Heel pain due to plantar fasciitis is common, but treatment options have come a long way. From injections to orthotics, NYU Langone Orthopedics experts update you on the latest.
Join Dr. Lauren Borowski, MD & Dr. Rick Delmonte, DPM as they explore the options for treating heel pain due to plantar fasciitis. From the possible causes to the options for finding relief, NYU Langone Orthopedics experts explore the ways to determine your risk, get the proper diagnosis, and discuss options for treatments, from physical therapy to surgery.
Narrator: SiriusXM presents an NYU Langone Orthopedics podcast. Orthopedics is just very important to the population in this country. Its ability to restore patient function. Problems related to cartilage, to someone who has more advanced forms of arthritis. Getting people back to their activities and the things that they like to do. Featuring NYU's experts in the field of Orthopedics trying to figure out that problem before it even is a problem. Problems with solutions. Well beyond physical therapy, to conservative pain management, to surgery. The best medical minds now come together. Applying all of our minds to solve these problems. We're here to get people feeling better so they can get back to their lives. And that's really what we try and accomplish. These are the Bone Whisperers.
Dr. Lauren Borowski: Hello, and welcome to this edition of the Bone Whisperers Podcast. I am this edition's host - I am Dr. Lauren Borowski, a primary care sports medicine physician here at NYU Langone Health, and I have the privilege of being joined by Dr. Rick Delmonte, our Chief of Podiatric Surgery here at NY Langone Health and the Department of Orthopedics. Thank you so much for being here, Dr. Delmonte.
Dr. Rick Delmonte: Thanks for having me. Very excited to talk about this today.
Dr. Lauren Borowski: I am, too. So I think we can just launch right into it. This is a subject that I find very interesting and it's a big part of my practice and obviously I know it is of yours, so we're just going to get right into it. Today we're talking about the plantar fascia and plantar fasciitis. So what is the plantar fascia? Where is it? What does it do?
Dr. Rick Delmonte: So the plantar fascia is a long, thick, soft tissue structure ligament that spans the whole arch of the foot from the plantar or the bottom aspect of the calcaneus or the heel bone, and goes through the arch and attaches to the front of the foot, metatarsal heads and the toes. And it's a support ligament, so carries a lot of weight certainly during walking. But even with more advanced activities like running, it can bear quite a bit of weight and it's under a lot of stress.
Dr. Lauren Borowski: Why do people get such issues with their plantar fascia? Why do you think it's such an issue, especially being here in New York City.
Dr. Rick Delmonte: Right. There's so many different etiologies of inflamed plantar fascia or plantar fasciitis or plantar fasciosis. Sometimes it's heels spur syndrome, which is another part of the talk a bit later, I'm sure. But there's a big demand on that fascia. It could be athletes, could be people overweight. It could be a certain foot structure, a high arch foot, flat foot, someone who over pronates. And it could be someone who just has just overbearing stress on the fascia. It could be someone who has an autoimmune disease or, uh, some collagen vascular disease that can cause pain in the fascia.
Dr. Lauren Borowski: Let's go back to something that you just said. You mentioned the heel spur. We can just, you know, launch right into that as well. So people come in all the time and they will have gotten X rays from their primary care doctor or some other reason that they would have gotten X rays of the foot because they've had this pain and it shows a heel spur. What is that? Heel spur. And does that cause pain?
Dr. Rick Delmonte: So heel spur syndrome and plantar fasciitis are kind of synonymous. And for years before I was finished with my residency 25 years ago, they used to go in and take the spur out surgically. And it didn't do very well. It was a large incision. Patients had problems with their wounds. They had nerve entrapments. And they found that patients still continued to have pain in their plantar fascia, where it attaches to the heel bone. So they realized it really wasn't the heel spur that caused the pain, but it was actually the fascia attachment to the heel causing this inflammation and this degeneration of the fascial fibers. And then we started to learn more about this over the years, where there's not only a mechanical problem with the fascia, but there's a biological problem with the fascia as well. So through all of evolution of the different etiologies and the treatments, we have so many different options for treatment today. We have to really just sort of focus in on what the etiology is and we can really fine tune a treatment plan for our patients.
