Foot and Ankle Pain - Ask Dr. P

Can Shockwave Therapy Help Plantar Fasciitis?

by Pain Doc | May 16, 2023 | Foot and Ankle Pain, Sprains and Strains

Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment option that is used for various musculoskeletal conditions, including:

plantar fasciitis
iliotibial (IT) band syndrome
shin splints
patellar tendonitis
frozen shoulder (adhesive capsulitis)
tennis elbow (epicondylitis)
post-surgical fibrosis (fibrous tissue growth)

ESWT involves the application of high-energy sound waves to the affected area to stimulate healing and reduce pain. The two main types of shockwave devices are piezoelectric and radial.

Piezoelectric machines have an applicator that contains an array of crystals made of ceramic material that are embedded in a concave bowl. A voltage is applied, which causes the crystals to deform very quickly. This generates a mechanical wave. The waves from the crystal array are focused by the concave bowl and directed into the patient’s body, through which it travels. Piezoelectric machines generate a high pitched, short “tick” sound with each pulse. The pulse frequency is varied by varying the power to the applicator. It is important to note that since the energy waves generated by piezoelectric machines are focused into a small area, treating large areas takes a lot of time/ treatment sessions.

Radial shockwave machines generate an energy wave using kinetic energy. An electromagnet inside the applicator accelerates a metal rod, called a “bullet,” against a strike plate. The strike plates are attachments to the applicator, and come in different sizes. Small attachments will concentrate the wave energy into a smaller area, but again, will require multiple treatments to cover large areas such as for shin splints or IT band treatment. Larger attachments will cover more area, but the energy is attenuated more because of this. Radial shockwave machines generate energy waves that cover more area than a piezoelectric generated wave, but are not as focused.

ESWT for plantar fasciitis:

Procedure: During ESWT, a handheld device delivers shockwaves to the plantar fascia, which is the tissue causing the pain and inflammation. The shockwaves help to break up scar tissue, promote blood flow, and stimulate the healing process.

Treatment sessions: ESWT is typically administered in a series of sessions, usually spaced about one week apart. The number of sessions required can vary, but it typically ranges from three to six sessions.

Effectiveness: ESWT has been shown to be effective in relieving pain and improving function in many patients with plantar fasciitis. Research studies have demonstrated positive outcomes, with reductions in pain and improvements in foot function.

Side effects: ESWT is generally considered safe, and serious complications are rare. However, some individuals may experience mild side effects such as temporary pain, redness, bruising, swelling, or numbness in the treated area.

Post-treatment: Following ESWT, it’s important to follow your healthcare provider’s instructions for post-treatment care. This may include rest, ice application, stretching exercises, and avoiding activities that may aggravate the condition. Physical therapy and orthotics may also be recommended to aid in the recovery process.

Suitability: ESWT is typically considered when conservative treatments, such as rest, stretching, orthotics, and medications, have failed to provide sufficient relief. Your healthcare provider will assess your individual case and determine if ESWT is a suitable option for you.

It’s worth noting that while ESWT can be effective for many people, individual results may vary.

Since it is a relatively save procedure with rare serious side effects, extracorporeal shockwave therapy is safe to do at home. There are personal devices available such as this one that allow consumers to apply the treatment to themselves. While it isn’t cheap, it is a fraction of the cost of the professional models and is just as effective.

The benefits of owning your own extracorporeal shockwave machine is that, if you have a chronic problem, such as in your shoulder, that surfaces a couple times a year, you can save a lot of money by doing the treatment yourself. A typical ESWT treatment at a physical therapist or chiropractor office runs anywhere from $50-$200/treatment, and they require you to get at least six; often more.

Bottom Line: whether you seek Extracorporeal Shockwave treatment from a therapist, or invest in your own machine, it can help your body heal from slow-healing soft tissue injuries by breaking down abnormal scar tissue and stimulating regeneration of newer tissue.

The 30 Day Pain Relief Challenge Kick Off

by Pain Doc | Jan 4, 2021 | Foot and Ankle Pain, Hand and Wrist Pain, Hip Pain, Knee Pain, Leg Pain, Low Back Pain, Neck Pain

It’s 2021 and time to kick off the 30 Day Pain Relief Challenge!

But first I want to acknowledge what’s on everyone’s mind.

