AO Postit Notes
Don't ignore your alignment!
I am pretty sure by now, y'all know equinus has at least something to do with non-traumatic foot and ankle pathology. In fact, it has just about everything to do with your hurting foot. Below is a list of what equinus causes and then makes worse if not addressed. Unfortunately, it goes unaddressed about 97% of the time, and that makes me angry. Sure, about now you are saying that you don't have equinus because you are not aware that your calf is tight. That's the big disconnect : equinus is...
This is why you should pay attention to equinus
A recent AO comment got me thinking, and that is always a dangerous thing. (Found in comments section Calf Stretching: Its the AO Way or the Highway , Kapil, 2022/03/10 at 9:30 pm) Kapil writes, " Hello AO, I started running/skipping lately and I overdid it which caused plantar fasciitis to both my feet and my feet soles hurt when I stand Or walk…please suggest what should I do? Also can I keep doing my workouts – jogging, skipping, weight training? Thank you. Sorry don’t be angry at me." ...
![Some questions and answers just beg to reach out! "Hello, I’ve been struggling with [plantar fasciitis] in both feet for at least 6 years, have done foot and calf massages, cortisone, tennis balls, laser, tens unit and have a Chiro running a vibrating ball over the bottom of my feet right now. I’m so tired of not being able to walk long walks. So I’ve also found a website King brand BFST that swears they have a cold compress item to take the swelling down and then they have a hot wrap to apply heat to the PF. They have all good reviews and relief from people that have tried this. They don’t recommend stretching. In fact, they have posted 10 PF “myths”. I’m so confused. What do you think of the cold/hot method?....Thank you for your advice..." And here is my response.... Hi Pearl (name changed to protect the innocent), You are a poster child for the plantar fasciitis herd mentality. If you have not read on my site at all, please do. The total message for this the problem is that it is not your foot, it is your calf.
The reason you have had plantar fasciitis for 6 years is that you have never treated it. Really!
You are confused because of the strong incorrect/false message all these mostly clueless medicals and non-medicals are feeding us. Just think for a second about cause and effect. The root cause is often not obvious or what you think. In your case, as in the great majority of those out there suffering, looking beyond the obvious heel pain location in your foot is basically impossible. And I get that, but that is what guys like me are here for: to steer you in the right direction. Tell you the truth. Just look at the star Mets outfielder Yoenis Cespedes.
Even the pros have it wrong. This guy has been plagued with foot issues for a long time, and I can guarantee you they are related to one thing: equinus or calves too tight. And they have not focused on addressing the calf one bit. Now they are talking about a very unnecessary, in my opinion of course, potential surgery. You say they have the best medical care available being professional athletes, right? Wrong. The athletic trainers and the team doctors basically across the board do not have a clue about equinus and the incremental damage it can cause.
It is getting harder for me to believe how so many people can be so vehemently far off track. The scientific evidence of the calf being the source of the problem and that calf stretching almost always works is there for all to see. Here is my suggestion. Do something different, something that seems so counter-intuitive and stretch your calves. Look away from the obvious, your heel, and treat the problem, your calf. There is a 95% chance you will be done, but be patient. "Undoing" tight calves will take time because they took years to get that way. Break from the herd, Pearl! I get comments all the time from folks how calf stretching has changed their world...but these comments are hidden in the blog comments section, where few will benefit from seeing. Get out there on social media and spread the word about stretching and where you heard it! Stay healthy my friends, AO
Current Conversation Add your questions, thoughts, and commentary to our current conversation below, I dare ya!](https://static.wixstatic.com/media/d6b712_f700226b279549c78123cda8c81eb31e~mv2.jpg/v1/fill/w_265,h_265,al_c,lg_1,q_80,enc_avif,quality_auto/Image-empty-state.jpg)
Albert Pujols, Looking in All the Wrong Places
Al, Al, Al…it is time to stop listening to your trainers, your team doc, and aunt Bessie and do the right thing. Here is a call to action to everyone in AngryLand. Somebody please get the word to Big Al and many more big leaguers who have plantar fasciitis, that calf stretching every day is the answer. Pujols was on the IR for plantar fasciitis last season, and I am certain stretching was not part of his solution. Okay, maybe he did just a little bit, which is tantamount to not stretching....
