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Do I really need surgery for heel pain?

Heel pain is one of the most common ailments experienced in the foot. It can be very debilitating, and in its severe state can be crippling. Heel pain is for the most part caused by chronic injury to a band of tissue on the bottom of the arch called the plantar fascia (plantar fasciitis). Contrary to popular belief, it is very uncommon for a bone spur in the heel to be the actual source of pain, although they are commonly found with plantar fasciitis. This spur is positioned parallel with the ground off the heel bone, and can extend in the direction of the toes maybe a half of an inch when severe. The spur itself simply extends the bottom platform of the heel bone, as it is not directly stepped on. Unless the spur fractures off the heel bone (which is uncommon), or unless there is a rare formation of a spur that points down to the ground from the heel bone (as seen in uncommon conditions like rheumatoid arthritis), the spur will be pain-free and does not contribute significantly to heel pain. So, what does cause this ailment? Well, the plantar fascia is a tight band of rubbery stretchable tissue that supports the bottom of the foot to a certain degree. It gets injured in one of three ways. The most common injury is seen when people with flat or flexible feet consistently strain the fascia as they walk or stand, leading eventually to microscopic tearing of the tissue. Every minute standing or walking will gradually worsen the injury. The second injury pattern is seen in people with high arched feet. This pattern is much less common. The foot needs to flatten a little to absorb shock generated by walking. High arched feet do not flatten enough to absorb the shock, and this shock eventually causes damage to the fascia. The third injury pattern is even more less common, and involves a direct trauma to the heel itself, such as stepping on a pointed rock or straining the foot on a narrow ladder rung. The fascia can even outright tear in half in certain injuries.

This brings us to the focus of this article. Is surgery really necessary for treatment? The short answer is typically surgery is not needed. As a foot surgeon, I operate on many kinds of foot injuries and deformities. However, it is rare that I have to operate for heel pain (and I treat a lot of heel pain). The key to understanding how to treat heel pain is understanding what is occurring and why it occurs. Simply stated, the pain is due to swelling of tissue in the heel and arch (which usually is not felt as a lump when touching the heel), where the microscopic tearing in the plantar fascia creates a reaction in the body that brings in fluid and cells for the purpose of healing the damage. This swelling irritates surrounding tissue, including nerves, and pain is felt with pressure on it. If left alone, healing would probably take place just fine. Unfortunately, we must walk and stand in our daily activities, and by the time the we actually begin to feel enough pain from this process, the damage to the fascial tissue is more advanced. This process repeats itself daily, and long-term changes in the strength of the plantar fascia can ensue. Now, one may ask why, if the condition is related to foot structure usually and this is the same from a young age, does a person not have this pain most of their life? Well, not everyone with flat or high arched feet will get plantar fasciitis. They simply have a greater chance than someone with a normal arch, and usually some minor unnoticed injury, twist, or turn starts the process, which may take years to gradually evolve. This process is the ‘why’ in what and why is heel pain occurring. In essence, treatment needs to address both of these factors in order to fully relieve heel pain. Non-surgical treatment usually consists of at the very least reducing the inflammation, which will reduce the pain. This can include any combination of numerous techniques, including stretching or a stretching night splint to make the fascia more relaxed, icing, anti-inflammatory medication, and/or steroid (cortisone-like) injections to reduce the inflammation process, physical therapy to push the tissue from a chronic injury state into a healed state, or immobilizing the foot in a walking boot or cast to fully relieve the pressure and allow the fascia to mend itself. The second part of non-surgical treatment involves support of the foot structure that has allowed the plantar fascia to become injured in the first place. This involves the long term use of prescription orthotic inserts to support a flattened foot, or to absorb shock in the high arched foot. This is certainly much easier than having surgery to reconstruct the foot structure to a more ‘normal’ position. Over-the-counter inserts can be considered, but are usually inefficient and ineffective in the long run and provide limited initial help. They also must be replaced regularly as they wear out, and many popular brands are simply designed for increased comfort and not so much for actual medical-grade arch support despite their marketing. Without addressing the foot structure, most patients are doomed to experience plantar fasciitis again despite an initial cure.

