Thursday, August 14, 2008

Plantar Fasciitis

Plantar Fasciitis is an injury caused by excessive stretching of a broad band of fibrous tissue which runs along the bottom surface of the foot, attaching at the bottom of the heel bone and extending to the forefoot. The band stores energy from heel contact in a windlass mechanism and returns most of it to push the foot off the ground. The term is often used to include the layer of muscles which adhere to it. A chronic plantar fasciitis eventually becomes a heel spur in most cases. My treatment will typically begin by determining and addressing the cause or causes of the injury. No injury can have a set cookie cutter treatment. Each patient's treatment plan varies according to the contributing causes.

The common causes and aggravating factors are:





  • Over-pronation (flat feet)


  • But also a foot with a high arch


  • A sudden increase in length and intensity of workouts


  • Excessive weight change


  • Pregnancy


  • Improperly fitting footwear


  • Tightness of the foot and calf (gastocnemius and solues are most common culprits)


  • Training errors


  • Old running shoes


  • Improperly fitting running shoes (especially too wide)


  • Improperly designed running shoes


  • Rheumatoid variant types of arthritis (HLAB27 antigen positive) and disorders of connective tissue healing


  • Running on surfaces too soft


  • fixated or subluxation at calcaneal cuboid and talo-crural joints


The use of medical grade silicone gel heel cushions, and compression socks used as first aid is as close as I come to a universal thing to do. This is rarely curative but is meant to reduce symptoms . Some people like to tape the foot. This is okay for short time intervals as a taping lasts 3-5 days. Socks with spandex woven into them when the need is likely to be more long term. Nonsteroidal anti-inflammatory drugs (e.g. aspirin, ibuprofen, etc.) have significant benefits only in arthritis induced cases. Arthitis induced cases are rare. Most cases of plantar fasciitis lack inflammation. Hence, such drugs often misused for this condition. Deep tissue massage is helpful in some cases. Night splints (which immobilize the ankle during sleep) are well hyped. They have been used with mixed results, at best over the last decade. Stretching and strengthening programs are good for those people who have a tightness of a weakness. Orthotic devices are considered only for those people with a biomechanical fault. A Cortisone injection into the scarred attachment has a success rate of about 50%. Healing modulators, such as injectable preparations containing Arnica Montana have been shown to speed the healing course. Manual mobilization of the calcaneal-cuboid and/or talo-crural joint help those people with subluxations or fixations. The final option, surgery to release the tight fascial bands has a 70-90% success rate. Shockwave therapy fits is as an alternative to surgery. Shockwave or more formally known as Extracorporeal Shockwave Treatment is a relatively new delivery of high energy sound waves to affected areas of the body. It is very similar to the units used in certain cases to brake up kidney stones. It works theoretically by creating controlled injury of the plantar fascia insertion. Proponents are claiming to have success similar to percutaneaous (small incision) surgery. It requires anesthesia and has a timetable similar to small incision surgery. Shockwave theapy is contraindicated in people with diabetes, concurrent nerve-related problems, vascular, pregnancy, clotting disorders (or taking any drug which thins the blood) or various types of arthritis.The present studies I have read on the effectiveness of this therapy are mixed and controversial. Because of this, it is not covered by many insurance companies. The positive studies so far have all been funded by companies who make the unit. I would like to see one by a source with no vested interest before I start to forge my own opinion of the therapy. Only time will tell how good this alternative will be. You have heard the phrase "time heals all wounds? Well time also wounds all heels.

There are also other treatments used in plantar fasciitis by me in cases of an atypical cause of the problem. For example, I remember one athlete on a college scholarship who had seen just about every sports medicine doctor in the Boston area. Both the athlete and her coach were very frustrated after over 3 years of inability to run. The only thing I could find was a wart on the ball of her foot. A wart does not hurt with direct pressure but it usually very painful with side to side pressure. To make a long story short, I removed the lesion and all pain went miraculously away. Not all heel pain is plantar fasciitis. Spinal impingement (at the 5th lumbar or 1st sacral vertebra), tarsal tunnel syndrome, nerve entrapment, Sever's Disease (calcaneal apophysitis), bone cysts and benign tumors can all mimic plantar fasciitis symptoms.

Hopefully this information will enlighten readers of this blog about their McFeet. For we all need help from the sign of the golden arches one time or another.

