Plantar fasciitis is the most common cause of heel pain presenting to the outpatient clinic and is most common with the middle age population. The plantar fascia is a flat thickening of connective tissue on the bottom of your foot that spans from your heel to your toes and primarily supports the arch of your foot.
Plantar fasciitis is thought to be an inflammatory process; however, it is actually a disorder of degenerative changes in the fascia.
Plantar fasciitis is diagnosed with:
1) history of pain on taking the first few steps in the morning or after sitting for long periods of time
2) worsening pain with weight-bearing
3) pain and tenderness to palpation over the medial calcaneal (heel) tubercle. Pain and stiffness can improve after several steps. Patients may have a collapsed arch (excessive pronation), flat feet, high arches, or tight Achilles tendon(s). It can occur in one or both feet and can happen with younger individuals that are on their feet a lot. Runners are especially susceptible to foot and heel pain.
Differential Diagnosis: Plantar fasciitis must be distinguished from other causes of plantar heel pain. Heel fat-pad atrophy typically occurs in elderly patients with pain in the central heel. These patients usually do not complain of pain upon first weight bearing in the morning. Tarsal tunnel syndrome is compression of the tibial nerve causing foot pain, weakness, and often times numbness or tingling in the sole or arch of the foot. A calcaneal stress fracture is confirmed on examination with use of the squeeze test of the calcaneus (heel bone). An X-ray would further confirm a stress fracture of the calcaneus.
Treatment: No single treatment is best for everyone since it can be caused by many different reasons.
Here are few things to try:
- Give your feet a rest, cut back on aggravating activities. Do not walk or run on hard surfaces
- In severe cases a walking boot or night splints are necessary
- Control inflammation by taking anti-inflammatory medication and icing the your heel
- Stretch both your calf muscles, gastrocnemius and soleus, and your toes
- Consider arch supports and/or a new pair of shoes if your current shoes are old or worn.
If these steps do not resolve your plantar fasciitis the source of your pain might be related to intrinsic foot muscle weakness or lumbar nerve irritation. Additional assistance with your condition would benefit from a manual physical therapist evaluating your movement patterns to determine the source of your plantar fasciitis.
Physician Assistant, Ashley Gilchrist downloaded and tested five different iphone apps and used them over several weeks.The ideal app for her is one that would be very easy, visually appealing way to track her intake. She tried iDrated, Waterlogged, WaterMinder, Daily Water, and Water Lite. The winning app that she will be keeping on her phone is iDrated.
Here is a review of the apps from her most to least favorite.
Features: This is a visually appealing app that has an integrated quick-start guide. You set up a male or female mode and specify your daily intake goal. The main screen is an interactive gestural based app. To add a drink you hold your finger down on the person and keep touching as you drag your finger up and down to adjust the amount. You shake to undo. As you record water it displays your percentage hydrated and visually fills up the person with water. You have quick access to your last drink, ounces or liters consumed, and an on/off reminder for your next drink. It shows you a weekly mini bar graph with percentage consumed and awards you badges based on how hydrated you stay each day. A side view shows you a scrollable bar graph with your progress. Swiping the screen to the right lets you easily edit past days. Instructions are clear to use and a ‘?’ icon gives you instant access to remind you of all the features. I like the way this app looks. At first, I found it difficult to adjust my finger to the right amount but I quickly got used to the gestural control. Adding a manual way to add water would be nice and I would also love the ability to delete drink logs rather than only delete the last drink or clear all. Overall, this app was the most fun to use, visually appealing, easy to adjust water amounts and the best graph function out of the water apps I tried. For encouraging me to drink 9 cups a day, it’s worth the $ ¼ of my Starbuck’s latte.
Features: The main page has a simple graphic of a water bottle that fills with each glass. You add water by recording your glass and fraction consumed. This can be customized to include a picture of your own glasses for easy recording. It is easy to delete drinks for the day if you made a mistake and edit past days. You set your custom daily goal and the app provides an informational article from kraftnutrition.com on IOM recommendation for daily intake to help guide you. You can set time, interval or random motivators to remind you to drink water throughout the day, however only one motivator is allowed before having to update. The badge number can be enabled to show the number of full days since the last recorded drink. Social media is included with facebook, twitter, and a way to connect with friends through your contacts – this was not so important to me but a nice feature if you need motivation this way. The graph function is only available when you upgrade to Premium. Premium is broken down to $0.99 for 3 months, $1.99 for a year, or $2.99 for a lifetime.