How does surgery fit into this picture? Well, as I stated, most people don’t need it. Non-surgical therapy can take several months to work, although most patients are pain-free within a month or two. Surgery is not something to simply leap into, as recovery is not as quick as one might think. I am often seeing patients who had only had a couple of the non-surgical treatment options listed above, continued to have pain for many years after giving up on treatment, and then present to me requesting I immediately operate on them. I simply explain that relief is not instantaneous, sometimes (though not usually) requires a large combination of many treatment options at the same time, and nearly always leads to full and long-lasting relief. Surgery is a fine treatment option, but it can on occasion have complications that may be worse than the original condition, and the fasciitis can potentially return anyway if the foot structure is not addressed after the surgery. Surgery for heel pain usually falls into two categories. The first category is the most commonly used technique, and involves making an incision along the side or bottom of the heel and removing a wedge of fascia. Only part of the fascia is removed, because if it is cut across the entire width the foot will become unstable. This wedge will fill in with scar tissue, effectively lengthening the fascia and reducing the tight traction forced on it by a flat foot. The heel spur, if present, is also traditionally removed at this time, although this seems to be a residual procedure from a time in which it was commonly believed the spur had something to do with the pain. Complications from this procedure can include a transferring of inflammation to the remaining uncut portion of the fascia, opening of the incision, or nerve damage to small but noticeable nerves in the area. If too much heel spur is removed, a heel bone stress fracture can also gradually occur. The second surgical category involves changing the tissue on the inside of the fascia by creating an acute microscopic injury in an effort to stimulate a rapid healing response in the tissue. Long term plantar fasciitis becomes chronically inflamed (as opposed to acutely inflamed when first injured), and converting it back to an acute inflammation may help promote a quick healing time. This surgical category can use radiofrequency waves from a probe inserted directly into the tissue, local high energy ultrasound-based shockwaves generated externally, or even newer techniques involving chemicals directly linked to the healing process applied into or on the fascia. Results have been variable, although generally successful, and may need repeat procedures for long term success. Orthotics and structural support still need to be used in the long term. Complications are less, but may include failure of the surgery to help in the long run. Recovery for both categories still requires protective weight bearing for a period of time after the surgery, and post-surgical pain is always possible within a month after surgery for most procedures.

In summary, while surgery has been successfully used for many years to treat heel pain, it is rare for this surgeon to have to resort to the operating room to cure plantar fasciitis. Non-surgical treatment is not instantaneously effective, but is long-lasting and nearly always successful. Some patients do require surgery to ultimately fix their condition, but it is never necessary to resort to surgery as the initial treatment, and uncommonly necessary to resort to surgery at all.

