Posts for: August, 2013

Heel pain is easily treated

Foot care
By Michael Zapf
Special to the Acorn


“I hate putting my foot on the floor in the morning. It feels like a nail in my heel,” said Carolee when I asked her about first step pain.

She was describing a common symptom of the most frequently seem problem in a podiatry office: the first step pain after periods of rest seen with plantar fasciitis.

The pain is usually caused by the too-strong pull of connective tissue that stretches from the toes to the heel. At one time the plantar fascia was useful to its owner by making the foot rigid when climbing barefoot, but now it seems its most important job is filling podiatry waiting room chairs.

Like many patients, Carolee was worried about having a heel spur, imagining a boney spike on the bottom of her heel. I could see one on her X-ray, but she was skeptical when I told her that it was not the cause of her pain.

In fact, about 40 percent of patients without heel pain have a spur and half of all patients with heel pain do not have a spur. As proof that the heel spur is not the cause of pain, surgery, which is rarely done anymore, usually just involves cutting the fascia, leaving the spur alone. It is routinely successful.

Carolee demonstrated the most common causes of the overuse of the plantar fascia: being overweight, wearing flimsy shoes while working and walking on hard surfaces. She worked in retail in sandals and was walking to lose weight in flexible deck shoes. (This is not to say that underweight men who wear dress shoes cannot also have this pain.)

Carolee suspected, correctly, that her flat feet contributed to her problem by excessively stretching her fascia.

When she arrived at my treatment chair, I touched a spot on her heel where the fascia inserts on the heel bone and she jumped a little, indicating that she had pain in the correct location for plantar fasciitis. (Sorry, Carolee). I measured the thickness of the fascia with ultrasound, and it was an overly large and painful 7 mm thick. Her other heel, the one without pain, was a normal 3 mm in thickness. Normal thickness is up to 4.3 mm.

The ultrasound measurement has become the easiest confirmation method used and is especially useful for atypical plantar fasciitis, where the problem is not exactly at the insertion site of the fascia on the heel. Here it can be used to guide injections into the correct location for greater effectiveness.

The treatment provided at this first visit was a special, almost magical, tape strapping called a low-Dye, after Dr. Ralph Dye, who first described it. The tape will often stop the pain in its tracks. This works so well that I use a positive response to the tape as one of my four criteria to make a presumptive diagnosis of plantar fasciitis; the other three being first step pain, pain with pressing on the insertion spot and thickness of the fascia over 4.3 mm on the ultrasound.

Home instructions for Carolee included wearing stable shoes; using an over-the-counter arch support; reduction in the most forceful activities like the treadmill in favor of cycling, swimming or a healthrider; and the application of ice to the heel for 20 minutes several times a day.

For icing I recommend using a plastic bottle filled with water that has been frozen. Sometimes patients can learn to apply the low-Dye on their own; videos are available on YouTube.

Over-the-counter medications like two or three ibuprofen two or three times a day are often helpful. Wall stretches of the Achilles tendon and plantar fascia are also helpful. The technique is available on the Internet.

If the low-Dye strapping is consistently more helpful than over-the-counter arch supports, more effective custom orthotics can be made. If patients wear a stable shoe, they can often achieve pain relief with custom orthotics.

Unfortunately Carolee could not be talked out of her sandals and deck shoes because, as she said, her feet “get too hot,” requiring another approach. For immediate pain relief I injected a little cortisone near her fascial insertion site, and she received profound pain relief. Cortisone injections in the heel are safe and effective, and usually can be done with little to no pain.

For more resistant pain I can repeat the injections up to three times, and physical therapy can do marvelous things with the techniques and tools at their disposal. Our office has the luxury of two inoffice licensed physical therapists.

Statistics show that, on average, heel pain resolves on its own in 18 months. These techniques can certainly improve on that, so Carolee does not have to wait until 2014 for relief.

For those few that do not resolve in an appropriate time period, both high-energy shockwave therapy and surgical approaches that are described on the website below are available.

Meanwhile, three low-Dye strappings and two cortisone injections have helped Carolee become pain free. Now all she fears in the morning is her alarm clock.

Dr. Michael Zapf, along with his partners, Drs. Darren Payne and Steve Benson are podiatrists with offices in Agoura Hills and Thousand Oaks. For more information on plantar fasciitis, call the office at (805) 487-6979 or visit

Bare feet in the office: How hygenic is kicking your shoes off in the work place?

Article Image
SHOES OFF: Office worker's feet up at work

By Daisy Yates

Bare feet in the office: a harmless way to cool off? Or a health and safety issue that isn’t too nice to see or smell either?

MM investigate free feet and get the lowdown from a University of Salford foot expert on what the dangers really are.


