Heel pain is a vague term that describes pain located in the back, sides, or bottom of one's feet. One of the more common types of heel pain occurs in the bottom of the foot. The pain isworse after periods of rest. Some even state that they feel like they are walking on a stone. This commonly caused by a process known as plantar fasciitis.

Within this process, the bottom of the feet may hurt upon standing. This pain is usually located at the bottom inside part of the heel. It may actually gradually get better after walking; but after a period of rest or extended periods of activity, the pain is once again felt.

The plantar fascia is a ligamentous structure that originates on your heel bone and fans out and inserts into the toes. The purpose of the plantar fascia is to hold the muscles of the foot in close relationship to the bones and also to provide some support in the arch of the foot. When the toes move upward against the foot, the plantar fascia stretches taught and pulls the heel bone closer to the ball of the foot. This is the mechanism that that provides the arch support.

Plantar fasciitis is most often caused by improper mechanics of the foot. The three fascial bands may encounter swelling or micro tears causing an inflammatory response and the associated pain people relate.

Many people have referred to this entire process as heel spurs. At times, there can be a heel spur present with plantar fasciitis. The heel spur is not the problem but rather a result of the problem. It forms because of the pulling of the plantar fascia. There are people who have heel pain without the presence of a heel spur. Conversely, there are people who have heel spur present, without heel pain.

If you have heel pain, a podiatric physician should evaluate you. While the explanation of the problem is very helpful, the doctor will need to feel all of the structures around the heel and possibly take x-rays to confirm the diagnosis and look for the presence of a heel spur.

After a history and physical, your podiatrist will be able to discuss the problem and treatments with you. Some of the treatments are aimed at relieving the symptoms while others are aimed at controlling how your feet move and function while walking. There are even times when your doctor might suggest surgical intervention for this problem.

The purpose of this newsletter is to educate and not replace the advise of a medical professional. If you should have any questions, please seek the assistance of a podiatrist or other health professional that will be able to further the discussion and recommend appropriate interventions.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

As many people now know, the use of tobacco products can be detrimental to your health. Many people understand the vast number of respiratory ailments, ranging from emphysema to lung disease and cancer can occur as a result of smoking tobacco. Does anyone understand that smoking can also affect your feet?

One of many ingredients in tobacco is nicotine. Nicotine is believed to have many effects in the human body, both positive and negative. As any smoker will attest, nicotine has a calming effect. Many scientists are researching the effects of nicotine on the human body. Nicotine and its derivatives have been studied for its potential beneficial role in patients with Parkinson's disease and decreased attention span. Much of the literature clearly states that it is the nicotine receptors in our brain that need this purified nicotine or an analogue. The nicotine from tobacco does not provide this benefit.

The immediate effects of nicotine on the body include:

• Increase in blood pressure
• Increase in heart rate
• Thickening of blood
• Narrowing of arteries
• Decrease in skin temperature
• Increase in respiration
• Vomiting, and
• Diarrhea

Long term effects of nicotine on the body include:

• Blockage of blood vessels, thus a slower heartbeat than a non-smoker's at rest
• Depletion of vitamin C
• Reduction in the effectiveness of the immune system - making it harder to fight off dangerous infections
• Cancer of the mouth; throat; and lungs
• Cancer of the upper respiratory tract
• Hurting physical fitness in terms of performance and endurance
• Bronchitis and/or emphysema
• Stomach ulcers
• Weight loss
• Dryness and wrinkling of skin, often times giving the skin a leathery appearance
• Production of abnormal sperm, causing birth defects

Of importance in this discussion is the effect that nicotine has on your arteries, the blood vessels that carry blood away from your heart.

Nicotine has an effect on the sympathetic nervous system (part of the nervous system involved in the classic "fight or flight" response); part of this effect is to cause the blood vessels within the body to constrict. Since, hopefully, the same amount of blood is still going through the body, this results in a net increase in the pressure within the system (think of what happens when you squeeze a garden hose). Why is it bad? The increase in pressure has to come from somewhere, and that's the heart that is trying to pump against this. Also, higher pressure can lead the "blowing up" of blood vessels, called aneurysms (think again of that garden hose and what happens if you hold it bent for too long).