Features: The home screen shows you an outline of a male or female and you customize your weight and water intake goal similar to the other apps. You can add custom cup sizes and easily add by tapping on the + icon. Reminders can be defaulted for every hour and a half or you can add a specific time if it isn’t included. The icon badge can be enabled to show you the percentage consumed. Social media for facebook and twitter is available. I can’t go back to a past day and update my consumption. I also can only delete the past or entire log. The graph function is limited compared to iDrated and shows only a four-day view. While I like the overall design, I think the features are limited when compared to the previous two apps.
Features: Main screen shows eight ounce glasses that you can set as default as full, ½ or ¼ of 8 ounces. You set the default glass size and then your goal for daily number of glasses. You simply tap a glass to record a full amount. This does not allow you to record a fraction of a glass at a time unless you edit the overall glass amount. You can add a schedule to remind you to drink and view your history in a weekly or monthly bar chart. You could export your data to an email if you desired. There is an advertisement built into the free version which I dislike. The badge can be enabled to show the amount consumed or remaining left for the day. This app requires the least amount of time to record as you simply tap but is very basic and I found it visually least appealing.
Features: The main screen looks like a wooden table top with a free-roaming interface. This app took me a bit to figure out how to add water. I realized I prefer seeing the amount I’ve consumed progress at a percentage of my daily goal, whether this is as a person or a glass. This app lets you add the multiple glasses you drink over the day and you can visually rearrange them on the table. You customize your container of water and ounces consumed by selecting one of four glass figures and either change ounces on a sliding scale or by inputting the amount. Once you “X” out of that screen you tap the table to visually add that glass. The glass can be stamped with amount or time consumed. A graph icon shows you the current percentage consumed with a letter grade for the day and a line graph displaying the percentage consumed in a 30-day period. You can upgrade for award features. Bottom line: I didn’t care for the overall appearance and found the features more confusing than helpful for easy use.
Download one and start tracking! Let us know your water thoughts, how you feel better when hydrated and any fun tips you’ve found that help you succeed. Cheers!
By Ashley Gilchrist, MPH, PA-C
iTunes App Store
This week we open the series and start with a very simple behavior change that reaps huge health benefits. We will explore the benefit of staying hydrated and associated water tracking apps.
Water is essential for life. Without it, we can only survive for days. The majority of our body is composed of water and adequate intake is related to our energy levels, weight maintenance, performance and overall functioning. While we know water is fundamental to our composition and survival, our current understanding how hydration specifically affects health, well-being and chronic disease is lacking. Water requirements are largely based at a population level from retrospective studies in healthy people. In the US, we get an estimated 22% of our daily water intake from a proportion of beverages and food sources such as fruits and vegetables.
As humans, we have a sensitive system of physiological controls to maintain body water. This is mediated by the sensation of thirst. When the body is thirsty, you have already been triggered to respond from water deficiency, or dehydration. Our kidneys play a key role in regulating our fluid balance and they function best with abundant water. A concentrated or dark yellow, urine causes the kidneys to work hard, expending energy, causing wear and tear and unneeded stress on these vital organs.
Most of what we know about the benefits of water is from deficits seen in those dehydrated compared to hydrated people. Here’s a short synopsis of studied differences.
Performance: Athletes can commonly lose up from 6- 10% of their body weight from sweat loss causing dehydration. Decreases in physical performance have been seen in as little as 2% loss of hydration. This can present as reduced endurance and motivation, more fatigue with perceived increased effort. Drink water before, during and after exercise.
Cognition, aka Brain Power: Dehydration can cause changes in mood such as fatigue and irritability and cognitive functioning such as concentration, alertness, short term memory, and performance on psychomotor skills. Feeling sluggish at work or moody at times? Try adding more water and seeing if you feel different.
GI Function: Dehydration may be related to constipation and can also alter the electrolyte balance in your body. Your body can lose significant amounts of water through the GI system and even lead to death in diarrheal diseases when the body can’t re-hydrate fast enough. The small intestines can absorb up to 15 liters of water each day!