Dr. Lauren Borowski: So let's say a patient comes into your office and they come in saying, I've had heel pain for the last two months. What are some of the questions that you ask to try to decide what this could possibly be, and what do the answers to those questions lead you to thinking?
Dr. Rick Delmonte: So two months, uh, and they haven't seen anybody else before, and I'm the first specialist that they've seen. It's all in the history. When do you have the pain? Patients typically have pain in the morning with their first step out of bed. We call that post-static dyskinesia, or pain after rest. Patients are in bed for five to eight hours. They're not using the fascia. It's very tight. They step down and wham, it's like a knife in the heel. As they walk, it gets a little bit better and loosens up. Um, typically I'll tell patients, uh, stretching is a very important, ah, treatment for fasciitis. Sometimes we put them, um, in a night splint, which will keep them sort of dorsiflexed or the ankle will be, uh, flexed towards their tibia or their leg throughout the night, which is very uncomfortable. But when they get out of bed in the morning, it's not as tight, so they don't have that wham, knife pain in their heel. Um, anti inflammatories are a really good first line of treatment for the patient who's had two months of pain. We sometimes tape their foot, we'll put a low-dye strapping on and they wear that for a few days. And we let them answer us in a few days, how did the tape feel? If the tape felt great, we know it's a mechanical problem. And then we may tell them to get an over the counter insert or an orthotic or even something custom if it's a more advanced type of fasciae - orthotics work really well for that.
Dr. Lauren Borowski: Does your approach to this patient change if they've had symptoms for six months or more or a year or more?
Dr. Rick Delmonte: You know, sometimes patients will come in and they'll have pain for six months to a year and to other specialists. And in the history, I find that they've had maybe four or five, six, up to 10 different injections of steroids. And they have all kinds of problems going on - it may not even be the diagnosis of fasciitis. It could be something else.
Dr. Lauren Borowski: Like what? What else do you say?
Dr. Rick Delmonte: Well, a lot of times I'll see, patient will come in, they'll say they have fasciitis and nothing's working. And they have something called calcaneal bursitis. And calcaneal bursitis is something that's millimeters away from plantar fasciitis – it’s on the bottom of the heel bone, there's a small bursa sac where if there's enough pressure put on this bursa sac, it will get inflamed and we call that a bursitis. And unless you inject the bursa sac with some steroid or sometimes we'll do some needling of the bursa down to the level of the bone. Patients typically do well with that and some sort of, uh, a Visco gel cup that will protect that area. And it's a different treatment than fasciitis. So it's important to get the right diagnosis, you can get the right treatment plan.
Dr. Lauren Borowski: We talked a little bit about the X ray. Do you think that X rays or other types of imaging play a role in the diagnosis of plantar fasciitis?
Dr. Rick Delmonte: Right. I typically don't get X rays or any advanced imaging unless I'm not 100% sure that it is fasciitis. In the history, uh, pain after rest. Uh, if someone says they're sitting at a desk all day, when they stand after an hour or two, that's when the pain, uh, is very intense. I'm very confident that's fasciitis. I push on the area of their chief complaint, which is typically the plantar or the bottom medial, which is the inside of the heel. The plantar medial tubercle is the main insertion point where patients typically have pain with fasciitis. If I have that in my clinical exam and their history is consistent with post-static dyskinesia or pain after rest, um, I'm very confident with my diagnosis. I don't need imaging now. If it's a little bit off - they don't have pain in the morning after their first step. Maybe it's during running. When typically patients with fasciitis have their pain after activity. It's not during the activity, because during the activity they're using that fascia. It stretches out. It's less painful. I may obtain an X ray to see if they do have something on the heel bone, maybe a large spur. A large spur may represent something like rheumatoid or psoriatic arthritis or Reiter’s disease, which is something very rare, but they do present with heel pain. Maybe there's a bone cyst or a bone tumor or maybe a stress fracture that's developing and they present differently. So then the treatment would be different as well.
Dr. Lauren Borowski: Touching base on stress fractures a little bit, if someone's coming in with this kind of heel pain, it's been going on a shorter period of time, maybe two or three weeks, and it is painful with running, are you thinking of all things being equal, they have pain in the first step, but also hurts with walking - do you think plantar fasciitis or are you already down another path?