Sunday, August 10, 2008

Tapestry



I lie curled up on a cot, shivering under a military blanket. I started to cry first as a whimper. But as the dam gave way, the trickle became a deluge. An EMT came over to quickly access the situation, “anything wrong? Are you in pain?” I turned and replied, “No it is just the pain going away.” A perplexed worker stood and stared, then finally walked away. Had I lost my sanity? Here is my story. It was a full blown New England Nor'easter as I waited inside the school for the start of the Ocean State Marathon. Huge thunder claps reverberated the room and lightning flashed in the gym skylights as I stretched on the floor. I overheard a passer-by say, “It sounds like a hogs heaven rally in the air going on out there.”

I said I would run another marathon when pigs fly. That was 1982 in the Foxboro Marathon. I was invited as the guest lecturer for their sport medicine seminar the night before. Running the race would be a good follow through for me. I prepared with long runs and a variety quality workouts. I trained and planned to be prepared. But somehow, even the best plans of mice and men can go awry. That is especially so at about the 21 mile mark when glycogen supplies of the muscles have a tendency to ebb. My brisk pace slowed to what seemed like a crawl. Less than 100 yards from the finish both hamstrings seized up. You've seen it before on the news. A runner doing an imitation of a telephone pole right before the finish. No matter how I tried to take even the smallest of baby steps, my legs would paralyze in spasm. I had come this far. The cameras, finish line spectators, and the clock were in front of me, creating a surreal nightmare. I reached down for something physical and nothing was there. When the flesh is weak, it is time to explore the spirit. I searched the recesses of my mind for an answer. An image then appears of my cat who loved to play with me by challenging me to catch her. She did so by staring me down while making her eyes look big and round, arching her back, escaping me while running backward. I never caught her. If I got too close, she would give a four legged leap 6 to 7 feet in the air all the while twisting and gyrating in ways that would make a gymnast jealous. Okay, idea strikes. If the hamstrings are out to lunch, why not pivot myself around and go backward to use the quads instead. Sure enough, I could move a little. I finished walking slowly backwards, much to the delight of spectators and film crews.

The loudspeaker breaks my reflections, “10 minutes till the start of the race. Please make your way to the starting line. Make sure your number and team tag if you are on one is on the front of your jersey.”

My team was one man short for scoring in this grand prix championship event. I had dedicated my performances in the grand prix to my cat, Windy, who lost her battle with cancer several months earlier. Some people are musicians and can write a song. Others are artists and paint or sculpt a masterpiece. I only have a reasonably fast pair of legs to define who I am. I raced wearing a tea shirt bearing her picture. I had run superbly in those earlier races but figured I would end my season before the marathon. Here was my chance to put an exclamation point on that tribute.

“We'd like to give tribute to the Mayor of West Warwick...” the starters bullhorn droned on. The rain, thunder and lightning had ceased. The weather was finally starting to cooperate as they ended the V.I.P. introductions.

Our introduction was awkward at best. This cream and blue calico cat came out of a side alley begging for food. She was a full grown cat that was emaciated down to just 4 pounds. My wife asked someone on the porch of a nearby apartment if she knew who the cat belonged to. The person replied that the cat was one of many strays that fend for themselves in the alley behind the building. Faster than you spell hooked, she brought the cat home to our no pets allowed apartment and raided our $10 a week food supply for something a cat would eat. I not only lost part of my week's sustenance, but she came right in and ate a spider in the corner of the apartment. I coexisted with this arachnid because it worked better than any can of poison to get rid of biting red ants in the apartment. Now I have a type of animal I never have had any previous contact with eating my precious few morsels of food returning me to a life of ant bites. The cat just stood there and blinked here eyes at me.

I blinked into a stray droplet of rain as the starters gun fired and the race went off. I settled into a comfortable 5:55 pace for the first two miles. Then the course takes a left turn once you reach the Atlantic coast to head northeast for the next 23 miles or so. This normally would not be a problem, except the start weather was just a lull in a powerful Nor'easter. A Nor'easter is October to April precipitation event named for the winds that blow in from the northeast and drive the storm up the east coast along the Gulf Stream. This a band of warm water that lies off the Atlantic coast fuels the storm to make it even more powerful. The winds took any spunk right out of your stride. I worked extra hard to catch up to 3 runners running side by side about 100 yards ahead. Even with the extra effort the pace slowed to 6:10 for the next mile. I already know that the marathon is a long and humbling race. It was time to tuck in behind them and “dog it” for awhile.

I was in a small park near my apartment with Windy on a warm spring day. She enjoyed the outdoors but we tried to do it in a supervised fashion. Suddenly a huge unleashed German Shepherd had her cornered. I rushed into the fray and quickly swooped here up. Windy immediately became calm once in my arms. “You mean she didn't claw you trying to get away,” my wife said, “I never heard of a cat doing that. There's some kind of a special bond between you two.” Windy always considered my lap a safe place to be.