As we all age, there are plaques building up on the inside walls of our arteries. Some people have this peripheral vascular disease (PVD). It is commonly recognized in the hands and feet because these are the points farthest away from the heart where the blood vessels are the smallest.

This PVD in combination with the effects of nicotine can lead to a painful lack of blood flow to our feet. Our skin is a living organ, which means it needs to have nourishment to remain healthy. The arteries are the conduits to bring that nourishment to all aspects of our body.

People relate to sharp, deep stabbing pains. Some people even relate to having very painful ulcerations, or openings in their skin. When ulcerations occur, it can sometimes be very difficult and time consuming for the skin to heal. When there is an opening in the skin, an infection can begin and spread throughout the human body, which can ultimately lead to amputation or even death in the worst cases. Appropriate wound care should be initiated after a thorough examination has taken place.

Smoking can play a vital role in your everyday health as well as in the health of your feet. As you know, your feet are important. They get you to the many places you have to go. Be wise, take care of your feet, and see your podiatrist.

The following are just a few of the thousands of links regarding tobacco:

• http://www.tobacco.org
• http://www.wellmd.com/cigar_smoke.htm
• http://www.peakofhealth.ch/smoke_main.html

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

What is a Callus?

Calluses develop from a buildup of dead skin cells that become thick and hard on the foot. Usually found on either the heel, the ball of the foot, or inside the big toe, calluses develop as a result of excessive rubbing and pressure. Calluses that have a deep-seated core known as a nucleation are called Intractable Plantar Keratosis.

What causes Calluses?

Some of the most common reasons people develop calluses are:

• Obesity
• Deterioration of the fat pad located on the bottom of the foot
• Wearing high heeled shoes
• Wearing shoes that do not fit properly
• Flat feet
• High arched feet

What treatments are available?
When treating a callused foot, do not cut or trim them with a razor blade. This will only make the condition worses and is particularly dangerous for those with diabetes. The best thing to do is wear an orthotic that has been fitted for you by your podiatrist. They will redistribute your weight to relive the pressure being placed on your callus.

If you are experiencing swelling, inflammation, discharge, or pain, your toenail is probably infected and you should seek the treatment of a podiatrist. He or she may trim or remove the infected nail with a minor surgical procedure.

Plantar Fibromatosis is a common soft tissue mass found in the foot and one of the most common lesions found on the sole of the foot. It is a locally aggressive idiopathic proliferative fasciitis of the plantar aponeurosis or subcutaneous thickening of the plantar fascia. It is usually bilateral and frequently seen in children and young adults. In older people it is often associated with Dupuytren's contracture of the palmar fascia of the hand. The basic microscopic pathology of Dupuytren's contracture and plantar fibromas is about the same. The causes are obscure, but trauma does not play an important role. The disease usually occurs in adult males after 40 years. A relatively small number of cases are bilateral. Whether these tumors are familial is not clear, although cases have been recorded in multiple members of a family. Compared with palmar fibromatosis, the plantar variety is rare, although the exact incidence is not known, since a large number of theses cases are not reported. The lesion was described by Dupuytren, and later it was described in more detail by Ledderhose.

In Allen and Woolner's series of 69 cases, 35% were 30 years of age or younger, including two cases that were present at birth. Among 200 consecutive cases, which were reviewed at the Armed Forces Institute of Pathology between 1960 and 1978, 111 (55%) occurred in patients 30 years or younger. Of the 11 cases, 22 were children 10 years or younger. Aviles et al., reported that 77% of their cases were encountered in patients older than 45 years. Zamora et al., Journal of Hand Surgery, 1994 showed that there is an increase in transforming growth factor beta in the early phase of Dupuytren's contracture and Plantar Fibromatosis.

As far as clinical findings are concerned, the lesion (plantar fibroma) appears as a firm, single, subcutaneous thickening or nodule that adheres to the skin and is located in the middle and medial portion of the sole of the foot. It may be asymptomatic, but it may cause mild pain after long standing or walking.

Locke has classified plantar fibromatosis as proliferative(increased fibroblasts and cellular activity), active(nodules are formed), and residual(decreased fibroblastic activity).

One should consider surgery if there is pain and a change in the course of the lesion (increase in size, contracture).