Pain Management

Pain is usually considered as a subjective experience that can accompany Nociception although pain can arise without a stimulus and may include an emotional reaction. Nociception is a neurophysiologic term denoting activity in nerve pathways, which transmit unpleasant signals, and pain is usually associated with tissue damage and inflammation. Pain is an important aspect of the defense system of the body and pain signals instruct motor neurons of the central nervous system to minimize harm or injury to the body. Pain is explained by the gate control theory which concerns cognitive and emotional factors influencing painful sensations and is determined by different pain states at the brain rather than pain at a particular injured area of the body.
Nociception is the perception of physiological pain although the term pain itself is a broader term and involve psychological pain as well. When nociceptors are stimulated, signals are transmitted through sensory neurons in the spinal cord and are ultimately relayed to the thalamus in the brain and perception of pain takes place. As the brain is itself devoid of nociceptors it cannot experience pain by itself and pain is usually referred to as tissue damage by some harmful stimulus. Pain can thus be both physiologic and emotional or either one of them, Nociception describes physiologic pain or pain related to physical injury to body tissues and pain picked up and transmitted as signals via receptors. Pain in general can however also be emotional or psychological and may be associated with neural factors not entirely known.
The main characteristic of pain is its unpleasantness and usually an organism uses all means to separate itself from any unpleasant stimuli that may be the cause of the pain. Pain can be due to an injury or may even indicate that an injury is imminent but it can also serve as a protective and defensive physiologic function as organisms tend to protect injured regions in the body from further damage due to the unpleasantness of pain sensations. Thus pain is an important part of human existence and is a strong defense of the body helping in organism’s survival. It is because we perceive pain as unpleasant that we tend to avoid harm and injury to the body. The study, treatment and management of pain include pharmacology, psychology and neurobiology and the subjective psychological aspects of pain is an important part of study for the search for neural correlates of consciousness.
Pain receptors are usually free nerve endings and are receptors to chemical, mechanical and thermal pain sensation usually found in the skin, internal and joint surfaces. Tissue damage in deeper part of the skin produces an aching dull pain spread across wider areas as pain receptors are fewer and spread around in deeper levels of the skin, so pain can also not be localized in these cases. In certain cases with prolong pain stimulation, excitation of pain fibers increases leading to a condition known as hyperalgesia.
Pain can be classified into several types including acute pain which is a short term pain from an identifiable cause and is related to tissue damage or a disease. It is sharp sensation followed by aching and is usually centralized to one area usually following an injury, trauma or fall. This sort of pain is usually treated with medications. Medically a chronic pain lasts six months or longer and this sort of pain does not help the body to prevent any further injury by being constantly present and is even more difficult to treat than acute pain. Medical advice is however sought for these cases and drug tolerance, chemical dependency and psychological addiction to drugs may also occur especially in case of opiates. The experience of physiological pain can be cutaneous, somatic, visceral or neuropathic. Cutaneous pain is referred to pain that happens due to injury to the skin or the superficial tissues of the body as cutaneous nociceptors terminate just below the skin and produce localized defined pain for short duration and include pain due to cuts and burns. Somatic pain is pain of ligaments, muscles, bones, tendons and blood vessels and may be dull and continue for longer duration than cutaneous pain. Sprained ankles, fractures and torn ligaments are examples of this sort of pain. Visceral pain involve pain originating in body organs and this sort of pain is located in internal cavities and organs producing an aching , poorly localized sensation that may be of much longer duration than somatic pain and the dull pain can spread to many areas. Neuropathic pain or neuralgia refers to pain in the nerve tissue due to injury or disease and can disrupt the ability of the nerves to transmit correct signals to the thalamus, so the brain may interpret pain although there may be no obvious physiologic causes of pain.
There are two different and distinct pathways for transmission of pain in the CNS. These are transmitted either through the neospinothalamic tract for fast pain or paleospinothalamic tract for slow pain. For transmission for fast pain Alpha-delta fibers terminate on lamina marginalis of the dorsal horns. Neospinothalalmic tract neurons branch off as long fibers and transmit signals upwards in the contralateral anterolateral columns. These fibers finally terminate on the ventrobasal complex of the thalamus. Fast pain is easily localized when A and delta fibers are stimulated with tactile receptors. Slow pain is however transmitted by the slower C fibers to lamina II and III or dorsal horns also known as substantia gelatinosa and neurons take off and join fast pain pathways and move upwards along the anterolateral pathway. These slow pain neurons terminate in the brain stem with a tenth of fibers stopping at the thalamus and also at the medulla, pons and mesencephalon although localization for slow pain is poor.
There is several clinical research studies conducted to help determine which pain management therapies are most effective in treating neck, back and body pain in general. There is no universally accepted definition, or classification of pain management techniques and pain management is usually grouped in terms of their effectiveness and invasiveness. Physical therapy methods are not invasive and do not involve the use of medications although pain medications may involve invasive techniques such as injections as medications are introduced in the body. Pain management can involve non-invasive non drug pain management, non-invasive pharmacologic pain management or invasive pain management.
Non invasive pain management may or may not involve drug administration and the non invasive non-drug treatments are widely available for back pain and neck pain and these can range from exercise, manual techniques such as massage, behavioral and cognitive behavioral therapy, cutaneous stimulation and electrotherapy. Exercise method can involve aerobics, flexions, water therapy or simple exercises necessary for musculoskeletal health. Manual techniques generally involve massage, osteopathy and are quite similar to cutaneous stimulation which uses hot and cold packs for heating and cooling of the skin. TENS or transcutaneous electrical nerve stimulation stimulates the nervous system by using low voltage electrical stimulation and is generally effective for back pain. Electrical stimulation or also known as Electroanalgesia uses low voltage electrical current in waves that interfere with the natural electrical currents of pain signals in the body, inhibiting them from reaching the brain and inducing a response. Electroanalgesia is generally the most common type of modality that patients choose to use to treat their pain along with their prescribed pain medications. Electroanalgesia is very effective in relieving the most common lower back pain and has a lower addictive potential and poses less health threats to the general public. Electroanalgesia has a wide variety of different and unique therapies to include not only the TENS unit but; Transcraniel Electrostimulation (TCES), Deep Brain Stimulation (DBS), Peripheral Nerve Stimluation (PNS), Percutaneous Electrical Nerve Stimulation (PENS), Percutaneous Neuromodulation (PNT), Transcutaneous Electrical Nerve Stimulation (TENS), Transcutaneous Acupoint Electrical Stimulation (TAES), H-Wave (HWT), Interferential Current Stimulation (ICT), and Piezo-Electric Current Stimulation Therapy (PECT). Here at Instant Medical care, we welcome all patients who are suffering from pain to stop in and try one of these electroanalgesia therapies to help relieve the pain and enjoy life to the fullest.
Noninvasive pharmacologic prescription pain management includes administration of drugs such as analgesics (narcotic pain medicine) such as Oxycotin, Morphine, Roxicodone, and Percocet, muscle relaxants to treat muscle spasms, non steroidal anti-inflammatory agents (NSAIDs) such as ibuprofen, antidepressants, anticonvulsants to treat nerve pain, and narcotic medications for acute and long term intractable pain; a severe, constant pain that is not curable by any known means. It is an ongoing problem that most physicians don’t separate chronic pain from intractable pain patients and tend to under prescribe narcotic medication to relieve pain. The physicians here at Instant Medical Care are fully trained to determine and diagnose your pain. We give you the respect you deserve and treat you as if we were the patient in pain.
The invasive pain management techniques involve using devices and instruments into the body such as injections. Some of the common methods of invasion on the body used as pain management techniques are using injections in which a steroid or anaesthetic is directly delivered to a nerve and provide temporary relief to pain. Certain surgically implanted devices such as spinal cord stimulators and peripheral nerve stimulators are used for pain management. In some cases a specialized device is used to produce heat to deaden the sensation of a painful nerve and this method is called Radiofrequency radioablation.
Modern methods of pain treatment and management stresses on holistic methods that are multidisciplinary and involve the application of a variety of drugs as also physical and psychosocial interventions including exercise and behavioral therapy. Pain Management is given to patients with chronic, acute, and intractable pain and usually a prescription for narcotic pain medicine is applied to help relieve the patient’s pain and is followed by other forms of therapy to help relieve the pain and eventually lower the dose of the medication.