2020 began with an unexpected crisis, the COVID-19 pandemic. A new corona virus strain emerged; highly contagious and deadly for certain individuals, and for which there was no vaccine. As of this writing, over 85 million people worldwide have contracted the virus, with 1.85 million dying from it. The United States is being hit the hardest, with 20.8 million cases and 352,000 dead. The numbers are expected to spike following the holiday season, thanks to many people choosing to get together in large groups and ignoring the risk. So please, remain extra vigilant the next two weeks because chances are, there are more viruses around you than there were a month ago, ready to find a new host.

As we navigate through COVID-19 in 2021, life must still go on. I know many have been hurt economically, and their number-one priority is to find a way to get back on their feet. It is not an easy thing to do, especially if you lost your job and the life skills you possess are in an industry that has been permanently impacted by the pandemic. If this describes your situation, I sincerely hope you find a way to re-position or re-invent yourself, to get back to earning a living.

While COVID-19 dominates the news and peoples’ attention, we must not lose focus on the many other challenges life presents that also need our attention. How would you rate your health at the start of the new year? How about your energy levels and endurance?

Quarantining and social distancing have a way of discouraging exercising and promoting over-eating, a terrible combination to health. When one is restricted from going outside and going to a gym (although a gym is not necessary for staying fit, but I digress…) and constantly bombarded by news of doom and gloom, the tendency is to stay home, surf the web, and eat, more than you typically do (what else is there to do in such a scenario?). And for many, the choice is high-calorie comfort food. This can lead to unwanted weight gain, muscle atrophy, joint pain, and so on.

If you are not feeling 100%, then I encourage you to open all the emails I’ll be sending over the next 30 days—the 30 Day Pain Relief Challenge is about to kick off, and email is how it will be executed.

And what exactly is the challenge? It’s about challenging yourself to get out of your comfort zone and do all the things I will suggest in the coming days so that you can get out of pain, or significantly knock it down to levels you haven’t experienced in a long time.

The other reward may be that you will lose 10 pounds or more; will have more energy, and will notice that your mind/ thinking is clearer. This is because the methods I’ll go over target your body and all its systems; not just the area of pain. It is wholistic.

But first let me explain how you will be measuring your results. After all, pain is subjective. You need some kind of tool to quantify your improvement, so read on.

Pain, aches, discomfort or whatever you want to call it affects your health. There is mental health and physical health; both important to happiness in different ways. Your physical and mental health are impacted, even just a little and perhaps unnoticeable to you, if you have chronic pain/aches/discomfort. Less-than-optimal physical and mental health impacts quality of life. Quality of life in this sense refers to your ability to physically do what you need or want to do; whether it be your job; recreational activity such as playing golf or swimming; or activities of daily living; i.e. taking care of yourself and your personal needs.

Why You Might Have a Disability if You Have Pain

If you live with chronic pain, you likely have some degree of disability.

“Me disabled?” you might be thinking. “No way!”

The word “disability” is often misconstrued. Disability doesn’t necessarily mean “disabled” and in a wheel chair. It simply means not being able to perform a certain task without some degree of difficulty or impediment; or not being able to do it at all.

Doctors (medical examiners) who issue disability certificates or write medical-legal reports are tasked to determine the degree to which someone is disabled. Their findings determine the patient’s disability compensation from the insurance company or government agency. They use observation, physical exam procedures, diagnostic tests like X-rays and nerve conduction; and instruments to measure strength, pain perception, reflexes, coordination, and range of motion. Any deficiency is expressed as a percent disabled, and there are laws that define levels of disability.

For example, in the insurance industry, the loss of both eyes, or the loss of two limbs equates to “100% disability.” Not being able to maintain a tight grip could be rated as 20% disability if the person’s occupation requires power gripping machinery.

Disability can also be subjectively quantified using Disability questionnaires where the patient rates his/ her ability to perform certain tasks on a scale of zero to some number; and the level of pain. In some questionnaires, the zero rating means you have zero difficulty doing the task (best score), while in others the zero rating means you cannot do the task at all (worst score).

For example, the following is one section of the Oswestry Low Back Pain Disability Questionnaire. Imagine having low back pain and rating yourself (0 to 5) on your ability to lift things:

LIFTING:

0 – I can lift heavy weights without extra pain

1 – I can lift heavy weights but it gives extra pain

2 – Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, i.e. on a table

3 – Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned

4 – I can lift very light weights

5 – I cannot lift or carry anything at all

When rating yourself, you must try to be as objective as possible—don’t over rate your ability; nor under rate it. Give each question some thought.

