Transcription:

Prakash Chandran (Host): If you’re dealing with chronic heel pain, one likely culprit is plantar fasciitis. It’s a common foot injury that can cause a stabbing pain in the bottom of your feet near the heel and I’ve probably gotten it a couple of times due to basketball. I’m Prakash Chandran and in this episode of Ridgecrest Regional Hospital Podcast, we’ll talk about planta fasciitis. Here with us to discuss is Dr. George Rivello, a podiatrist at Ridgecrest Regional Hospital. Dr. Rivello, thank you so much for educating us today.

George Rivello, DPM (Guest): Thank you for having me on your show.

Host: So, I wanted to get started by just understanding what plantar fasciitis is.

Dr. Rivello: Yeah, I think that assuming we have narrowed things down to plantar fasciitis; it’s a musculoskeletal problem. And there is a structure on the bottom of your foot. It’s a band of connective tissue and it originates in your heel bone and it divides into ten slips and goes into your toes and it kind of acts like a string across a bow, such that when you take a step down; the string stretches out.

What happens especially with adults, is that structure gets chronic tears and that’s what we believe causes the pain.

Host: And I imagine that the cause for these tears comes from just heavy use playing basketball or running. Is that correct? I’m assuming because that’s where I think I get the injuries from.

Dr. Rivello: That’s absolutely correct Prakash but there are some other reasons you might get it too. A lot of the – my patients have a profession that lend themselves to this type of injuries. A line cook or a correctional officer or a hair dresser. Someone who is standing on their feet all day; they get that repetitive stress just by standing in one place. Similarly, if a patient is obese; they are putting more stress on that structure. I also get athletes or even professional runners or ultramarathoners who are just pounding on their feet and that can certainly be an area that can be painful after sports.

Host: I see. I’m glad you clarified that because I always thought about it something coming or originating from impact sports, but it sounds like if yo are standing on your feet all day or if you a little bit overweight; it can cause plantar fasciitis as well. What are the symptoms for specific plantar fasciitis versus like bruising in the heel for example?

Dr. Rivello: I think every foot and ankle surgeon knows this so well. Because it’s such a common reason to come and see a podiatrist or foot and ankle surgeon. And we can almost make the diagnosis in under a minute. The patients will typically come in and just by age and location; we can narrow it down. So, for example, a patient will point to the bottom of their foot and the medial side of their heel which is the big toe side and just by location; you know okay this is probably it. And the story is usually I get out of bed in the morning and I have a painful first step. And typically this isn’t a rapid onset meaning I was fine and then the next day I woke up and I had an incredible pain. It’s usually a slow progressive onset without a history of any traumatic incident happening.

So, just those things. Age, location and then that story of painful first step in the morning; that’s almost diagnostic for this problem.

Host: Yeah, so let’s say I am one of those patients that has this problem. Is there any way for me to first try and self-treat at home before coming into a doctor?

Dr. Rivello: Absolutely. If you are anything like me, you are going to try to fix it yourself. Because that’s what I love to do. I loathe seeking the advice of a professional. I want to fix the problem myself. And I would say that – and this is usually what I would tell a patient on the first visit is that first thing I look at before the patient even comes in the room; I’m watching them walk down the hall with flimsy pair of $3 drug store flip flops. So, the first thing I look at is what is on the patient’s foot? Are they wearing a high quality shoe that has supportive arch or are they wearing something that’s rather flimsy. So, numero uno treatment for this high quality shoe gear possibly an insert in the shoe or an orthotic to support the arch.

There are stretching exercises that you can do, and you can do these at home. You don’t need to be an expert. You don’t need to go to the physical therapist. You probably should avoid walking barefoot, even in your home. People are so used to walking barefoot in their house, but you’re adding stress and strain to that structure. You can wear – if you don’t wear shoes in the house; you can wear an orthopedic slipper and support your arch.

And then lastly, I would say – I kind of try to ask the patients some social questions. Like are you training for a ultramarathon? Did you just start a Zumba class? And start to maybe modify some of those activities in your life that are contributing to the problem if possible.