Surgical incisions may be linear, S-shaped or zig-zag. The surgeon needs to perform a wide excision of the mass. The patient should try to remain non-weight bearing for 3 weeks if possible.

Some complications are recurrence, nerve entrapment, skin slough, scarring, hematoma, and arch fatigue. Simple excision appears to be a poor method of treatment. Allen et al. noted recurrences in 15 of 28 patients treated by simple excision. Patients who underwent local excision had a 57% incidence of recurrence at the excision site, whereas those who underwent side excision (fasciectomy) with or without skin graft had a more favorable result (8% recurrence).

What are mallet toes?

A mallet toe occurs when the tip of the toe functions in a non-straightened manner. The tip of the toe is pointed down toward the sole of the shoe causing pain, discomfort and sometimes an infection. These infections are of major importance to the diabetic foot which is at a higher risk for abscess ulcerations, osteomyelitis (bone infection) and digital amputations.

It is very common to have a corn on the tip or top of a mallet toe due to rubbing against the sole and/or top of the shoe. The corn (hyperkeratotic lesion) is hard lifeless tissue which is discolored and looks bad.
This deformity alone has caused embarrassment when others see it sticking out like a "sore thumb". Sometimes a circular, light, hypo pigmented spot appears from the toe and shoe friction while other times a circular, dark, hyper pigmented spot discolors the skin on the toe. Changes in skin color can be permanent with a mallet toe deformity when left untreated.

Several other factors can lead to a good mallet toe going bad. Poor circulation, diabetes, edema (swelling) and non-leather shoes are examples of conditions that endanger the well being of a mallet toe. Complicating factors will produce sores on a mallet toe with puss, infection and drainage. Sometimes this scenario makes the toe begin to swell to almost twice its normal size, putting pressure on the surrounding toes causing those toes to be affected with lesions, sores, abscessed ulcerations and swelling too. Aching toes will alter ones walking pattern (gait cycle) and a cane or crutch could possibly be needed. Sometimes a lot of pain is present while other times absolutely no pain or discomfort is noticed because of nerve damage, decreased sensations in the feet from possibly a stroke or diabetes.

Most recently, sensory disorders in a patient's foot were caused by a closed head injury incurred during a snowmobile accident. Hemi paralysis of his right side required physical therapy to help regain function of his entire right side. Hard work and determination resulted favorable results for use and function of his right arm and lower extremity but the nerve damage is taking a long time to return to normal.

He decided to join some friends on a week long ski trip where he took beginner ski lessons and was able to manage this task quite well. The trip was uneventful, safe and he had a lot of fun on the slopes. Upon return he noticed some drainage from his second toe right foot coming from the side of his toenail. The toe was red and slightly swollen at the tip and around the eponychium (cuticle). The nail was partially detached and loose. His mallet toe deformity was exacerbated from the friction of his ski boot and he was unable to feel the pain secondary to the nerve damage existing in his foot and leg.

Without anesthesia, I removed the offending portion of his nail and had him soak his foot twice a day. No antibiotics were given and a week later the redness and infection were gone.

What causes a mallet toe?

Often times the bones and muscles in the toes are imbalanced causing mallet toes. You are more likely to develop mallet toes if you:

• Are on your feet for the majority of the day
• Participate in sporting activities on a regular basis
• Already suffer from arthritis
• Have nerve damage to your back, leg or foot
• Have too high of an arch or very flat feet
• Wear shoes that "just fit" or are too small
• Have a toe deformity from birth

Some conservative treatments you could try are:

• Wearing shoes with a large toe box
• Toe crest or buttress pad
• Gel toe shields and /or caps

Some surgical treatments your Podiatrist could try are:

• Arthroplasty or partial bone/joint removal
• Joint fusions in the toe
• Flexor tenotomy or lengthening (spelling)
• Amputation of the tip of the toe

For more information on this subject, or to schedule an appointment with a footDrHorsley Podiatrist, please call (877) 372-6048

Gout is a disease in which tissue deposition of monosodium urate crystals occurs in and about the joints with acute or chronic arthritis. It initially is seen in men aged thirty to sixty years. In women it usually occurs after menopause. But, gouty attacks can be precipitated by trauma, certain foods, alcohol intake, diuretics, and kidney failure. Kidney excretion is the major route of uric acid disposal.