Dr. Rick Delmonte: It could be fasciitis, but typically you talk about marathon runners, patients who run their first marathon or even when they're training for their first marathon, they come into our office with stress fractures because their body's just not that mileage. And that exam is a bit different than fasciitis. It's not so much the pain in the morning, but they have medial and lateral pain, compression pain on the calcaneus. Sometimes it's bruising, sometimes it's swelling. So it's a little bit different than fascial type pain. And then obviously, an X ray can show that. And if I can't see it on an X ray, I may obtain some advanced imaging like an MRI. It should be more clear than an X ray.
Dr. Lauren Borowski: You mentioned, um, stretching earlier and how stretching can be very helpful and should certainly be a part of treatment of this. Are there other things from a physical therapy standpoint that you feel like are helpful for plantar fasciitis?
Dr. Rick Delmonte: Yeah, so a lot of patients, I would say the majority of patients with fasciitis have what's called equinus or gastrocnemius equinus or tight calf muscle. And calf stretching is really important with plantar fasciitis. In fact, the education that we provide patients with their fasciitis, one of the things is they need to learn how to stretch at home. And calf stretching is fantastic. I also tell patients to take a frozen soup can, and they roll their arch on the frozen soup can, which gives them sort of ice massage to the fascia and also stretches the fascia out directly with that cylindrical object. A soup can or a frozen Pepsi can or something. Coke can. Sorry.
Dr. Lauren Borowski: I say water bottle.
Dr. Rick Delmonte: Bottle.
Dr. Lauren Borowski: Frozen.
Dr. Rick Delmonte: I say bottle.
Dr. Lauren Borowski: The plastic usually gives a little bit more.
Dr. Rick Delmonte: Yeah, but something cold and that's cylindrical will actually stretch out that fascia as well. So, um, yeah, that's something that I always add to the treatment plan.
Dr. Lauren Borowski: One of the things I talked to my patient population about a lot. So I see a lot of dancers and performers that have feet problems. So I talk a lot about the intrinsic muscles of the feet and those muscles that are contained within the foot and that help to support the arch, just like the plantar fascia does. So it almost kind of takes some of the workload off of the plantar fascia.
Dr. Rick Delmonte: So there are some really good stretching and strengthening techniques that mostly the physical therapists will provide when we send them to physical therapy, because I find that a structured program with these patients going maybe once or twice a week to a therapist, they have a copayment, they put value on going. That routine really does help a lot. If I tell patients stretch at home two or three times a day, they may not do it as much as going to a therapist. So I find that that structured plan with a therapist works really well. But as far as intrinsic muscle strengthening and flexibility, I'll tell them to take a towel, take their foot off and they'll step on it and they'll just grab it with their toes. And that will actually strengthen some of the intrinsics in the arch that provide function and mobility to the toes. So that's definitely helpful.
Dr. Lauren Borowski: Let's talk a little bit about orthotics. So an insert for your shoe. So I think that this is very commonly talked about and prescribed with a plantar fasciitis issue. Can you talk more about why they might be helpful? Yeah, let's start there. Why might they be helpful?
Dr. Rick Delmonte: There's a lot of controversy whether or not custom orthotics are worth getting, that maybe some of the over the counter 50 dollar device is just as good. And I think there's definitely an argument there. I think that some of the over the counter devices today are excellent and they do work, but they don't last that long because the materials aren't as robust as something that you would have made in a lab. So we always let patients know that the majority of insurance companies don't pay for orthotics now and they can run anywhere between $400 and sometimes in Manhattan they could be $1,000 for orthotics, which is somewhat costly item. So we offer the patients something over the counter because I do believe the over the counter devices today are excellent. They just don't last as long. Another thing that you have to consider with custom orthotics is a lot of patients do have significant deformity in their foot. They may have significant heel valgus or the position of their heel is in what's called an everted position, which will tension the fascia even more. And there's no over the counter device that's going to be able to post that heel or put it into a neutral position that a custom device could do with a prescription from one of us. So I find that when there's a little bit more deformity in the foot, more excessive pronation, more of a flat foot, or someone who has more of a cavus foot or a high arch foot, I think that being able to post these devices with a prescription, which is custom, which is expensive, is - there's definitely room for that in our treatment armamentarium. But I offer patients something over the counter first, so we do both.
