily.
5. Never be afraid to get off your bike and run through a stranger’s sprinklers! You may look like an idiot, but cooling off and wetting your clothing can only help you stay cool! Putting ice down your shirt can also be helpful!
6. Listen to your body. Especially in the beginning of your heat training, listen to the symptoms of heat illness. If you are nauseous, cramping, can’t spit, have dry mouth, notice your hands and wrists are getting puffy and you are starting to feel goofy; STOP! Go home to run or ride another day.
7. Avoid anti-inflammatories if you can. Ibuprofen and Tylenol actually can affect your kidney function. This can increase you chances of suffering from hyponatremia.
8. Sunscreen, sunscreen, sunscreen. A bad sunburn will thwart your normal heat-regulation system. Heavy duty 70 plus water-proof sunblock is your friend!
9. Weigh yourself before and after your training. Replace your weight loss with more fluids.
10. Carry money. You never know when you may get lost and need to stop at a store for more sports drink or water.
11. Train with a friend. They may notice your symptoms of heat-illness way before you do. Denial is never a good companion.

Heat-illness is real! Be smart while training this summer! Follow these tips, heat acclimatize over a period of several weeks and be diligent about your hydration plan while training in the heat. Let’s get to those fall races stronger and without any heat-related training drama! See you on the run!