Gout may be divided into the following phases: asymptomatic, acute gouty arthritis, intercritical gout (follows acute attack), and chronic tophaceous gout manifested by monosodium urate crystal (tophi) deposited in the soft tissues of the body.

Classifications of gout include primary-elevated serum urate levels or urate deposition appears to be a consequence of disorders of uric acid metabolism not associated with another acquired disorder, secondary-gout is a minor feature secondary to a genetic or acquired process, uric acid overproduction-about 10% of patients excrete excessive amounts of uric acid into the urine, and uric acid undersecretion-the majority of patients show a relative deficit in the renal excretion of uric acid.

Clinical features include acute gouty arthritis most commonly at the 1st metatarsophalangeal joint of the big toe. 10% of the patients have no recurrence, but up to 60% of patients experience a second attack in less than a year. The ankle, tarsal area and knee are commonly affected. Affected joints are usually red, hot, swollen, and extremely tender. Diffuse erythema is present. A patient may be awakened at night from the pain. High grade fever may be associated with acute attacks. The most common sites for tophi are the base of the great toe, Achilles tendon, elbow, knees, wrists, and hands. About 10-20% of patients with primary hyperuricemia develop uric acid kidney stones. Renal disease is the most common complication of gout except for the arthritis.

On x-ray one may see soft tissue swelling, and joint effusions, rat-bite erosions, cyst-like or punched-out erosions. Many lesions are expansile with overhanging margins(Martel's sign) that are displaced away from the axis of the bone. Joint spaces are preserved until late in the disease. Ankylosis and joint subluxation may occur in advanced cases. Gouty tophi (white, chalky crystals) may be seen within soft tissues.

The diagnosis of gout is confirmed by the presence of strongly negatively birefringent monosodium urate crystals identified on joint aspiration.

Treatment for acute gout includes colchincine, NSAIDS(indomethacin, sulindac, naprosyn, ketoprofen), corticosteroids, and glucocorticoids.

Treatment for chronic gout includes colchicines, allopurinol, and probenecid and sulfinpyrazone.

Prevention of recurrence can be obtained by avoiding foods high in purines like anchovies, organ meat, liver, spinach, mushrooms, asparagus, oatmeal, cocoa, sweetbreads, shellfish, beans, peas, and lentils as well as avoiding alcohol, aspirin, and diuretics.

Bibliography

• Banks, Alan S., et al McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia:Lippincott Williams and Wilkins, 2001.
• Ferri, Fred F., The Care of the Medical Patient.Philadelphia:Mosby, 2001.

In order to ensure fewer nail problems, the shoe selection is important. The shoes must be wide and tall enough to accommodate your feet. If you trim your own nails, try to cut the nails straight across without going into the corners. If you have circulation problems or diabetes, please see your podiatrist before doing any self-care.

Ingrown Toenails

An ingrown toenail, or onychocryptosis, occurs when the nail grows down into the skin instead of outward (happening most often to the big toe). It can cause the toe to become infected and may be very painful. Redness, irritation, swelling, and an uncomfortable feeling of warmth are associated with an ingrown toenail. The best ways to prevent ingrown toenails include trimming your nails properly, guarding your feet from trauma, and wearing shoes that provide adequate room for your toes.

What causes Ingrown Toenails?
Many things can cause ingrown toenails.

The following are a few of the most common causes:

• Cutting toenails incorrectly
• Toenails are too large
• Toes curl, either congenitally or from diseases such as arthritis
• Frequent stubbing of the toes
• Wearing shoes that are too tight

What treatments are available?
As soon as an ingrown toenail is noticed it should be treated. If the toenail is not infected, you may find relief in these simple steps:

• Soak your feet in warm salt water
• Dry them with a clean towel
• Rub on an antiseptic solution
• Cover the toe with a bandage

If there are no signs of infection, your doctor will cut the ingrown portion out. Depending on the severity and the presence or absence of infection, the side of the nail may need to be removed back to the level of the cuticle. Antibiotics may also be required if infected.

