I’ve been an orthopaedic surgeon for over 25 years. I specialize in foot and ankle, but I’m interested in other areas of medicine as well. In short, I’m passionate about medicine, as well as the truth… That’s why I’ve taken to the web. I’m going to use this as a springboard to discuss real issues in medicine, and hopefully guide patients to a better experience with their medical needs.
Some, namely my colleagues, may find my point of view dissenting. For that, I don’t apologize. My goal is to help the patient, not win a popularity contest. For those of you reading, I appreciate your time.
If you have any issues you would like to discuss, you can post on the entries here, tweet me @angryorthopod, write on my Facebook page at Angry Orthopod or find me on Quora.
I know this post is older but after reading it I felt the need to pass something on.
I developed PF almost 3 years ago after a two-week course of prednisone which caused my feet to swell to the point that I could only wear this pair of flip-flops that I used by the pool. I walked in these exclusively for three weeks until I could get my feet back into normal shoes comfortably. The next week there was that nasty pain in my arch.
Podiatrist insisted I wear a popular brand of OTC insoles. I dutifully complied but they made the pain so much worse and they were hurting my opposite foot as well. She insisted I would get use to them and to “tough it out”. After 6 weeks I started to develop lateral pain in both feet. She used some foam to build up the insole, but that didn’t help. I switched on my own to an insole that seemed a little friendlier to my feet but since my arches were “normal, or neutral” and strong, I started to wonder why I was using these insoles at all.
Nearly 18 months later and still dealing with not just PF but lateral foot pain, my brother’s friend notices me with my shoe off massaging my feet at my niece’s birthday party. He’s a personal trainer and asked what the deal was. After explaining my long journey through Hades he suggested that I take the insoles out, put the factory insoles that came with the shoes back in and give it two weeks. What did I have to lose?
It was a rough two weeks, my feet were screaming at me because of the lack of artificial support but they settled down and I realized after two weeks that my PF seemed to be nearly gone, the lateral pain in that foot was gone completely and the lateral pain in my “good” foot was better but not gone.
I was relieved and furious at the same time. Almost a year after removing those insoles I am still dealing with lateral pain in my non-PF foot and so I found a new podiatrist who diagnosed peroneal tendonitis for which I am alternating an AirCast boot and a sports brace.
I know personally for me, I will never put an orthotic in my shoes again, regardless of the ailment.
This is a very eye opening story for everyone not because it is unusual, but because it is extremely common yet basically unknown. For some reason arch supports/orthotics in the US are the rage and in my opinion way over prescribed. I find in my patients who have orthotics or had them in the past caused more the original or even another new pain (like you) or do nothing at all. Yet we do as the doctor says and keep on wearing them. All in all they really don’t cause any real harm in most cases except to one’s cash flow.
On the other hand calf stretching is amazingly unpopular, yet very beneficial in most cases because it solves the problem at the source, the calf contracture. So you pick your solution. Spend money on the quick cure that does not work, orthotics. Or stretch your calves for free and slowly fix your problem the right way.
Dawn, you made the right decision. Now make one more and stretch your calves.
Stay healthy my friends,
Hi Dr. AO, I had ankle surgery about 12 years ago, after being hit by a car. I had a medial malleolus reattached with a few screws, they have since been removed (11 years ago). I have lost a small amount in the range of motion compared to the good foot. I have suffered from PF on and off thru the years. I run about 20-30 miles per week. On a good note, doctors and PTs have prescribed calf stretching thru the years. However, this time, stretching cause sharp pain at the insertion point of the PF. Trigger point or foam rolling causes immediate relief but does not last…is it ok to stretch the calf thru the pain?? Working on ankle mobility to see if that can help as well. Thanks
Your question has frankly upset me a bit, so the morning got off to a good start. Thanks for that.
As long as you have reasonably characteristic plantar fasciitis the pain is acceptable with stretching. Just make sure to modify the amount of your foot is on the step which will also adjust the intensity of the stretch. More foot on the step means less intense stretch and vice versa. Of course, never get too far off the step as the intensity actually reduced due to inhibition and the metatarsals get overloaded unnecessarily. I don’t mind some easily tolerable pain during the stretch process or after. What I do mind is a trend to worsening over time.