I stayed with that group as if their was a rope around my lap attached to them. Two of them fell off the pace at 9 miles. The other runner took off ahead of me at 10 miles as we passed through in 61:20. I was happy to keep pace and let him go. The rain was really starting to intensify, again. The wind didn't seem quite as bad but still had a bite to it.

I was on the porch of our apartment in Massachusetts. Another cat came across the lawn and became friendly with me. Windy she sat on the other side of me while I pet the cat. She scrunched her eyelids in an disapproving manner. Suddenly the cat bit me on the hand for no apparent reason. Windy growled and leaped over me chasing the cat right off the property. She stopped at the property line whipping her tail back and forth staring down this fleeing feline.

The rain was starting to pick back up as I passed that same runner between mile 14 and 15. At about mile 17 there was a stream coming down a street across my path. It feels more like a steeplechase rather than a marathon. Someone once said that I was so thin that I could run around in a shower and not get wet. However this was no ordinary rain. By mile 18, I was so cold and drenched that I was numb below mid calf on both feet. It was a very strange sensation when running, indeed. At least my feet did not hurt.

There was a wet matted area on the fur of her neck. I found this to be odd for an immaculately clean cat. I brought her in for her 5 month overdue annual check-up. The veternarian found a growth on the underside of her tongue and thought the possible diagnosis was bad. I had him perform an excisional biopsy. The diagnosis was squamous cell carcinoma, an extremely aggressive and deadly cancer in cats. Windy was unusually good for a cat. She took all the pills I gave here without much fuss and even let me give her subcutaneous fluids with a needle to take the stress off of her now straining kidneys. She would give me adoring soulful eye contact even after this painful treatment. It was as if you understood the whole situation.

I hit the 20 mile mark in 2:01:40. I became leery of the dreaded marathon wall that was the start of my undoing 15 years ago.

Sometimes I wondered how she escaped my room to greet patients in my office attached to my home. Then one day I had her in the room with me while I was resting in bed with the flu. I heard a sound and rolled over in bed to see Windy on a chair next to the door. She was “standing” on her hind legs using her two front paws to jiggle the door knob. The door opened and out she went.

Instead I felt better than I had all race. It was as if someone had opened a door in the marathon wall. I picked up my effort through a small village. I felt invincible but knew better than to keep the hammer that far down as the legs started to fatigue at about mile 24.

One day early in June, she felt well enough to issue me the arched back catch me if you can game. I caught her for the first time ever. Rather than gloat about my victory, I fell into a tearful embrace of her. She in turn, looked at me and rubbed her cheek onto side of my face.

Shortly thereafter, we turned out of the wind, but the slowly mounting fatigue made the loss of the wind handicap, unnoticeable. The flooding roads were camouflaging potholes in the road construction as the rain continued to fall. I stepped into one of those potholes with my right foot. It was about 2 feet deep. I went down onto the flooded road face first.

I had a lousy Father's Day. First I was lead off course while running what would have been a nationally ranked masters 10K time. Then I come home to the real bomb. For the first time, Windy won't let me give her the daily medications. At the local animal hospital, they take some tests. The advancing cancer had ulcerated right through the lining of her mouth and could not be repaired. This was causing massive infection which could be controlled by antibiotics but not stopped. The cancer had also spread to hear lungs. I should have known something was up. Usually she sleeps on or next to my legs. That morning, I woke to her on my chest with both front paws in full embrace of my neck. Windy took the journey to the rainbow bridge that following Monday morning. She sat on my lap, the safe place, as the series of three injections were administered to finish the lethal process. It was the most difficult thing I have ever had to do.

Picking myself up out of a 2 foot pot hole in a storm during a marathon was a small hurdle on the steeplechase course of life after black Monday. I got up and made my way up to the finish line. The clock said 2:42 as this weary 43 year old body crossed the line a full 17 or 18 minutes behind the young Kenyan winner. It was not a day for times and records. It was a day for courage and commitments. That was fine by me for I had kept mine to a special fury friend.

The EMT tried to take my wet shirt away from me. “No!” I yelled, “it's source of warmth as I clutched it even closer to me. He completely gave up to attending me after that. But, the pain was leaving and the shirt with her image was warm. The sampling of the memories I have shared of here are tightly woven into my adventures like a strong but beautiful tapestry. Such fabrics resist the fraying stresses that life brings along its journey.