Dr. Lauren Borowski: One of the questions I get a lot from my patients is how often should they be replacing their orthotics? Whether it be an over the counter or custom, someone may come in having had a custom orthotic made five, seven years ago. What do you look for to say, okay, it's time?
Dr. Rick Delmonte: Yeah, it's a good question. Um, I usually tell patients that orthotics that we make that you pay for, typically last three to five years. Now I've had patients come in 15 years later and say, you made me a pair of orthotics 15 years ago, and it was a life changer. And they're here and they're still alive. And I look at them, and they're still rigid and they're still supporting body weight. Uh, maybe the posts that we put on there have worn down, but we could just replace the posts and keep costs to a minimum. So, yeah, we do see some orthotics lasting several years, and sometimes patients who are running three or four or five marathons a year, with all that training, they may need to go through something maybe once a year. So it depends on the mileage and how they wear and how their shoes are wearing, etc. So I usually test them, and it's all about the materials. And I think that's one of the big differences between the over the counter and the customs - the materials, the polyethylene thermoplastic materials that we use are a little stronger, so they last a little bit longer, too.
Dr. Lauren Borowski: When a patient has a pair made, what do you tell them to do in terms of, should I wear them in my dress shoes? Should I wear them in all my shoes? Should I put them in my running shoes? How do you navigate that situation?
Dr. Rick Delmonte: Big problem. So a lot of my patients are ladies, and they like to wear fancy shoes.
Dr. Lauren Borowski: Yeah, their foot doesn't fit into it. Now that they have this orthotic thing.
Dr. Rick Delmonte: Um, they don't fit. And so there are some orthotics that are thin and streamlined, and they call them dress devices. They're not as robust as something that you would wear in a running shoe or a cross trainer or something that you would play sports with. But this is what they've done to accommodate some of these ladies’ shoes. I don't think that they work as well but there are women that find shoes that they could sort fit them into, and they're happy enough, they sort of meet me halfway. And I have that conversation with them. But something that's expensive, you need to let patients know that these will not fit into your lady shoes. But we can make something thinner. And typically the thinner devices don't have the posts on them which control that heel motion I was talking about earlier. So it's difficult to fit a good orthotic with a lady shoe. But the nice thing about women with fasciitis, if they're in a heel, they typically don't have plantar fascial pain because they're taking the tension off the fascia being in that supinated position, which is the opposite of the flattening. So you don't really need the support so much. So that's a nice thing that they can do is with fascia they can wear heel, there’s less pain.
Dr. Lauren Borowski: So tell me, what are some of the things that are risk factors for developing plantar fasciitis? We've mentioned a few of them along the way, but maybe not in such explicit terms.
Dr. Rick Delmonte: Certainly patients who are carrying a few extra pounds. You definitely see fasciitis in the obese patient because they're just really stressing that fascia. Athletes who really are putting a high demand on the plantar fascia with certain sports, specifically - basketball, tennis, football - you see a lot of patients with fasciitis with, uh, high energy sports. You can have patients who have, like I said before, structural problems with their feet, know, a flat foot or a high arch foot. These are things that we see that would put an undue stress on the fascia. Just their structure of their foot alone, and then the demand of weight and then the activities on top of that will cause more stress.
Dr. Lauren Borowski: So coming back to a patient, let's say you see that person who's had pain for two, three months, say, okay, try the stretching, maybe lose a couple of pounds, see if that helps. Try these orthotics, see if that helps. Go to physical therapy, and then they come back two more months later still painful. Where do we go next?
Dr. Rick Delmonte: And I'm certain that it's fasciitis. I mean, I've been wrong. But you're saying I'm confident with the diagnosis at, uh, this point?
Dr. Lauren Borowski: Let's say yes.