Stay healthy my friends,
Hello Dr. AO,
I have suffered from PF for about 2 years. My doctor prescribed ASTYM therapy which had no effect whatsoever after 10 treatments, so he did a steroid injection, inserting the needle into several areas of my heel. He called this “swiss cheesing it,” and described the goal of causing an inflammatory response so by body would heal itself. It worked for nearly 5 months! No pain whatsoever. Then it came back. I got an MRI which show very mild thickening of the plantar fascia, but prominent varicose veins. I told my dr that I felt a burning sensation in my heel even at rest and that morning pain was not the worst as is typical with PF. He feels my problem is nerve entrapment. My nerve conduction test revealed no obvious problem with the nerves. He said it could be Baxter’s nerve entrapment and surgery (tarsal tunnel release) could help but there are no guarantees. Should I forgo the surgery and just do your calf stretches? Would this work for burning nerve pain?
In addition to my above question, I am also wondering about this: when I do your recommended stretching, I feel WAY MORE stretch in my non affected leg. That is to say…my leg and foot with the problem already feel stretched out. How can I adjust the stretch so that it does more to my leg with the sore and burning heel?
My first answer is absolutely forgo the surgery and stretch! I must fess up that I know little about ASTYM therapy. What I do know, it like just about everything else treating plantar fasciitis, does not address the root cause. In the case of plantar fasciitis, the root cause is equinus. No doubt it may help in some way, but it is off the mark in my angry opinion. This would explain why it worked-and then it didn’t. The root cause was not addressed!
As to your second question, the sensation of there being a stretch I agree seems to be necessary. However, in reality it is not. I have had countless patients comment no stretch was occurring, yet as they stuck with it at my insistence they ultimately resolved their problem at pretty much the same as those who felt a stretch. Having said that, you can increase your stretch force by shifting your body weight to the affected side by just reducing the weight bearing on the opposite side. Think of it as sort of shifting your weight to one side.
Now for the anger! Why would a doc do a Nerve Conduction Study (NCS) for heel pain? Even if one believed in Charley Baxter’s nerve, a NCS would never detect it. Sorry, those are the facts. To be frank, Baxter’s nerve is much like plantar fasciosis and chronic plantar fasciitis. These are made up diagnoses to explain when all the BS treatments, that do not address root cause, fail. “Oh, your treatments failed because you have a different, and more severe problem. You have Baxter’r nerve. Time to step up the treatment plan and consider surgery.” Noooooooo.
Stay healthy, my friends,
I developed several issues during my pregnancy that have not resolved, even after bilateral bunion surgery, PT, modalities, and many over the counter orthotics. I’ve lost all of my pregnancy weight, and then some. My forefoot widened (making the bunions worse and more painful). Note: I had bunions for about 10 years prior to my pregnancy, so faulty walking mechanics had to be present for a long time. I have also developed PTTD, or stage 1 adult acquired flat foot. I read that this is a progressive, debilitating condition. My hindfoot and heel are constantly moving regardless of shoes, inserts, etc. I have become desperate and am waiting for a pair of custom orthotics to arrive. I am going to try the calf stretches (your way), and remain hopeful. With your experience, is there any hope of my pain associated with PTTD going to improve, or is it just chronic? I’ve even been so desperate that I saw a chiropractor (I know), which did not help. Thank you for your time.
You bring up one of my PTSD triggers- PTTD (posterior tibial tendon dysfunction) along with issues post pregnancy foot issues. These are two areas my colleagues have it completely wrong, almost all of them, boom. Indeed PTTD is a miserable thing, or can be in time, but you got this.
Being blunt- CALVES GET TIGHT DURING PREGNANCY for several reasons (I will not delve into it here) and this is the SINGULAR reason these foot problems develop or worsen. Let’s look at your problem.
Again, being straight to the point blunt- CALF STRETCHING has a >98% odds that your PTTD will resolve, completely. The only caveat to that is if you have an accessory navicular that is the source of your pain and not PTTD. An x-ray can determine that.
The bunion could also be contributing to the pronatory forces, but the primary, modifiable deforming force is your equinus. The bunion, if contributing at all, can only be modified with more surgery; don’t go there, but I probably don’t have to tell you that. Any contribution of a bunion to PTTD all depends on the bunion procedure you had done and if there is remaining first ray/metatarsal hyper mobility. Nonetheless, that is essentially not modifiable, which brings us back to the calf. Modify your situation by stretching and you will be happy.