Though to some it is a harmless way to cool off or relax during an unbearable and seemingly endless day in the office, bare feet airing off under the desk are a lot of people’s worst nightmare.

Sometimes it’s pure desperation that drives us to a wriggle of the toes under the desk; that can be forgiven.  

The true crime, it seems, is that one co-worker who capers around the office airing their hobbit feet for the whole world to see (or smell.)

Perhaps it’s just prudish and petty to hold such a vendetta against shoeless colleagues but nevertheless a significant portion of office workers class it as a major pet peeve.

 Nick Clegg has revealed he’s prone to kicking off the leather and adding a fresh and possibly more pungent thorn in Mr Cameron’s side.

The Deputy Prime Minister admitted his indiscretions to LBC radio: “I was padding around in my office without my shoes on yesterday, but obviously in public events when I have to respect the dignity of the office I put my shoes back on.”

Clegg added: “I’m perfectly relaxed actually about people who work in my office, as long as they’re not doing public facing jobs where they have to obviously keep up appearances, but if they’re in their offices working hard, as they do, I’m very keen that they shouldn’t overheat.”

However, evidence suggests that an overwhelming number of people find it offensive when their colleagues traipse around the office without shoes on and Mancunians were no exception. 

Beverley Edwards, 44, who works in an office in the city centre, said: “Personally this is something that I would never do, purely for health and safety purposes.

“However I did have the misfortune of sitting beside somebody in the workplace who used to slip their shoes off occasionally, the disgusting smell that lingered can only be described as stale cheese.”

Bethany Eaton, a 19-year-old office worker from Hale, said: “People should keep their shoes on because they should respect other people’s opinions and it’s not nice to smell feet when you’re trying to work.”

Jo Forrest, 47, working in Bowdon, agreed.

“It depends if they’re just at their desks and if their feet don’t smell,” she said. “But if they smell and they’re walking around the office with no shoes on then there’s no excuse. They should be forced to keep their shoes on and if their boss has to get involved then so be it!”

A survey conducted in the US by recruitment firm Adecco last July confirms the general disapproval of this behaviour with 43% of the 1,010 participants saying they don’t like co-workers going barefoot in the workspace.

A further 76% also thought that flip flops were inappropriate for the workplace – even in summer.

Yet boldly going against this is the Barefoot Alliance – an ‘advisory board’ apparently made up of bare-footers and scientists.

Founded in 2010, the alliance declare their prime objective is to make society more ‘barefoot friendly’.

“We CAN live barefoot even in the developed world, and even in public,” their website states. “We advocate for people to go barefoot and let feet live free in their innate condition.”

They claim that there are no laws in the UK or US against walking around barefoot and even driving barefoot (aside from riding a motorcycle in Alabama, apparently) – though they admit many shops will have their own rules on what is allowed.

But what about in the office?

The Barefoot Alliance believe kicking the shoes off in work will actually make you moreproductive.

Citing The National Institute for Occupational Safety and Health’s assessment that environmental conditions – including ergonomics involving chairs, desks, shoes – are contributing factors to workplace stress, the alliance believe the solution is simple: kick off your shoes!


They even refer to German ergonomics researcher Dr. Dieter Breithecker, who claims that putting the bare soles of your feet in contact with different sensations will help to relieve tension and reduce stress.

“If we're more comfortable and have less non-work-related problems on our minds –like how uncomfortable our shoes are – we can focus better on the tasks at hand,” the alliance claim. “Better focus means higher productivity.”

But what about the health implications?

Aside from the smell, one of people’s biggest fears is being in a cramped office with someone’s bunions, boils, athlete’s foot, fungal infections, bacteria build-ups, corns and calluses exposed to the air conditioning and carpet underfoot. Sound pretty gross, right?

Well the alliance still believe going barefoot is the solution.

“Barefoot workers will also have healthier feet,” they say. “If an employee can avoid sticking their feet in cramped, uncomfortable shoes for eight hours or more each day, they will be far less likely to deal with common shoe-caused afflictions that remove workers from the job.”

But curing your bunions in the workplace doesn’t sit right with all office workers.

Joe, 32, works for a South Manchester-based accountancy firm.

“I don’t care if airing your feet might eventually mean your feet will be healthier,” he said.

“Before getting to that stage you have your athlete’s foot and fungal infections out in the office, dropping bits of skin everywhere and walking on the same carpet everyone else walks on – it’s simply disgusting and unhygienic, and there's no excuse for it!”

But how unhygienic is it really?

MM caught up with Senior Lecturer in Podiatry at the University of Salford, Dr Anita Williams.

Myths of potential feet-induced epidemics as fungi go airborne through the air conditioning were busted by the foot-expert.