Dr. Rick Delmonte: Definitive m When patients come in, I typically will talk to them about orthotics. We'll send them to physical therapy. We'll give them some stretching, exercise to do some ice massage techniques like we talked about. And oftentimes I'll drop some steroid in there, I'll give them an injection in the area because it's not only for therapeutic purposes to make them feel better as an anti inflammatory, but it's also a diagnostic tool. And there's also a confidence builder because if you send someone for, uh, physical therapy, you make them an orthotic and you give them an injection, they're leaving that room probably pain free for a period of time. This steroid is going to last maybe a month or two. Sometimes you get lucky it's a few months, but that's temporary. That's just for the local inflammatory properties of the fasciitis. The orthotic is more long term, the stretching and the icing and the PT is long term. And then that will move us into the new stuff with the biologics that we're now using. Because now we understand it's not only mechanical, but there's also a biological component to the fasciitis. So I think it's now more of a mechanical, biological combination of treatment. And I think that's what really works best. I used to do a lot more plantar fascial surgery than I do now. And it's because a lot of the different treatment modalities we have now is because we understand so much more of fasciitis as a mechanical and also biological problem that patients are doing so much better now without any surgical intervention.
Dr. Lauren Borowski: I'm glad you brought up the point about the steroid injection and how they can definitely be helpful, but it's not something that's typically going to provide long term relief. So we usually see that it's maybe a month or so, like you said, maybe those patients that you'll see in the office had swear by them that they had one three years ago and it was helpful until recently. But that's kind of the outlier. It's usually more of that one to three or so months. So then what? You mentioned, the biologics or that classification of biologic treatments. What are some of the other things that we're doing for plantar fascia now before we get to the stage of possibly needing a surgery?
Dr. Rick Delmonte: So PRP injections, shockwave therapy, those are two of the more common modalities that we're both doing now, both of us. And I pretty much send my shockwave patients to you because I don't have a shockwave machine, you do so much more of it and patients do really, really well with that PRP injection. So PRP is basically platelet rich plasma which we take blood out of the patient's arm about 50 to 60ccs. We put the blood into a machine, we spin it down to a centrifuge it. We separate the hard components of the blood and the liquid which the hard components comprise all of our growth factors, our stem cells, our cytokines, which are all these inflammatory modulators and so forth. And then we re-inject that right back into the area and that's the biologic repair that we're trying to achieve with this injectable. And there's a lot of great studies out there that support the efficacy of PRP injections. Shockwave therapy, which it's originally from treating renal stones with lithotripsy, is just shock waves that bombard the area hoping to create angiogenesis or new blood flow. And it can also intercept the pain receptors and sometimes intercept some of the other modulation at that area and works pretty well. So problem with those two, they're both not covered by insurance and they can be costly. But again, it's funny, I think people in New York are willing to pay for it, especially if the other treatment modalities haven't been so successful. PRP and shockwave therapy are both excellent treatment modalities for fasciitis and it's being more utilized today than ever.
Dr. Lauren Borowski: I mean there's pros and cons to both. They kind of similarly try to change the environment in which the plantar fascia is currently. Um, the PRP is an injection. The shockwave is uh, essentially an ultrasound device, uh, which is not an injection but takes, has more treatment sessions. So with PRP we usually do one. Most of us at NYU, I have seen we do one and then we see how the patient does in response. And then with the shockwave we're doing anywhere from three to five sessions typically. And like you said, most of the time they are not a covered service. It's very rare that these things are being covered by insurances at this point. But being in a place like New York where we walk so much, it is something that people find extremely helpful and are willing to go the extra mile and do, because it’s needed.
Dr. Rick Delmonte: It's disappointing because the evidence is there. The evidence is there. There's so much literature that supports the efficacy of both those treatments and it should be covered. Now some doctors probably don't want it to be covered, because, you know, that's how they make a living. But I'm not so sure I'm from that school. You know, we all take insurance, and it'd be nice if you could do the right thing for the patient. And the right thing is what works.
Dr. Lauren Borowski: Mhm.
Dr. Rick Delmonte: So, you know, that's my experience with it.
Dr. Lauren Borowski: Yeah. I think that with PRP in particular, you know, we've learned over the years that it's not this magic bullet that we thought it was going to be. It was this cure-all that we could put it anywhere and it was going to be helpful. But there are certain conditions where it seems to be more effective than others. Plantar fascia being one of them, lateral epicondyle, the lateral elbow, the outside of the elbow for tennis elbow being another one. The outside of the hip in those tendons. So there's definitely evidence there that it can be helpful. And I think when you are a patient and you've tried all of these other things and you don't want to have surgery, these are very reasonable things to try if you have the financial means to do it.