Headaches: Dehydration can lead to headaches and can trigger or prolong migraines. One randomized trial found that those who added 1.5 liters water/day to their current diet found reduced intensity and duration of their headaches. For dehydration headaches, usually drinking water will provide relief in as soon as 30 minutes. If you are prone to dehydration headaches, stay ahead of the game rather than try to catch up with headaches.
Skin: Our skin is made up of 30% water and is a crucial barrier to the outside world. Skin is important in maintaining our water levels and preventing water loss. There is not good established evidence to show that drinking water contributes to ‘glowing’ skin but it will improve skin thickness and hydration.
Chronic Disease: As water is essential for our health, it makes sense that dehydration could contribute to chronic diseases. Hydration has been associated with reduced incidences of constipation, exercise induced asthma, urinary tract infections, high blood pressure, fatal coronary heart disease, clot formation, and stroke.
Weight: Staying hydrated can help with weight loss, reduce the amount of calories consumed and reduce hunger. Many times the sensation of hunger is mistaken for thirst. You can reduce your overall energy needs by an estimated 10% when you replace sugary drinks, soda, juice, and whole milk with water. Drink water before or with each meal and in between. If you are trying to lose weight, drink a glass of water 30 minutes before you usually eat and swap out sugary juice and soda for flavored water.
Clearly staying hydrated is important. But how much should you get? There is great variability between water needs with different ages, physical activity, weight and metabolism. The Institutes of Medicine has determined an adequate intake (AI) is roughly 3 liters (~13 cups) for men and 2.2 liters (~9 cups) for women of total beverage per day. Eight 8-ounce glasses of water a day is about 1.9 liters so the common “8 by 8” rule is not too far off.
• If you exercise, add 1.5-2.5 cups of water for short exercise and even more if you are exercising intensely for longer than an hour.
• Add more water with hot or humid weather and high altitude.
• Pregnant women should drink 10 cups and breast-feeding woman even more with 13 cups a day.
• When you are sick with a fever, or have vomiting or diarrhea you lose more fluids than normal. Your doctor may ask you drink re-hydration solutions as plain water may not replenish electrolytes you have lost.
Generally speaking, drink enough fluid that you rarely feel thirsty and your urine is colorless or light yellow. You can drink too much water, but this is uncommon in healthy adults and usually only seen in endurance athletes.
Here are some tips to help you succeed. Find a good water glass. I’ve discovered I drink considerably more water with a straw. Prefer flavored water? Try experimenting with your own flavors. Infuse water by adding fresh cucumber, lime, lemon or orange slices. Mix in crushed herbs such as thyme, rosemary, mint or basil. Buy an edible organic extract such as peppermint and use a drop or two in a water bottle. Try seltzer water for a bubbly change. Experiment and have fun!
Have a suggestion or a certain topic that you would like to see discussed, comment below. Be sure to like us on facebook for the inside scoop of all the happenings at VSI!
By Ashley Gilchrist, MPH, PA-C
Water, Hydration and Health. Popkin, BM. D’Anci, KE, Rosenberg, IH. Nutr Rev. Author manuscript; available in PMC 2011 August 1. Accessed here.
Water: How much should you drink every day? By Mayo Clinic staff. Updated July 13, 2013. Accessed here.
Are there times that you feel like you need a translator to decipher your doctors appointments? Our doctors take their time with each patient and diligently explain complex spinal diagnoses. However, if you are still taking the time to digest the terminology and what it all means, this explanation as seen in Real Simple magazine may prove helpful:
Or click here for the PDF version
Painful discs in the neck or low back are common causes of severe back pain and disability. The ability to get these to heal without surgery has been a long-term goal of many patients and physicians alike. We are now on the verge of creating those possibilities.
At the Virginia Spine Institute, we are working with two different approaches to help degenerative injured discs heal without surgery. The first is injecting a person’s own blood products into the disc to cause it to heal. This is using a substance called PRP or platelet-rich plasma. To do this, we aspirate blood from a person’s vein, centrifuge it down, collect the platelets and growth factors out and then inject that into the disc under x-ray guidance to stimulate the healing process. We have been doing this for the past several years with great success in improving patient’s functional levels and with greatly reducing pain without surgical intervention.