Then, you add up the numbers, divide it by the total number of points and multiply by 100 to get a percentage score.

If the zero rating is assigned to “full ability to do the task” (like the Oswestry above), then the score is interpreted as “percent disabled.” So, an individual with no low back disability whatsoever will score zero out of 50 and his rating will therefore be zero percent disabled; i.e. 100% functional. If his score is 30, then 30/50 x (100) = 60% disabled.

Below is an example of an Oswestry Low Back Pain Disability Questionnaire completely filled out:

oswestry low back pain disability questionnaire

In the above example, the total points out of all ten questions is 19, which is considered a Moderate disability, out of No, Mild, Moderate, Severe and Total Disability. In this case, 19/50 x 100 = 38% disabled due to low back pain. Now this person has a baseline for his condition, and can set goals to lower it each time; perhaps to 20% after a month, then 10% after three months of therapy.

If the zero rating is instead assigned to “no ability to do the task,” the score is interpreted as “percent functional.” This is how the Upper and Lower Extremity Disability questionnaires are designed. So a score of zero in this case means zero percent functional (totally disabled), and 30% means you are 30% functional (you lost 70% function in that limb).

Please note that Disability questionnaires are used as tools to quantify and set baselines for pain and functional capacity; your scores do not officially establish any disability you may have, they simply provide a more tangible interpretation of pain.

Quantifying pain/disability, even if subjective, gives you a sense of how significant it is; i.e. how much it affects your life. Secondly, it can be used as a tool to measure your improvement over time, after doing some therapy and/or rehabilitation (strength and coordination exercises). This lets you know if what you did works for your condition, and therefore, whether to continue or discontinue it.

For example, if your baseline Oswestry score was 60%, and you were prescribed some McKenzie exercises for one week and a follow- up score was 40%, it suggests that those exercises improved your condition and you should continue or progress to the next level. If it was 60% or higher, you should discontinue the exercises and try another approach.

You don’t have to see a doctor to use Disability questionnaires to subjectively assess your disability. They are fairly straightforward to use and you can download the forms from the internet (see below; I’ve done it for you).

Determine Your Pain/Disability Baseline

If you have low back pain, neck pain, shoulder pain, or lower or upper limb pain then I suggest monitoring your condition using the appropriate disability questionnaire. If you are getting therapy, your doctor should be having you fill these forms (or something similar) out each visit and going over the results with you. It’s substandard care if you don’t know if the therapy you are getting or exercises you are doing is helping; these questionnaires will prompt you to think about the change or lack of change in your functional capacity, and will help you assess your care so that you can take appropriate action.

Below you will find forms to assess any musculoskeletal pain you are having. If you wish to participate in the 30 Day Pain Relief Challenge, print out the appropriate disability questionnaire; rate your abilities as objectively as you can and calculate your score; set it aside, and be ready to fill out a new questionnaire after 30 days of diligently doing the things I will cover over the next 30 days.

My goal is for participants to experience at least a 50% improvement in their pain/ disability scores. If you have any friends who might be interested in participating, please refer them to my site, https://PainandInjuryDoctor.com and have them enter their email in the opt in form.

Download the Low Back Pain Disability Questionnaire

Download the Neck Pain Disability Questionnaire

Download the Shoulder Pain and Disability Index Questionnaire

Download the Upper Extremity Disability Questionnaire

Download the Lower Extremity Disability Questionnaire

Can Custom Foot Orthotics Help Back Pain?

by Pain Doc | Dec 25, 2011 | Foot and Ankle Pain

Shoe orthotics are custom made shoe inserts that doctors (podiatrists, chiropractors and orthopedic MDs) use to help patients suffering from foot, ankle, knee, hip, or back pain. The concept is that, since the feet are literally the foundation of a standing human body, any problems in the foundation will translate to problems further up the body.