Dr. Rick Delmonte: Yeah. And that's how I address the patients. I'll say, listen, we've done everything here. You're not doing well and you don't want surgery. And I understand that. There are two other modalities we can try. Unfortunately, it's not covered by your insurance, and this is what it costs. And the majority of them actually will pay because they don't want surgery. And I encourage them to do the PRP or the shockwave therapy.
Dr. Lauren Borowski: Let's talk about surgery. So let's say you have this patient. This patient is now a year into their whole saga of heel pain. They've tried everything that we've just mentioned, and they've tried PRP, they've tried shockwave, and it is just not better. And now we're talking about possible surgery. Tell me what that looks like. What does that entail?
Dr. Rick Delmonte: Well, you know, something that I'll definitely do before surgeries. I'm certainly sending the patient for a battery blood test to make sure they don't have anything autoimmune or something rheumatologic going on, because you can get fooled. Um, and there may be some marker that shows up that shows that they have psoriatic arthritis. Uh, that's someone I would not want to operate on because I'm sure that it may not help them. And then you have a bigger problem. So I try to talk them out of the surgery. Although it does work. There's two ways of doing this. You could do an open technique where you release the fascia, or you could do it endoscopically. Uh, I've always done what's called an instep small incision fasciotomy. The fascia is directly under the skin - there's no other structures there. You make a small incision, you spread with a hemostat, you find the, um, the medial band of the plantar fascia, which is maybe a, ah, quarter of a centimeter in length. And you just cut that fascicle and you see a gap. And once that's done, you throw one stitch into the skin. Patients walk that day because you don't want it to reattach by being off weight bearing. Uh, I get him into physical therapy at the second week when the stitch comes out. And I can tell you it's a very successful procedure as far as getting rid of plantar fascial pain. However, there are complications like a plantar scar. And if you have a small plantar scar in your arch, that's a more unhappy patient than before they had the surgery. So people get these painful scars probably 5 or 6% of the time, and that if you're doing a few of these a year, it may not be that many, but you get one patient who's unhappy, it's a problem. The endoscopic approach is two incisions, one on the medial side of the heel and one on the lateral. You go in with a camera, you can see the fascia, and then you go in with the blade from one side and you resect one third or one half of the fascia and again a stitch on each side. Now there are so many people that do it that way. It's quick, it's easy, it's effective. You don't get that plantar scar. But I have seen nerve entrapments from those incisions. And so there are complications with both. So you try to get away, if you can, from doing these procedures and hoping that everything non-surgical works is really my approach.
Dr. Lauren Borowski: There are some times where people will come in with very acute painful heel and - to the point where you're like, they can't walk. Right. And you're thinking maybe they ruptured their plantar fascia. It had maybe some partial tears previously and now they've ruptured it. How do you approach that? And is that a different approach to you?
Dr. Rick Delmonte: Right, so it's a great question. And I have a great story for you. So I had plantar fasciitis about five years ago. About the time that my son became like a grown man and my heel was killing me. I was in orthotics. My partner gave me an injection of steroid. I was on anti inflammatories, I was stretching and it just wouldn't quit for about two months. And I was really somewhat debilitated. So my son and I were wrestling one day and I felt a pop in my fascia and I tore my plantar fascia. And it was pretty bad for about two weeks. And it was probably a result of the injection and the force I put on this by planting my foot and dorsiflexing my foot and tearing the fascia. I went into a walking boot for two weeks and never had the pain again. So the rupturing or the tearing of the fascia is sort of the same procedure as the fasciotomy releasing the fascia. So I'm grateful that I tore my fascia with my son, but I don't have fascial pain anymore. So yeah, so some of the complications from like injections, say. We didn't really talk on this but you could give enough injections where you can cause a rupture, which is a problem in the early stages. Uh, you can also cause fat pad atrophy, which is a big problem. And we've seen that before where the steroid will sort of liquefy the fat in the pad of the heel, making it much thinner. And then you have bone that's on skin and that's a pretty high demand strike when you hit the ground on that heel. And patients have problems with that as well. So it's not great to do too many injections in that area of steroid. I'm not sure if I answered your question.