The second option is injecting stem cells into the disc. These stem cells are harvested from the patient’s own iliac crest or hip bone, centrifuged down, collected, and then injected into the disc, stimulating healing of the disc by using these primitive blood cells to stimulate regeneration of the collagen within the disc. This technique has been done for the past year and again we are excited to report improvement in the patients.
The ideal candidates for these novel procedures are individuals who have mild disc injuries or mild tears and intractable back pain in spite of six months of appropriate exercise, activity modification, and therapy. For people who have failed the non-operative management that are not prepared to undergo a major surgery and have problems limited to one or at the most two levels, then this is a reasonable option. The more collapsed the disc is, the more arthritic changes, the less likely these procedures will be beneficial for a given individual. However, time may allow us to increase the variety of conditions treated with these technologies.
Not all patients will be a candidate for these disc regeneration procedures. For those few that are the ideal candidates, this provides them great hope with reduction in pain, improved quality of life without the need for major surgery. We are excited about these great advances in health care and look forward to helping achieve the betterment of our patients and patients across the nation.
Click below to get the printable matching game. See if you can match the Virginia Spine Institute Physician Assistants’ with their fun facts!
BREAKTHROUGH CELL-BASED THERAPY HAS PROMISING OUTCOMES FOR PATIENTS SUFFERING FROM BACK PAIN ASSOCIATED WITH DEGENERATIVE DISC DISEASE
Back pain affects all of us at one time or another in our lives. One of the most common cause of back pain, is degeneration of the lumbar discs. As the disc ages, the shock-absorbing nucleus pulposus (inner disc) loses water and the disc cells begin to die off. To date, no therapy exists that can regenerate the nucleus or reverse this degenerative process, leaving surgical intervention as the only option. In the United States alone, more than 400,000 lumbar discectomies and 500,000 spinal fusions are performed each year for symptoms related to lumbar disc degeneration. Both procedures also have significant drawbacks, such as restricted mobility and continued degeneration of the affected discs.
Using NuQu (ISTO Technologies, Inc) to restore a damaged disc could save the disc and prevent further degeneration. NuQu is composed of culture-expanded juvenile cartilage cells (stem cells) in a protein-based carrier. These cells have been proven to have far greater regenerative potential than adult cartilage-forming cells based upon preliminary investigations.
After evaluating hundreds of patients for the FDA trial comparing these cartilage forming stem cells to a saline placebo, the spinal experts at The Virginia Spine Institute were able to enroll 5 patients in the study. Although the early results have been promising, the evaluation will not be complete until a full year passes after the injection.
Although NuQu is an early-stage, cell-based therapy aimed at treating the cause of back pain associated with degenerating discs, we remain optimistic that it has the potential to cure this disease. This pioneering cell therapy, currently under investigation by our physicians, shows promise in restoring the structure of degenerating discs and alleviating pain after other non-operative treatments have failed and before surgery even becomes a consideration.
We’ve gone pink today in support of Breast Cancer Awareness Month. If you happen to be in the office ‘show your pink’!
Did you know? Bone loss can occur from breast cancer treatment. To prevent or decrease the rapidness of bone loss, there are several steps you or your loved one can take.
Early diagnosis and treatment is critical in reducing bone loss caused by breast cancer treatment. A lifestyle that includes regular physical activity is important for bone health throughout life. All types of physical activity can contribute to bone health. Activities that are weight bearing or involve impact are most useful for increasing or maintaining bone mass. Some activities that are not weight bearing or are low impact may help improve balance and coordination and maintain muscle mass, which can help prevent falls. 30 Minutes or more of moderate physical activity is preferable seven days a week, to remain physically active.
In addition to regular exercise, a healthy diet and daily supplements of calcium and vitamin D can help prevent or slow cancer treatment-related bone loss. Calcium is a critical nutrient for bone health and vitamin D aids in the absorption and utilization of calcium.
Things to avoid:
- Heavy alcohol consumption and smoking are associated with reduced bone mass and increased fracture risk
- Phosphates/Phosphoric acid, which are present in all “fizzy drinks” and gives cola drinks their “bite”, leaches calcium from bones
To make sure bone loss is identified quickly, breast cancer patients should receive bone mineral density tests every 1 to 2 years.
For more information and resources on breast cancer, Click Here.