Pain may be along the side that the nail is ingrown or even throughout the entire toe. Walking seems to make the pain worse. To evaluate the problem, your podiatrist will evaluate the toe around the affected area.

Fungal nails

Fungal nails tend to be thick, crumbly, and discolored. Fungal nails can be very difficult to trim without the assistance of a podiatrist.

You will need to talk to your podiatrist regarding treatment of fungal nails. Treatment can include solutions, creams, removal of problematic nails, or even oral medications.

Toenails can have changes similar to the ones that are present in fungal nails without the presence of a fungus. Your foot doctor can examine the nails to determine if a fungus is present or if there is another underlying condition.

Black and blue nails

Black and blue nails are most often caused by a traumatic event. Many times this happens from sport activities or a heavy object falling onto the toe. There could be pain associated with this discoloration if the injury is sudden.

Your podiatrist should examine the nail and the rest of your foot to ensure that there is no infection present. Treatment can include doing nothing, drilling a hole into the nail plate to relieve the pressure, or removal of the entire nail plate.

You should discuss the treatment choices with your podiatrist.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Have you ever gone over someone's house and been ashamed to take off your shoes? Ever gone to the beach and buried your feet in the sand? Do you wear closed toed shoes because you are ashamed of toenails? Don't worry, you are not alone. This is what millions of Americans experience. If you have dry, yellow, brittle, and discolored toenails, you may have Onychomycosis, better known as fungus nail. With Onychomycosis, the nail has been penetrated by bacteria or some type of fungi. In this article we will discuss Onychomycosis and treatment options.

How would you know if you had onychomycosis? Your podiatrist will be able to diagnose your condition. In order to do so, debridement of the nail plate saving the most proximal section is advised. Three tests can be performed on the nail clippings. The most accurate diagnostic test of onychomycosis is the PAS test. PAS is very specific and less operator dependent. Onychomycosis usually doesn't affect children and is increasingly common as one gets older.

In order to manage Onychomycosis, your podiatrist can suggest three treatment options; debridement of the nail, oral therapy, and topical therapy. Debridement of the nail is going to give the patient satisfaction temporarily because the fungus nail can and will possibly grow back. Oral therapy requires the patient to follow a pill regimen and may have drug reactions with other medications that a patient is taking. Oral medications may also irritate your liver. Topical therapies cause no harm to the patient. They can be taken with other medications without harm to the liver.

There are many nonprescription treatments for onychomycosis. Natural oils have been shown to be effective in its control. Camphor, menthol, eucalyptus oil, cedar leaf, nutmeg oil, thymol, clove, and tea tree oil have all been used. The way these over the counter products work is that they kill fungus on the surface of the nail where the discoloration, brittleness, and dryness occur. Many podiatrist have topical products which contain the essential ingredients. These ingredients not only clear up the current fungus on the nail but promote healthy nail growth. One such topical antifungal is NailEsse. NailEsse can be used on both hands and feet. Daily use on requires daily application on the hands for 6-8 months and 8-12 month period for toenails. The current fungus on the nail will be killed and the new nail that grows will be fungus free. This product should be available at your local podiatrist office.

The key to treating fungus nail is to make sure that you visit your podiatrist so you can accurately be diagnosed and treated. Just because you have an abnormal nail, it may not necessarily be onychomycosis. Home remedies are not effective as treatment your podiatrist can provide. The correct combination of oils in topical antifungals is key to effective treatment.

A shock wave is the resultant acoustic energy wave of an explosion. For kidney stones, the shock wave must be focused to specifically apply the energy wave to the desired area as well as in the foot.

ESWT offers improvement in pain relief of Plantar Fasciitis (inflammation of the plantar fascia) and functional restoration with negligible (few) complications. It is a safe procedure and has lack of risks and complications. The cost is very expensive and the cost of ESWT is not covered by all insurances and the patient is forced to pay out of pocket. The procedure can cause micro-fractures of the calcaneus (heel bone). Also, some patients require several treatments.

Indications for ESWT include plantar fasciitis, chronic heel pain, avascular degeneration, and where conservative treatment has not prevailed and the condition still persists.

The OSSATRON is indicated for use in patients with chronic proximal plantar fasciitis who have failed to respond to conservative treatment such as physical therapy and stretching exercises, orthotics, night splints, NSAIDS, (non-steroidal anti-inflammatory drugs), cortisone injections, or previous surgery.