Dr. Lauren Borowski: No, you did, you did. Uh, I kind of wanted to talk about that walking boot and you got to it. So there are times where a walking boot is appropriate for a patient. I would say it's rare that I do it, but you know, someone's coming in and I think that they've ruptured and their gait is so off that I want to give them some comfort.
Dr. Rick Delmonte: Yeah, actually I use walking boots a lot, uh, when patients come in with this severe acute fasciitis. Whether it's a tear - because there is tearing with fasciitis, these micro tears at the insertion. But I'm like a rupture, it's ecchymotic or black and blue at the site. They usually have some history of an injury, like I had um, I'll put them in a walking boot and also give them like a Medrol dose pack or a low dose steroid, oral steroid and then reevaluate them in a couple of weeks. And usually by that time they're 50, 60, 70% better. I can get them out of the boot, maybe get them into therapy and they do quite well to the walking boot is fantastic. Especially, um, being in New York City walking. People have to go to work. It's hard to say, well, stay home - I got to go to work. Put them in a boot. They can get around. Especially with that type of an injury, they can wear a boot and get to work.
Dr. Lauren Borowski: You mentioned the scar that can happen after a surgery. There's also some other things that can happen underneath that plantar fascia, like a fibroma. So a thickening of the tissue of the plantar fascia. So plantar fibromatosis. What do you do for those patients that have this painful lump in their arch?
Dr. Rick Delmonte: Right. So we do see plantar fibromatosis and there's a high correlation with Dupuytrens, uh, contraction in the hands. And it's funny because recently we've been sending patients to radiation oncology. And radiation oncologists now are doing radiation for these fibromas and I believe there are a bunch of radiation oncologists here at NYU that are doing some really big work on the fibromas and also now with even arthritis of different joints with radiation oncology. So it's something that I don't have a lot of experience with, but I know there are people that are starting to do this and I know that I just saw a patient the other day who was a radiation oncology fellow who's doing a lot of work on fibromas and radiation treatment. So I thought that was kind of interesting. I typically tell them warm compresses, I've injected steroids there to hope to shrink them. You can remove them. It's not the best surgery. It's a large incision. Usually it's not one fibroma, but multiple fibromas. So you really have to do an end block resection of the entire fascia with the fibromas or take the whole fascia out or do a fasciactomy. Because if you just denucleate or take out that one fibroma in the fascia, it's going to come back and they'll have a painful scar too. So I always talk patients out of that surgery. I just don't find it to be a good surgery.
Dr. Lauren Borowski: So we've talked a lot about plantar fascia and the diagnosis, the treatment, some of the newer things that we're doing. In closing, what are some of the departing words of wisdom that you have for our listeners on how to keep their feet healthy and just overall foot health?
Dr. Rick Delmonte: Yeah, that's a really good question. I think that people today are super active and they pay a lot more attention to their shoulders and their hips, their knees, uh, when they're stretching for their sport or their activity. And I think that the foot may be somewhat neglected when patients are stretching in the gym. I know when I'm at the gym I don't really stretch my foot, but I think there are certain things that we can do to prepare the foot for potentially less injuries and being just a healthier foot. Stretching, uh, just some of the intrinsic muscle strengthening techniques that we talked about, uh, sometimes if you're questioning having some problem in orthotic, whether it be over the counter or custom may help you. So I think those are the things that may be helpful, uh, for just healthy feet moving forward.
Dr. Lauren Borowski: Great. Well, thank you so much for being here with us. That's this edition of the Bone Whisperers here at NYU Langone Health.
Dr. Rick Delmonte: Thanks for having me.
Narrator: The Bone Whisperers is a co production of NYU Langone Health and SiriusXM. The podcast is produced by Scott Uhing, sound design by Sam Doyle. SiriusXM's executive producer is Beth Ameen and senior operations manager is Emily Anton. Narration and additional sound design by Michael Luce. Don't miss a single episode of the Bone Whisperers and subscribe for free wherever you listen to podcasts. To hear more from the world renowned doctors at NYU Langone Health, tune into Doctor radio on SiriusXM Channel 110 or listen anytime on the SiriusXM app. For the Bone Whisperers podcast, I'm Michael Luce. Join us next time for the latest advances in orthopedics on the Bone Whisperers.