Heel Pain: The Seinfeld Solution

by Joseph C D’Amico, DPM

Dr.Joseph 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.

My diagnoses included:Musculoskeletal Biomechanical

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.

Prescription for Success: Career Direction

by Warren Joseph, DPM

Dr. Warren Joseph DPMWhen the Editor of this ABPM Resident Newsletter, Dr. Mitchell Shikoff, whom I have known since our days together at the Scholl College, invited me to author an article, I am sure that he had in mind an update on some infectious disease topic.  After all, I have made my “name” in this profession working in the area of both bacterial and fungal diseases of the lower extremity.  Or, as Editor of the Journal of the American Podiatric Medical Association for over 20 years, perhaps I could talk about the proper way to write a scientific journal manuscript.  Frankly, I could easily have done either of those topics….but I have chosen not to.  Rather, I have decided to take a less well traveled path and speak to you about my own personal less well traveled path and how what I have learned may apply to you as you begin your new lives in this profession.

I realize that this may sound egocentric.  Here I am, some “old timer” (Geez, I hate that thought!) in podiatric medicine trying to impart some words of wisdom to the next generation. But, it has been almost 32 years since I graduated from SCPM and by most all accounts and measures I believe I have been pretty successful. So, I ask that you please indulge me in this folly.

I attribute whatever success I have in podiatric medicine to two principles I followed early in my career and have not regretted:

1.  Think outside the box

2.  Find an appropriate mentor

Neither of these amounts to a huge revelation.  You may have heard variations of these principles from others.  Yet, it seems that many do not heed the advice. Allow me to expound on how each of these played a major role in my professional development.

THINK OUTSIDE THE BOX

When I graduated SCPM in 1982 I envisioned a career that would follow the path of every podiatric student at that time.  We all came into school enamored with the thought of being a surgeon!   We had visions of walking into the operating room, having nurses glove us while the patient lay prepped on the table.  It was a glamorous dream encouraged by our faculty.  At Scholl we prided ourselves on graduating with more cases under our belts than graduates from any other college of podiatric medicine.  There was a mad scramble for one of the few surgical residency spots that were available. You may think that there is a residency crisis now, and I agree that there is, but back in the early 1980s only 50% or fewer of graduates actually served a residency.  If you were one of the unlucky that did not match, you hoped for a “preceptorship” where you could perhaps learn a few surgical procedures while working with a practicing DPM but were otherwise afraid you would be relegated to a life of primary podiatric care. The day of the match I was at an externship at the Westside VA hospital in Chicago.  Of all of the students on rotation that month I was the only one who matched.  Not only that, I had matched with one of the few two year surgical programs available at that time and it was back in my hometown of Philadelphia.  I was set.  My career path was firmly established!

My residency at St. Joseph Hospital was a revelation.  I was one of four 1st years, two of whom were PCPM ( now TUSPM ) graduates and one from the NYCPM.  We had a very mixed bag of second year residents and a few attendings who, frankly, made our lives a bit of a living hell.  If your attendings even tried to pull a quarter of the stuff foisted on us you would probably be in the Administration office threatening a lawsuit!  It was a different time and place.  Despite these trials, I discovered I was becoming a pretty decent, if not gifted, podiatric surgeon.

We were fortunate to have some excellent medical and general surgical rotations.  The Infectious Diseases service at the hospital was covered by the ID group from Hahnemann University Hospital and chaired by Jack LeFrock, MD, a well recognized specialist in the area of diabetic foot infections.  I looked forward to rounding with Dr. LeFrock since I really felt I graduated school knowing absolutely nothing about antibiotic therapy and, possibly more important at the time to a poor resident (we were paid $2500/yr and were told by our DPM attendings that this was too much and we should be paying them for the privilege of learning from them), Dr. LeFrock always bought us lunch.  One day late in my first year/beginning of my second, as we were eating, Dr. LeFrock casually mentioned to me that he felt that I had an interest in ID and asked me if I was interested in spending a year with them at Hahnemann as an ID Fellow.  As he would later state in his inimitable fashion: “If you podiatrists are going to be treating diabetic foot infections you better damn well know HOW to do it right!”