Because the OSSATRON has not been tested on subjects with the following conditions, it's safety and effectiveness is unknown: diabetic neuropathy, ankle or foot fracture, Peripheral Vascular Disease (poor circulation), skeletally immature patients, pregnancy, severe osteoarthritis, rheumatoid arthritis, osteoporosis, metabolic disorders, osteomyelitis (bone infection), and systemic infection.

There are no known contraindications to ESWT with the OSSATRON for treatment of chronic proximal plantar fasciitis.

Patients with bleeding disorders that may prolong clotting time may be at risk for bleeding following OSSATRON. Anesthesia should be administered prior to the procedure.

Between April 1998 and November 1999, 302 patients were treated for chronic proximal plantar fasciitis using OSSATRON ESWT. 260 received active or placebo. 42 were not randomized. Pain scale was 5-10 with10 being severe. Evaluations were obtained at 4, 8, 12 weeks post-treatment.

234 randomized patients showed a statistically significant difference in treatment versus placebo groups. Following one OSSATRON ESWT, 62% of patients met with success. 76% of all patients who received treatment, had acceptable results after 1 treatment and no longer required long term treatment or surgery. 38 complications were reported of 302 subjects.

The patient should be instructed to discontinue any medication containing aspirin or an NSAID for 3 days prior to ESWT to minimize bleeding. Patient should bring running shoes to wear home as weight bearing is allowed after the procedure. ESWT should be performed with anesthesia local or regional since the procedure is painful. Position the OSSATRON perpendicular to the patient table with the therapy arm in the horizontal position, and the coupling membrane near the plantar surface of the affected foot. The head may be placed in the vertical position, coupling membrane up, for the affected side aligned with the membrane. A total of 1500 shocks are delivered for effective treatment of chronic heel pain syndrome. Total OSSATRON treatment time is 13-15 minutes for delivery of 1500 shocks at 2.0 Hz. Upon discharge, patients are advised not to participate in stressful activity for the affected heel for 4 weeks. Orthotics are encouraged.

What is extracorporeal shock wave (ESW) treatment?

"Extracorporeal" means "outside the body". Shock waves are created by very strong acoustic (sound) energy.
Your ESW treatment will be performed with a device called OssaTron.

The OssaTron is a shock wave generator very similar to the shock wave devices used to treat kidney stones without surgery. The shock waves are created by a spark plug that is enclosed in a soft plastic dome filled with water. During ESW treatment, this dome is placed close against the heel so that the shock waves pass through the dome to the heel. ESW treatment has recently been found to be effective for treating chronic proximal plantar fasciitis, a condition that causes pain in the heel of the affected foot and is sometimes called "heel spurs".

Who should not have ESW treatment for proximal plantar fasciitis?

• Anyone taking medications that may prolong or interfere with blood clotting should not have ESW treatment.
• Anyone with a history of bleeding problems should not have ESW treatment.
• Children should not have ESW treatment.
• Pregnant women should not have ESW treatment.

Because the OssaTron has not been tested on people who have the following conditions, its effect, safety, and effectiveness on someone who has one of the following conditions is unknown:

• Tarsal tunnel syndrome or other nerve entrapment disorders (damage or pressure on the nerves to the foot)
• Diabetic neuropathy (nerve damage due to diabetes)
• Fracture of the foot or ankle
• Significant peripheral vascular disease (problems with the circulation in the blood vessels in the legs)
• Severe osteoarthritis
• Rheumatoid arthritis
• Osteoporosis
• Metabolic disorders
• Malignancies
• Paget's disease
• Osteomyelitis
• Systemic infection

Your doctor can provide you with additional information about these and other conditions and how they might affect the decision to perform ESW treatment.

What side effects and complications could happen?

• The ESW treatment may cause skin reddening or bruising of the treated foot. This usually clears within a few days.
• The ESW may cause numbness or tingling in the treated foot.
• The ESW procedure may cause the plantar fascia to tear.
• The ESW treatment may not help heel pain in your case. You may have episodes of pain similar to the pain you had before treatment. The pain may continue for a few days to several weeks after treatment.
• Shock waves directed at large blood vessels or major nerves may cause damage to these structures. Misdirected ESW may result in nerve or blood vessel injury.