The Virginia Spine Institute team is excited to announce a new treatment option for chronic pain sufferers; an implantable pain-blocking device approved by the Food and Drug Administration (FDA) that is safe for full-body MRI (magnetic resonance imaging). The device utilizes neuromodulation technology that has been used for decades, but is now showcasing some recent advancements in the technology. Many patients that would need MRI’s for diagnostic reasons were previously not considered for this device. In today’s medical practice, MRI examinations are necessary and routinely performed for diagnosis and clinical care. It is very likely that a patient with chronic pain, spinal disease, neurological and orthopedic disorders will require multiple MRI scans. However, until now, this was not feasible with Spinal Cord Stimulator (SCS ) implants.
For many years, neuromodulation therapy, also known as spinal cord stimulation, is an interventional pain management technique that uses a small, battery-powered transmitter to deliver signal through electrical leads implanted near the spinal cord. The signals interfere with pain messages traveling from nerves to the brain to a perception of tingling numbness. The spinal cord stimulator(SCS) devices work extremely well for patients with chronic, intractable neck and back pain with associated extremity nerve pain. Unfortunately, SCS therapies were limited due to relative contraindication with MRI scanners. There was concern of possible tissue injury if energy from the MRI was absorbed by the SCS device.
Medtronic recently introduced the first and only neurostimulation system, called RestoreSensor system, “for the treatment of chronic, intractable back and/or limb pain that is approved by the U.S. Food and Drug Administration (FDA) for conditionally safe* full-body Magnetic Resonance Imaging (MRI) under specific conditions.”
The ability to safely perform MRI scans after a spinal cord stimulator implant (SCS) is an important advancement and a major benefit for our patients at the Virginia Spine Institute.
Our spine and pain management specialists will evaluate your individual pain to see if neuromodulation therapy is indicated and if this treatment option is right for you.
SI-BONE recently announced that their innovative iFuse Implant System has reached an important milestone; over 8,500 patients have been treated with the iFuse resulting in over 25,000 iFuse implants placed in patients worldwide. The iFuse system is a minimally invasive surgical device used to fuse the sacroiliac (SI) joint when conservative measures fail to provide long term relief. The iFuse Implant System is the only device used in minimally invasive SI joint fusion for which there is published peer-reviewed clinical safety and effectiveness data. In minimally invasive SI joint fusion, the iFuse system accounts for over 90% of all of these minimally invasive procedures.
Our very own spinal specialist, Dr. Michael Hasz has been performing SI fusions for nearly 20 years using various techniques, and in more recent years the iFuse Implant System. Dr. Hasz is a lead principal investigator in SIFI, an SI-BONE national prospective outcome study. His expertise in SI fusion techniques and involvement in SIFI allows the Virginia Spine Institute to offer iFuse devices for sacroiliac fusions. Dr. Hasz continues to be a leading national and international educator regarding SI dysfunction and surgical options. He is locally increasing awareness about SI joint related pain by providing educational presentations to health providers.
The sacroiliac joint is a strong weight bearing joint in the pelvis that connects the sacrum and pelvis. These joints move together as single unit and provide additional shock absorption for the spine. Just like other joints in the body, this joint can become unstable and dysfunctional. When SI joint dysfunction is severe, this joint can refer pain to the hip, groin, buttocks, and even down the back of the thigh. Pain may be worse with movements that stress that joint, such as standing up from a seated position, walking up an incline, elliptical exercise, prolonged sitting or walking, or twisting when rolling in bed at night. SI joint dysfunction or inflammation can mimic pain similar to degenerative hip disease, hip bursitis, lumbar disc herniation, or pinched nerves.
Over the past several years, there has been increasing awareness and recognition of SI joint pain as a potential and common source of low back pain. A 2009 study published in Spine by Sembrano et al. found that up to 25% of patients presenting to a spine clinic had significant pain from the hip or SI joint. In 2011, DePalma et al in Pain Medicine identified the SI joint as a low back pain generator in 43%, and possibly as high as 61%, of patients with continued back pain after a lumbar fusion. Initial conservative treatment options for the SI joint typically involve physical therapy, medication and injection management. When these non-surgical treatments for the SI joint fail, surgical options such as the iFuse exist to provide permanent stability and pain reduction. We are very proud of Dr. Hasz and his leading expertise in SI joint related pain. Our surgeons remain on the forefront of providing innovative evidence-based spine treatments.
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