This was new and groundbreaking.  No podiatrist had ever served a medical ID fellowship. In fact, the entire concept of fellowship training in podiatry was relatively unheard of at the time.  My mouth hit the table.  I thanked him for the offer and impulsively accepted immediately. Only then did the questions come:  What was I doing?  Would I be paid? If not, how would I live? Would I be accepted at a major university medical school/teaching hospital?   Would my fellowship be recognized by our profession? I was venturing into totally unexplored professional territory.  My first stop was to my parents.  I explained the situation including the unknown question of a salary.  They were enthusiastic and immediately supported my decision.  They figured they had supported me for this long, what was another year.  I then spoke to one of my favorite podiatric surgical attendings, a man who is still considered one of the all time great foot surgeons.  His response was sobering:  “Doctor, you are a surgeon, why would you possibly want to do an ID fellowship?  How are you ever going to make a living?”  Finally, I visited the APMA Headquarters to meet with the Director of Scientific Affairs whom I had known and greatly respected when he was Dean of the Scholl College.  I explained the fellowship offer and asked if there was any way that the APMA could “recognize” it.  Although he had to tell me that there was no pathway available for official APMA recognition of the training, he strongly urged me to accept.

The rest, so they say, is history.  Not only did I serve the fellowship at Hahnemann, I even received the stipend of a medical PGY III at a livable $25,000.  The decision to accept the offer of the ID fellowship despite the dire predictions of my surgical attending changed my life both professionally and personally.  It has defined my career despite it being a pathway that I would have never imagined while applying for surgical residencies during my 4th year of school.

FIND A MENTOR

Having been involved with student and resident education my entire career, one of my great satisfactions comes from having someone I helped train come up to me, usually years later, and thank me for what I taught them and how they never appreciated it back while they were in school or residency.  To know that I have a positive influence in somebody’s life is why I have always taught.   This drive to help the next generation comes from my good fortune of having two exceptional role models/mentors who pushed, supported and directed me early on in my professional development.  Without either of them I would not have become who I am today and I am certain my career would have taken an entirely different course.

The first is the aforementioned Dr. LeFrock.  He saw the need to train a DPM in ID and didn’t let obstacles stand in his way.  In order to get my fellowship approved at Hahnemann he faced negativity at every turn.  He was told by the Chief of Orthopedics, a well know podiatry opponent and very powerful force within the hospital that “This is a medical school, we don’t train podiatrists here”. Even members of his own ID division were not enthused and gave major pushback.  It took him close to a year of fighting, but he eventually went to the President of the University to plead the case. Only then, with the President’s blessing was the fellowship approved.  Dr. LeFrock lived by the pledge that if he gave me his word, as he did by inviting me to work with him, he would not back down.

During the fellowship I was approached by the Chairman of Medicine at PCPM, Harvey Lemont, DPM about joining the Department at the college.  He had a vision, unique at the time that “Podiatric Medicine”, defined at most of the colleges and by the profession as the treatment of corns, nails and calluses, was actually a true specialty consisting of dermatology, neurology, ID, radiology, rheumatology, vascular medicine, etc.  Having trained in pathology he was building a Department of fellowship trained specialists. I signed on to that vision and that position.    Dr. Lemont was my Chair for most of my 15 years at the PCPM/TUSPM.  During that time he gave me the freedom to build the specialty of podiatric infectious diseases.  He funded me to go to major ID conferences.  Whenever I requested a book or journal subscription he found the monies for it.  He saw the importance of training the profession in ID and gave me the time to attend podiatric CME meetings and lecture throughout the country. In return he expected production in terms of publications and teaching of the students.  This was not a free ride.  If not for Dr. Lemont I would not have been able to take the base of knowledge I gained from Dr. LeFrock and build on it to be the specialist I am today.

I know that this is a lot about me. You can’t say I didn’t warn you up front!   I hope that by sharing my story it may better enable you to think about the future with a different perspective.  If you are satisfied with the way your training and future career are heading, congratulations and my best wishes to you.   However, if you want something a bit unique and want to consider the “road less traveled”, then please let this story be at least some inspiration to you.  You have options.

 

ABPM Resident Newsletter

ABPM Resident Newsletter Read a celebrity case study by ABPM Diplomate Joseph D’Amico, DPM, Heel Pain: The Seinfeld Solution and career reflections by Diplomates, Warren Joseph, DPM and Mitchell Shikoff, DPM.  Also find answers to many Frequently Asked Questions about ABPM.

 

 

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