What will happen on the day of the ESW treatment?

Your doctor will probably ask you to come the hospital or surgery center a few hours before your ESW treatment is scheduled. You should wear shorts or lose fitting clothing that can easily be rolled up to the knee of your affected leg. Otherwise, you may be asked to change from your own clothes into a hospital gown. The staff may take your temperature, pulse and blood pressure and ask you some questions about your general health. They also will make sure you have signed a consent form for the ESW treatment.

The ESW treatment my cause some pain or discomfort, so an anesthetic is commonly given before the procedure. Usually, this is a local anesthetic or a regional anesthetic called a heel block. During the ESW treatment you will be asked to rest comfortably on your back while your doctor holds your foot up to the OssaTron shock head.

An ESW treatment for chronic proximal plantar fasciitis usually takes about 30 minutes. The ESW treatment is performed as an outpatient procedure. No overnight hospital stay is necessary.

What will happen after the ESW treatment?

Immediately after treatment, you will stay at the hospital or surgery center until the anesthetic wears off enough that it is safe for you to walk. Your doctor will probably ask you to restrict "stressful activity" involving the treated foot for four weeks after treatment. "Stressful activity" may include running or jogging, doing heavy housework or yard work, and participating in sports.

Some patients need a mild pain medication following ESW treatment. Although some patients in the clinical study felt immediate relief from pain after the ESW treatment, it is more common for it take up to six weeks for pain relief to begin.

What are the expected results from ESW treatment?

In the OssaTron clinical study, patients with chronic proximal plantar fasciitis were graded "Success" or "Fail" according to four measurements: 1) The doctor graded the amount of pain with pressure on the heel: 2) the patient graded the amount of pain during walking first thing in the morning: 3) the patient graded the time and distance he or she could walk without pain and 4) the patient reported the amount of pain medication he or she needed for the heel pain.

Percentage of Patients with Successful Outcome at 12 Weeks

Your doctor will ask you to return to the office for a follow up visit, six or eight weeks after your OssaTron treatment. Please check with your doctor about this follow up visit.

I have more questions about ESW treatment for heel pain. How can I get more information?

Talk to your doctor. In order to use the OssaTron to treat chronic proximal plantar fasciitis, your doctor had to complete a specialized training program. The training program not only allowed your doctor to learn how to perform the ESW treatment, but it also included information about shock wave energy in general, and information from the OssaTron clinical study. Therefore, your doctor is the best person to talk with if you have any questions or concerns about ESW treatment for chronic proximal plantar fasciitis with the OssaTron.

What other treatments are available for treating chronic proximal plantar fasciitis?

Doctors know that many people who have heel pain get better with time, even with no treatment. Many other people get better after trying one or several conservative treatments, which include:

• Rest from excessive or abusive activity and the application of heat or cold.
• Physical conditioning exercises
• Use of a shoe insert or heel cup
• Physical therapy, including ultrasound therapy
• Over-the-counter pain relievers, such as aspirin or Tylenol (acetaminophen)
• Prescription pain relievers
• Non-steroidal anti-inflammatory medications (NSAIDs), such as Advil (ibuprofen) or Aleve (naproxen)
• Steroid injections (cortisone)

Apply Biofreeze during the day to cool those hot, inflamed and swollen bones & joints.

In difficult cases of chronic proximal plantar fasciitis, open or arthroscopic surgery may be performed.

Who should consider having ESW treatment for proximal plantar fasciitis?

ESW treatment with the OssaTron is for patients who have had heel pain for at least six months and who have tried other methods for treating their heel pain. In the OssaTron clinical study, the treated patients had failed to respond to at least three attempts at conservative treatment: two prior courses of non-invasive treatment, including physical therapy and the use of an orthotic device: and one prior course of pharmacological treatment.

ESW treatment with the OssaTron is for patients who can tolerate anesthesia prior to the ESW procedure. ESW treatment with the OssaTron is painful.

ESW treatment with the OssaTron is for patients who can tolerate hearing protection to reduce the risk of hearing impairment due to the sound of the OssaTron.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.