by Joseph C D’Amico, DPM
The thing that struck me the most following my initial office visit with Jerry Seinfeld, was his remark that during a performance, 20% of his concentration was focused on how badly his feet hurt. He would continually be trying to change his position or sit down during his routine. How ironic is it that one of the most famous stand-up comics in the world couldn’t stand without being in pain, while trying to make everyone else forget their troubles and have a few laughs?
Jerry’s initial complaint was bilateral heel pain, left more severe than right, of 30 years duration. The discomfort varied with the type and amount of activity performed. It was present upon arising even though he was utilizing a night splint. The current average comfort level was 65% and had been noticeably worse over the past 18 months. The patient denied any history of trauma associated with this condition.
Previous professional care provided by orthopedic surgeons, physiatrists, physical therapists, and podiatrists did not definitively relieve his discomfort. Management included steroid injections, PRP injections, night splints, NSAID’s, CAM walker, orthotic devices, slant board stretching. Jerry had 3 PRP injections performed at a major New York City Hospital. The treating doctor asked Jerry how he was coming along and his reply was “I was at 0% when I started this painful process and I’m still at 0%.”
His current carbon-graphite composite devices were fabricated only one year ago, but Jerry stated that he hadn’t seen that doctor for many years. Upon further questioning, discovered that these devices were made from a neutral subtalar positive plaster impression cast molded 18 years ago! Jerry had been religiously stretching his plantar fascia and Achilles complex for many years and had recently added a slant board to his routine.
Physical examination revealed an absence of visible inflammation at the site of the chief concern, lack of palpable tenderness along the plantar fascial course, except at its medial tubercle origins with a (+) 7-8/10 left and (+)6/10 right. The orthoses did not conform to pedal morphology. The vascular and neurologic parameters were found to be well within normal ranges.
Proximal Plantar Fasciitis bilaterally, Left > Right
Collapsed Cavus bilaterally
Partially Compensated Rearfoot Varus bilaterally
Compensated Forefoot Varus bilaterally
Compensated Forefoot Equinus bilaterally
Genu Recurvatum bilaterally
Markedly Limited Internal Hip Rotations bilaterally
Limb Length Discrepancy, Right > Left
Hallux Flexus bilaterally
Weightbearing radiographs of both feet, as well as observational and computer assisted gait analysis, confirmed the above impressions. The presence of an inferior calcaneal spur, right greater than left, was also identified radiographically. The gait analysis revealed a premature heel lift bilaterally.
Barefoot computer assisted gait analysis (CAGA revealed a short center of force pathway (COF) on the left and normal on the right. Increased pressure on the left calcaneus and the 2,3,4 metatarsal heads on the right was noted. Active propulsion was 21 left, 13 right Single support, time, solitary limb support were equal however midstance was 33% right and 27 % left (norm up to 30%)
(CAGA) with Nike sneakers revealed a limb length discrepancy evidenced by calcaneal stance duration 13% greater on the left side, and increased left midstance phase 37% to 30% on the right, and propulsion increased on the right side 20% versus 14% left side.
My initial management included:
1) neutral subtalar plaster impression casting
2) weight dispersive rest strapping without longitudinal arch pad left
3) continuance of current orthoses
4) heel raises
5) counsel on footwear (discard present ones)
6) discontinue slant board and all other posterior group stretching
7) avoidance of barefoot walking
8) continue night splint
9) hip internal rotation exercises
I had also considered adjunctive NSAID therapy as well as steroidal injection, but Jerry refused. He indicated that he had tried those therapies previously without success. He stated that due to his knowledge of mechanics as a car aficionado, he preferred to try a biomechanical approach instead.
At his subsequent visit 9 days later, when I asked Jerry how he was doing his response was “Excellent. 100%”. I dispensed his orthoses consisting of carbon graphite composite for daily use and high density polyethylene for activity participation. Hip rotations were still severely restricted.
A follow-up gait analysis was performed two weeks later with the patient still at 100% comfort level. During Nike Sport orthotic walking with CAGA, excellent symmetry and waveforms were noted with active propulsion 26 left, 22 right.
Since the patient wears Nike sneakers for daily use, they were tested with the graphite composite devices and revealed a reduced midstance phase 21left, 23 right and increased active propulsion 34 left, 32 right with all other parameters being symmetrical as well. Mild increased pressure sub 2nd metatarsal head was noted bilaterally primarily because these devices ended at the metatarsal heads, unlike the sports devices in which the correction was extended to the sulcus and then a soft tissue supplement to the toes was added.
The hip internal rotations were not improved.
One month later the patient was still at the 100% comfort level and wearing his orthoses whenever weightbearing. The hip rotations were not improved and I suggested that he return to his physical therapist for management. Upon palpation of the area of chief concern there was still noted +7/10 tenderness bilaterally.
Two months later, with the patient still at 100% comfort level and “doing great”, there was only +3 tenderness noted at the medial calcaneal sites. Jerry told me “this has completely changed my life”.
So why after 30 years did his heel pain resolve? Maybe I was just the right doctor at the right time who took a little more time, did a little more analysis. Maybe it was just a combination of factors, but in any case, what I did was something that any one of us could have done.