If you stop to consider this, it makes a lot of sense. You don’t have to have any special training to realize the connection. For example, if the foot rolls inwards when walking (called prontation) it can place twisting forces in the knee and hip. This will require more effort from the locomotor muscles, which are not only your leg muscles, but also your gluteus (buttock) muscles and psoas muscle (major hip flexor) which attaches itself to the lumbar (lower back) spine. This happens subconsciously behind the scenes, but you will definitely notice the effects: pain in the weight bearing joints, back stiffness, reduced mobility/agilitiy, and fatigue.

Take a moment to look at the soles of your shoes (find an old, heavy-used pair in your closet). Are they worn out a lot more on the inner edges? If so, chances are you are over-pronating. This is common with people who have flat feet, or “fallen arches.” If this is the case, a pair of shoe orthotics shaped in a way to counter the rolling-in action can be prescribed. They may be rigid or semi-rigid, depending on what the doctor thinks is more appropriate. If the rolling in can be minimized by the shoe orthotic, then there will be less twisting forces to the knee and hip, resulting in a more efficient gait (walking motion) and less strain to the lower back.

A May 2011 study in the Journal of Manipulative Physiological Therapeutics studied the effects of custom shoe orthotics on a test group of 50 people experiencing lower back pain. Some were treated for 12 weeks with the orthotics, some had no treatment, and some were treated for 6 weeks. It found that from 0-6 weeks of treatment, there was improvement in subjective scores for pain. From weeks 6-12, improvement was maintained, but did not continue to improve. The people who did not use orthotics continued to experience the same level of pain.

These findings suggest that there is a relationship between foot biomechanics and lower back pain, and that improvements can be effected by correcting imbalances in the foot. However, it also suggests that more studies are needed. What I take from it is that orthotics prescription is appropriate when indicated for treating lower back pain, but must be complemented with other types of interventions, depending on the case. This may include exercise rehabilitation, somatic exercises, nutrition, and spinal manipulation.

If you desire to get custom made foot orthotics, you can seek out the services of a podiatrist. Some chiropractors can prescribe orthotics as well. Two of the main brands chiropractors use are Amfit and FootLevelers. An off the shelf brand that I have found success with is the WalkFit orthotics. These come with a gel cushion for the heel and acupressure massage surfaces to help with blood circulation. If you wear sandals, which can pose a problem for traditional, doctor-prescribed orthotics, the come with sandal attachments. Plus, they are a lot less expensive; less than $20.

To Run Barefoot or Not?

by Pain Doc | Dec 9, 2011 | Foot and Ankle Pain

If you suffer from foot pain, knee pain, or lower back pain of unknown origin, then it might be related to your shoes: Scientists recently held a conference in England to debate shoe running vs. barefoot running. Over the last five years, the barefoot movement has gained a lot of recognition among runners and experts in human biomechanics. I wrote about the merits of going barefoot last year. The movement was apparently started by the book “Born to Run” by Christopher McDougall. In it, he tells of time spent with members of Mexico’s indigent Tarahumara tribe, who routinely run long distances barefoot, often very fast, apparently without suffering the injuries that plague many avid runners in the developed world.

The issue is whether or not putting on a pair of running shoes implicitly causes the person to run in an unnatural way; a way that goes against nature’s design, due to a “false sense of security” offered by the thick cushioning of the shoes, especially in the heel and arch.

In a study published in the scientific journal Nature last year, Daniel Lieberman, an evolutionary biology professor at Harvard University, sought to find out how our ancestors, who ran and hunted for millions of years in bare feet or simple moccasins, coped with the impact of the foot hitting the ground.

Lieberman and colleagues from Britain and Kenya studied runners who had always run barefoot, those who had always worn shoes, and runners who had abandoned shoes.

They found that barefoot endurance runners often land on the fore-foot (the ball of the foot) before bringing down the heel, while shoe runners mostly rear-foot (heel) strike, prompted by the raised and cushioned heels of modern running shoes.

The study further discovered that barefoot runners incur less collision forces on their feet compared to shoe runners, despite the heel cushioning of the shoe, and that they use their calf muscles more efficiently.

As of this date, there isn’t a large scale study that gives definitive data on what is better for the human body, going barefoot or wearing shoes. People are taking sides based on their beliefs, biases and experiences. Major athletic shoe companies generally are against the barefoot running idea, for obvious reasons; but some are experimenting with “minimalist” shoes to capture this growing market. These are shoes that offer protection to the feet but with the least amount of restriction.