Best of luck and please give the AO Nation feedback when all is resolved.
Stay healthy, my friends,
Two questions: what do you think of custom orthotics? The orthotics that are being fabricated for me will have a hindfoot rear posting and a deep heal cup to help align my foot to address increased pronation associated with PTTD. I am a skeptic because over- the-counter orthotics did nothing for me. Hyprocure: the good, bad, and the ugly? On the surface, Hyprocure makes logical sense….but is it too good to be true?
Somehow you found a way to trigger my anger twice. Way to go sister.
I think custom orthotics, for the most part, are a waste of time and out of pocket big bucks. No doubt they help a few. In my practice, I took about 9 out of every 10 custom orthotic away (actually gave them permission to quit using them) from patients who were using them. Here is the typical conversation with a patient wearing custom, OTC for that matter, orthotics for 6 months or greater.
Me: “Do they help you?”
Patient: “No. They actually make my feet hurt worse.”
Me: “Are they helping the original pain?”
Me: “Why are you still wearing them?”
Patient: “I was told to wear them.”
One would think they would just stop wearing them on their own. It is a mystery!
And this is the same patient that would not stretch after a detailed explanation of the importance of stretching convincing them it was THE fix. Not until the third visit, and voilà, they finally do them and their symptoms resolve. Go figure.
Your custom orthotics are apparently on the way so give them a try. However, like so many other people you will likely find they cause more pain than they may help. That pain will likely be experienced under your arch. That is what happens when you place a rock under a pressure point. However, if they help, by all means use them. Interestingly, ground reaction orthotics (like yours) typically are more applicable to the knee and above, not the foot. Still, they are widely prescribed, which begs the question, “Why?” Two reasons: makin’ money and the misguided belief that the human arch must be held in a “normal” position (see ‘flexible flatfoot is a normal variant’ below).
Custom orthotics are a cash cow. Typically the cost to the patient is +/-$350 and the cost to the physician is ~$75. Hell yea you need orthotics.
It is well known that orthotics only change the foot structure when worn. No matter how long (years) the orthotics are worn, the flatfoot returns when the orthotic is removed.
Hypocure? Seriously? Let’s just say that I have a lot of experience removing them and none inserting them. In theory, Hypocure seems like a good idea, but there are innovations in which a sprinkle of critical thinking, a dash of experience, and a pinch of mechanical engineering tell this surgeon no, no, no. And did I mention the evidence does not support this device. To be far, I have seen patients who benefited from these devices, but the percentage is lower than a major league baseball player batting on the Interstate.
The Hypocure, actually all sinus tarsi “jack up” implants, function by jamming in a screw to jack up the sinus tarsi jacking up one of the most sensitive and loaded joints in your body, the subtalar joint. No doubt it can make the foot look more “normal”, but it is tantamount, in most cases, to a beautiful woman disfiguring her face with plastic surgery. What could go wrong, right?
Ask yourself, “Why did my foot cooperate until 3 months ago at the age of 45 (or 55, etc.)?”
The flexible flatfoot is a normal variant and the great, and I mean great majority of folks with it have no problems except when they look at them, talk to well meaning friends or family member or they see a doctor. In almost all cases a flexible flatfoot problem/pain arises for one reason. As we age and our calves get tighter (equinus) and this my friends creates tremendous leveraged loads on a mechanical susceptible foot. Calf stretching reverses basically all of the root cause, sans the original flatfoot, and the foot goes back to its happy place before equinus causes permanent damage.
And there you have a novella answer.
Stay healthy, my friends,
Thank you for the tips. They may have saved me from making a horrible mistake. Last dumb question: can plantar’s fasciitis or Achilles tendinitis, or both, cause pain when seated? My heals hurts when standing or seated now. I have only been doing the stretches for a few days. I realize it may take a few months for things to change with the calves. Okay I’m done.
Another good question. While pain seated is not the norm it can definitely be part of the picture. It might be a sign of the longevity off your pathology, but does not imply that treatment (stretching) is any less effective. I have a feeling you will se improvement way before a few months. Stretch on!
Stay healthy, my friends,