Host: I think it’s so funny that you mentioned the $3 sandal example because I am certainly guilty of that. Because we don’t really think about heh, this sandal looks nice, it’s only $3, I’m going to get it, but that is the thing that is supporting your feet and your entire body and can lead to all of these problems. So, a great preventative measure everyone listening is making sure that the support and the shoes or the inserts that you get are of quality because you are on your feet all day. You’re moving around and that’s the best preventative measure. Right?

Dr. Rivello: Oh yeah. I think that I probably spend a good percentage of my day talking to patients about what is the appropriate thing to have on their feet. When I was a resident doctor, I used to work with this near retirement podiatrist, and he was so fed up with looking at these lousy sandals and thongs and flip flops that he would just take the patient’s shoes and pick them up and throw them out in the hallway and say this is your problem.

Host: Oh, that’s so funny. Okay so let’s say that a patient has been preventative. They do have the proper footwear, but maybe through impact sports or for things that are outside of their control, they get plantar fasciitis and they come into see you. How do you go about treating them and how long does that treatment take?

Dr. Rivello: Medical literature says that this problem goes away and it’s self-limiting in about eight or nine months with the nonsurgical treatment. So, that usually lets the patient know right away. The good news is this is probably going to go away, and we are not going to have to do anything special. On the first visit, I go over shoe gear, inserts, and I teach the patient how to stretch that structure in their foot. And we go over specific stretching exercises. Sometimes, I’ll dispense a device called a night splint which is essentially a brace that holds your foot at right angles to your leg and stretches that structure out at night and then that can help diminish some of the pain that you have when you take your first step in the morning.

That’s usually it for the first visit. And then, I say let’s try this and if you are not significantly improved in six weeks; come back and we’ll consider doing a corticosteroid injection in the heel. And so I feel that sometimes I can frighten the patient into improving. But in all reality, some people have such severe plantar fasciitis that they can do all of those things and not improve, and I’ve had really good success with a corticosteroid injection and in fact, I feel that a lot of times, after that first injection; patient tends to start to improve and get back to normal. And that’s for the most part, is how most patients respond to treatment.

Of course, there are a few people who do not improve with injections.

Host: And so, if the patients aren’t improving with those injections that you’re talking about that cure most people; is there a more kind of extreme surgical option that they can look to, to help this pain?

Dr. Rivello: Absolutely. And I should clarify though that if we were to look at a pie chart and of all the people that I’ve seen for this problem; we are now talking about a very small slice of the pie. But in between an injection and surgery; there are a few things. There is something called platelet rich plasma injections, prolotherapy injections, extracorporeal shockwave therapy and more recently, stem cell injections. And these are all kind of newer treatments with varying support in the medical literature, but probably worth a try if that’s your last step before surgery.

Another tried and true method that I like to use is just cast immobilization. Can I put the patient in a CAM walker boot and immobilize them for four to six weeks? And can we calm that structure down that way? And on occasion, I have put patients in a walking cast for three weeks because they are so active, and they are unable to slow down that you kind of have to put a boot on them. You got to stop them from going so much.

And then finally, for me, I do a surgery and there are many approaches to surgery for plantar fasciitis. But I take an endoscopic approach. So, I make a small incision on either side of the heel, I put an arthroscopic camera so I can visualize the plantar fascia band and then release a third to a half of that structure to relieve the pressure and pain on the plantar fascia.

Host: Well like you said, it sounds like that is such a small slice of the population that needs that and there are so many preventative measures and treatment measures that are out there including restricting movement by putting them in a boot. So, thank you so much for educating us on all of this today Dr. Rivello. Is there anything else that you wanted to share with our audience before we sign off today?

Dr. Rivello: No, I think you asked excellent questions and I think that I’m hoping that one person listens to this and it helps them. I mean that would make me thrilled.

Host: Dr. Rivello, I’m going to throw out my Hawaii sandals immediately after I get off the call. So, you already helped one person out. So, for everyone else, for more information, please visit www.rrh.org. My guest today has been Dr. George Rivello. I’m Prakash Chandran. Thank you so much for listening.