She told MM: “It depends on the environment but in a carpeted area the chances of infection are unlikely.

“The risk is minimal, it isn’t really an issue, it’s only a problem in places like a swimming pool.”

She added: “Sweaty feet are more likely to spread the spores and viruses that cause fungal infections and verrucae.”

Instead, Dr Williams warned of the health and safety ramifications for those actually going shoeless.

“Walking barefoot isn’t an issue but shoes are a good protective mechanism, especially for foot conditions like flat feet, wearing the right shoes can really help,” she said.

“There’s obviously the danger of dropping objects on your feet or walking on things like drawing pins which may be a problem with health and safety, but otherwise it won’t cause any damage.”

Picture courtesy of Slyworking2

August 22, 2013
Category: Uncategorized
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Health Tip: Fit Your Teen's Feet

(HealthDay News) -- Trying to find the right athletic shoes to fit your teen's growing feet?

The American Podiatric Medical Association offers these guidelines for choosing a teen's athletic footwear:

  • Choose the right shoes for a specific activity, such as basketball shoes or running shoes.
  • Take your teen to a store that specializes in athletic shoes.
  • Choose shoes that fit well in all areas of the foot and offer plenty of support.
  • Inspect the tread and replace the shoes when they show signs of wear.

- Diana Kohnle

August 22, 2013
Category: Uncategorized
Tags: Untagged


Diabetes affects 26 million people in the US and more than 366 million people worldwide. Diabetes Association

The top 10 diabetes nations 
International Diabetes Federation /
Diabetes kills more people annually than breast cancer and AIDS combined.
American Diabetes Association, 2009

80% of people with diabetes are from low and middle income nations
International Diabetes Federation, 2012

The number of people with diabetes is increasing in every single nation
International Diabetes Federation/World Health Org 2012

Half of people with diabetes don't know they have it.
American Diabetes Association / International Diabetes Federation, 2012

Quiet. Slow. Deadly. Expensive: Chronic Diseases Account for 75% of our Healthcare Costs.



Seconds Count: Every 7 seconds someone dies from diabetes. Every 20 seconds someone is amputated. 

International Diabetes Federation /
Armstrong, et al, Diabetes Care 2013 , In Press
By 2030, at least 550 million people will have diabetes- approximately 10% of the world's adult population.
International Diabetes Federation (IWGDF), 2011

There are now approximately 79M people with pre-diabetes in the USA
That is the equivalent of the total population of 30 states. 
American Diabetes Association, 2012
2010 United States Census

The population of diabetes in the USA is greater than the population of the nation's 10 largest cities.
American Diabetes Association, 2012
2010 United States Census

The population of Diabetes in Arizona (home of SALSA) would make it the fourth largest city in the state.
American Diabetes Association, 2012
2010 United States Census


60-70% of those with diabetes will develop peripheral neuropathy, or lose sensation in their feet.
Dyck et al.  Diabetic Neuropathy 1999
More than 90% of people with diabetic peripheral neuropathy are unaware they have it.
Up to 25% of those with diabetes will develop a foot ulcer.
Singh, Armstrong, Lipsky.  J Amer Med Assoc 2005

The yearly incidence of diabetic foot ulcers ranges rom 2% to 32%, depending on ADA risk classification
Boulton, Armstrong, et al, Diabetes Care 2008
Lavery , et al, Diabetes Care  2008
Sibbald, et al, Adv Skin Wound Care, 2012

More than half of all foot ulcers (wounds) will become infected, requiring hospitalization and 20% of infections result in amputation.
Lavery, Armstrong, et al.  Diabetes Care 2006
Diabetes contributes to approximately 80% of the 120,000 nontraumatic amputations performed yearly in the United States.
Armstrong et al. Amer Fam Phys 1998
"Every 20 seconds, somewhere in the world, a limb is lost as a consequence of diabetes"
DFCon11, Bakker (after Boulton),
Boulton, The Lancet (cover), Nov. 2005
After a major amputation, 50% of people will have their other limb amputated within 2 years.
Goldner. Diabetes 1960
Armstrong, et al, J Amer Podiatr Med Assn, 1997
More than half of people with  osteomyelitis of the heel will undergo high level amputation
Faglia, et al, Foot Ankle Int, 2013
The relative 5-year mortality rate after limb amputation is 68%. When compared with cancer – it is second only to lung cancer (86%).  (Colorectal cancer 39%, Breast cancer 23%, Hodgkin's disease 18%, Prostate cancer 8%)
Armstrong, et al, International Wound Journal, 2007
Amer Cancer Society; Facts & Figures 2000
Singh, Armstrong, Lipsky et al. J Amer Med Assoc 2005
Icks, et al, Diabetes Care, 2011