My take on this: it makes a lot of sense to walk and run barefoot. It is a natural act, and it’s tough to argue against nature because it has its ways of cancelling out bad traits. Our human ancestors walked and ran barefoot for millions of years, and were fine. I believe that walking barefoot exercises the muscles and small joints of the foot and takes more of the load off the knees, hips and pelvis in doing so. On the contrary, wearing shoes binds the feet, prevents the foot joints from doing their job of distributing the body weight and cushioning the shock, and makes the leg and back muscles work in a less efficient manner. It is easy to see how this can result in lower back problems. So, walk barefoot more than you currently do– not just in the house, but on pavement, hilly terrain, and the nearest park. Then, when you feel that your feet have acclimated to the new sensations, give barefoot running a try!

Handling Foot Fatigue and Plantar Fascitis

by Pain Doc | Apr 23, 2011 | Foot and Ankle Pain

As you age, the tendons and ligaments in your body get weaker/looser, which changes the dynamics of your joints. It’s probably related to the decrease in human growth hormone levels as we age.

Tendons attach muscles to bones, while ligaments attach the ends of bones forming a joint. The area that you will notice first when your ligaments weaken are your feet, as they bear all the body’s weight when standing.

I’ve noticed that my feet have flattened over the last ten years (I didn’t have big arches to start with). When your feet flatten, a couple of things can occur:

1. You will walk slower. The foot arch is like a mechanical spring device that is integral to bipedal locomotion: in mid-step, it loads up potential energy (using the plantar fascia– a broad ligament in the sole of the foot), and in toe-off helps push off the foot from the ground and initiates forward leg swing (think of a steam catapult on an aircraft carrier, assisting jets to take off and fly). When your feet flatten, you lose a lot of this ability and have to rely more on your leg muscles to walk.

2. You can develop calluses under your metatarsal joints (ball of the foot). The flattening effect places more pressure on these joints when you stand.

3. You can develop foot pain and fatigue.

4. You can develop ankle, knee, hip, and lower back pain.

#s 2, 3 and 4 are more likely if you are overweight.

If you have any of the above symptoms, and have flat feet, here are the things you can do to lessen the effects:

1. Take joint supplements that support healthy connective tissue.

2. Eat bone broth soup to give your body a ready supply of the building blocks of collagen, which is the main component of connective tissue.

3. Get foot reflexology treatment. I go to this local Chinese massage center that does Asian foot massage. It is one of those painful pleasures– after soaking your feet in a hot water tub for 15 minutes, the therapist kneads out all the sore spots under your feet, including the small muscles of the toes. My feet feel great afterwards.

4. Roll a golf ball under the sole of your feet: back and forth, and in circles. Do this while you’re sitting, and control the deepness of the massage by varying the amount of pressure you place on the golf ball. Great exercise to do while sitting at your desk; your co-workers won’t even know you’re doing it as they pass by.

5. Walk barefoot outside, as much as you can. This exercises the intrinsic muscles of the foot, and all the small joints. You do not get this benefit if your feet are constrained in a shoe.

6. Consider wearing a foot shoe, like the popular Vibram Five Fingers brand. This lets your toes move independently when walking, which exercises the foot muscles, and is the next best thing after going barefoot.

Relieving Foot Pain from a Morton’s Neuroma

by Pain Doc | Mar 11, 2011 | Foot and Ankle Pain

If you notice a gradually developing pain in your forefoot (just past your instep) between the tarsal bones of the 3rd and 4th toes that is worse when you press it between your thumb and index finger, you most likely have what’s called a Morton’s Neuroma.

Despite it’s name, it is not a true tumor. It is a buildup of fibrous tissue that surrounds the sheath of one of the nerves that innervate the foot. The nerve lies between the muscles that connect the tarsal bones and due to the fibrous buildup gets compressed within this narrow confine. It is worse when standing and walking.

Morton’s neuromas are usually treated with orthotics (custom shoe inserts to help counter flat arches, over pronation, or other abnormalities of the foot) and cortisone injections to the painful nerve. Sometimes surgical removal of the excess fibrous tissue is done if the condition does not resolve.

A simple remedy that can provide welcome relief, and perhaps allow the nerve to heal faster is inserting rolled up gauze or cotton between the 3rd and 4th toes. This spreads apart the tarsal bones and creates more room for the nerve. Sometimes simple things make for effective remedies, and this is one of them.