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Secrets of The Weight Loss Twins

The father of the famous Weight Loss Twins, George Germanakos, used to say, “The only way to get something done is to get it started.” Imagine how delighted and proud he would have been if he had lived for long enough to watch his twin boys, Bill and Jim, diet and exercise their way to victory on series 4 of the enormously popular NBC weight-loss show The Biggest Loser to become well known as The Weight Loss Twins. Surprisingly, it wasn’t always like that, though Jim Germanakos has traditionally been a great fan of the series. Jim’s a Manhattan cop and a big family man. Up to 2 years before, whenever his shifts allowed, he would sit on the settee before the TV munching away on high-cal comfort snacks, soaked up by the exploits of the shrinking contestants, but not particularly worried about his own 295lb ever growing frame. That was before his “ahaa” moment, before he was one of the Weight Loss Twins.

The Weight Loss Twins weighed into the show at 361lbs and 334lbs. Jim and Bill had been large guys all their lives. The Weight Loss Twin’s pop, George, had been a large man also and had died of obesity related complications when they were young. In spite of this, Jim was an active guy, a dedicated fire-fighter and cop who enjoyed messing around and play with his kids. He didn’t think his own weight was really a great obstacle. His other half, Val, was a big woman as well. In common with lots of us, they enjoyed their food. As Jim puts it, when you reach 295lbs you come to accept your obesity and keep on snacking..

That’s until the moment when your weight begins to get in the way of your folk’s happiness! It was when his sixteen year old son, a keen eagle scout, eventually got himself and his father accepted on an exciting adventure trip, that Jim suddenly understood his obesity was potentially a massive drawback. Whilst taking part in a rigorous training session, when the coach found out that Jim weighed more than 300lbs, he had to ban father and son from the adventure. It turned out that the helicopters couldn’t evacuate anyone with a weight of over 250lbs. His son was so distraught he was crying all the way home. He loved Jim but he understood that his father had let him down. For Jim this was a slap in the face, his “Ahaa moment” and he resolved to do something about it – as one of the Weight Loss Twins.

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Since then the Weight Loss Twins have been featured on TV shows like Larry King Live and Entertainment Tonight and have gained universal affection and world wide fame. They have quite rightly become celebrities in their own field. Particularly, they’ll soon be turned into video game icons when they appear as characters in the very popular Nintendo Wii video game fitness series. Most importantly in the period since they were winners in the show both the Weight Loss Twins have shown they can keep almost all of the wonderful weight loss they achieved at the time when they appeared on The Biggest Loser.

Would you like to lose some excess weight like the Weight Loss Twins? How do your family members feel about your size and weight? In a similar way to money and alcohol problems, excess weight gain may be a gigantic reason for marriage break-ups. How honest is your family doctor? Have they informed you that the multiple hazards to your health due to your excess weight might mean that you can never live to watch your children graduate or get to walk your daughter down the aisle? If that’s the case, have you had your own “ahaa” moment yet?

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