Median time to healing for diabetic foot wounds: 147,188, and 237 days for toe, midfoot and heel ulcers.
Pickwell, et al, Diabetes Metab Res Rev, 2013 

People with a history of a diabetic foot ulcer have a 40% greater 10 year mortality than people with diabetes alone.
Iversen, et al, Diabetes Care, 2009
Every 30 minutes a limb is lost due to a landmine.
Every 30 seconds, a limb is lost due to diabetes.
Bharara, Mills, Suresh, Armstrong, Int Wound J, 2009
  1. Having a wound immediately doubles one's chances of dying at 10 years compared with someone without diabetes.
  2. Iversen, et al, Diabetes Care2009
    One third of patients seeking care for ischemic wounds die unhealed
    Elgzyri, et al, Eur J Vasc Endovasc Surg, 2013

    For people on dialysis receiving an amputation, 2 year mortality is 74%
    Ndip, et al, 2012, Diabetes

    Diabetic foot ulcers double mortality and heart attack risk while increasing risk for stroke by 40%
    Brownrigg, et al, Diabetologia, 2012

    Chronic wounds affect some 8 million Americans each year. That's one wound every 3.8 seconds in the USA, alone.
    Harsha , 2008 and Tomic-Canic 2010
    Each $1 invested in care by a podiatrist for people with diabetes results in $27 to $51 of healthcare savings.

    JAPMA, 101(2), 2011

    Podiatry care not only reduces amputation risk, but also dramatically impacts rate of hospitalization and reulceration
    Gibson, et al, Int Wound Journal, 2013

    Podiatric medical care in people with history of diabetic foot ulcer can reduce high level amputation from between 65% and 80%
    Gibson, et al, Int Wound Journal, 2013

    Instituting a structured diabetic foot program can yield a 75% reduction in amputation rates and a near four-fold reduction in inpatient mortality
    Weck, et al,  Cardiovascular Diabetology, 2013

What to do about top 5 foot woes

From athlete's foot to bunions, we've got cures for foot concerns. 

By Nancy Ripton

What to do about top 5 foot woes
1. Warts
What they are: Bumps caused by a viral infection 
Why you get them: The wart virus enters through small (even invisible) cuts and abrasions, usually when you’re barefoot. 
How to prevent or treat them: If left untreated, warts can grow to an inch or more in circumference and can spread into clusters. Visit a podiatrist to make sure the bump is a wart and not a corn or callus. Your doctor may use liquid nitrogen, another chemical or a laser to remove the wart. Avoid using over-the-counter wart treatments. They contain acid that can inadvertently destroy the healthy surrounding tissue. In particular, people with diabetes should steer clear of these treatments.
2. Athlete's foot
What it is: A skin fungus
Why you get it: It develops when sweaty feet are trapped in shoes.
How to prevent or treat it: Avoid wearing the same shoes every day and put wooden shoe trees in your shoes between use. To treat the fungus, apply a topical antifungal cream once or twice a day. Call a podiatrist if it’s not effective. Don’t just ignore it. “Athlete’s foot can lead to toenail fungus,” says Dr. Sheldon Nadal, a podiatrist in Toronto. Nail fungus is much more serious and requires lasers or pills to treat. 
3. Plantar Fasciitis
What it is: Heel pain (that’s especially pronounced when standing) caused by excessive pressure on the main ligament in the sole of the foot 
Why you get it: Plantar fasciitis is highly unpredictable, but it can often 
be found in people with flat feet and tight calves.
How to prevent or treat it: “It’s difficult to predict what will work,” says Dr. Timothy Kalla, a podiatrist in Vancouver. Options include: orthotics, stretching, physical therapy, oral anti-inflammatories, cortisone injections and Botox. There are even special socks, called Strassburg Socks, that can be worn at night to help alleviate pain by stretching your calves while you sleep. “The problem is, you need to sleep on your back with your legs straight for the socks to be effective,” says Kalla.
4. Morton’s Neuroma
What it is: Intermittent pain caused by a pinched nerve between toes 
Why you get it: It’s usually the result of tight, uncomfortable shoes. 
How to prevent or treat it: Wear comfortable open-toed shoes. 
You can also wear metatarsal pads between your toes, get cortisone shots or, in extreme cases, have surgery. 
5. Bunions
What they are: The swelling of misaligned big toe joints, causing the first joint of the toe to slant outward and the second joint inward, toward the other toes.
Why you get them: Bunions tend to be hereditary, but they can be aggravated by narrow shoes.
How to prevent or treat them: Wearing wide, comfortable shoes 
will help.

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