![Here is the question that must be asked. Where is all this new money coming from? The Answer: The money is coming from all the employed physicians FACILITY FEES charged by their employers! And the docs are oblivious to it happy they are making more money. The hospital systems perpetrating this power play are capitalizing on a longstanding crevice in the system, but this one is actually the size of Grand Canyon that is wildly increasing their profit. And this loophole is costing all of us except for the beloved non-profit hospital systems. In fact, they are making out like never before, but they don’t want you to know about it. Non profit has the ring of “we are on your side”, and we protect the little people who can’t take care of themselves. In most cases this non-profit concept might actually be true, but not in the case of the non-profit hospital employers. Everyone, especially you, gets screwed except for these longstanding institutions. Even the docs are getting screwed, they just don’t know it…yet. Forget the ACO (Accountable Care Organization) implemented by Obamacare as the singular source of all these shenanigans. What I am talking about is across the board blatant greed. I want everyone of you to ponder this as long as it takes for the truth to settle in, because it needs to settle in loud and clear for all our sake. With me so far? It gets SO much better and once you get it-you need to get mad as hell. FINALLY, I GET TO THE POINT. WHEW! Makes me sort of angry it took so long. So here is a simplified example of how it works. Today I see you in my private practice and I charge you for a simple visit ($100) and a set of X-rays ($50). The insurance company will pay me, after adjustments, etc., $60 for the visit and $35 for the X-rays. That is the entire charge, no additional “facility fees” or other random charges. Please keep in mind the numbers I use here are very rough and for demonstration purposes only, but close enough. Next week I become a hospital employee – smarter, wiser, happier, richer – and I work out of the exact same office where I just saw you, however now i am working out of a facility because I am employed, right? Magic! Now my salary has doubled because my loving, caring, big brother hospital will pay me more because I am important to them and their benevolent cause. But how can they pay me double, build all these new buildings, and do all their advertising and competing? Get ready because here it comes. The increased revenue is not because there is more business or more effective billing practices as they would have you believe. Nope! It’s because of facility fees charged for employed doctor office visits as well as other services. Price gouging comes to mind. Now, as a hospital employee I see you in my facility office (again, same digs) and I charge you for the same visit ($100). However, the X-ray charge, now a hospital ancillary service, and other things I charge for can be as much as 2 to 5 fold increase. In addition, you are likely to get stuck with an additional “facility” usage fee amounting to hundreds of dollars to pay for the overhead. In other words, you have to pay a lot extra now for breathing the air and walking on the floor of the “facility”. It is no different than operating room or emergency room fees. And believe me, we all pay for it. Looking at in my typical cynical , irritated way you are paying more for less. Now a ~$150 visit is up around $500-750, and the visit is rushed and you get less time. Poor "quality" and less value. Here's the thing. Your insurance, the third part payer, for some strange reason pays without batting an eye. You are mostly unaware and all is well. I almost coughed up a hairball. “The root of these increases are controversial charges known as “facility fees,” …. routinely tacked on to patients’ bills….because they’ve [physicians practices] been purchased by hospital-based health care systems.” Fred Schulte of The Center for Public Integrity wrote it brilliantly, “One family accustomed to paying about $120 in out-of-pocket costs for doctor visits and other medical services was outraged when they ended up forking over more than $1,000 for similar visits, Mullin [Senator Kevin Mullin, VT] said, mostly for seeing doctors whose practices had been bought out by a local hospital.” Furthermore he wrote “The panel noted that hospitals buying up medical practices in recent years have been tacking on facility fees that increase the patient’s bill even when the doctor is working from the very same office.” See, I didn’t make this stuff up?! By one estimate, under its current reimbursement system, Medicare is paying in excess of a billion dollars a year more for the same services because hospitals, citing higher overall costs, can charge more when the doctors work for them. With the rapid migration of doctors from private practice to hospital employment, the percentage of outpatient visits eligible for facility fees is soaring. More employed docs, more facility fees, more money. Here is the thing: the facility fees charged for these doctor visits have been possible since 2000, but they are NEW because the more recent implementation of the ACO and hospitals luring these docs in like a dog chasing the rabbit at the dog track. Just to make sure this point is clear, this is a completely new and extra source of revenue for these hospital systems and as McDonalds says, sort of, "They're lovin' it".. To be fair I must look at the other side of the argument. What is the hospitals excuse for all these new charges? Schulte wrote “The American Hospital Association argues that phasing out the payments “threatens patient access to care.” The group said that hospitals tend to treat “sicker, more complex patients” and are better equipped than doctors’ offices and should be paid more.” These same hospitals were doing quite well before they discovered the physician based facility fee Holy Grail; they are just making a lot more now. All the while their expenses really never changed. How do you feel about paying for luggage when you fly? Facility fees for doctor office visits are no different. Drip, drip, drip, gas lighting hospital style. Currently the battle to help control these facility fees is waged in the form of “transparency”. What great political wordsmith; transparency. The ACO’s are increasingly being forced to inform the patient/consumer up front about the facility fee for an office visit that has never existed before. Now there is a novel concept. Connecticut HB 5337 was passed this past spring with pressure brought by CT Attorney General George Jepsen. It will be implemented into law October 1, 2014. At least this is a start. Alas! In the end there may be justice. The US Office of the Inspector General (OIG) is on to this facility charge shell game and when the off-campus facility fees are stopped, Katy bar the door, because the exodus of these employed physicians will be like yelling fire in a theater. In the words of Jeff Foxworthy, it will be pandelerium. Doctors will be patted on the back and told to move on to life’s work just as end-of-career professional athletes are told to do when their usefulness has ended. They might be wandering around the streets pondering what just happened with no place to go. Everybody looses except for the hospital systems! Finally, Dr. Scott Gottlieb painted a very grime future for my colleagues, and ultimately you, in Forbes in 2013, “If these new doctor-hospital marriages fail again, then this time around the doctors may not been able to go back to what they were doing. They will be financially stuck in these relationships. They will be unable to even raise the capital to re-start their own offices. They may have trouble getting bank loans…………The doctors will get squeezed but the real misfortunate will befall patients. We will increasingly be getting our medical care out of busy, hospital-run clinics. Our doctors will be salaried employees, more beholden to the rules that hospitals erect to manage their activities than the medical practices that they once owned.” Just sayin'. Stay healthy, my friends, AO Gottlieb Forbes http://www.theatlantic.com/health/archive/2014/05/should-doctors-work-for-hospitals/371638/ http://www.wakehealth.edu/outpatient-clinics/ http://www.heritage.org/research/reports/2014/08/how-the-affordable-care-act-fuels-health-care-market-consolidation http://www.ctnewsjunkie.com/archives/entry/attorney_generals_report_on_hospital_facility_fees_encourages_legislative_a/ http://www.publicintegrity.org/2012/12/20/11978/hospital-facility-fees-boosting-medical-bills-and-not-just-hospital-care https://www.youtube.com/watch?v=xtwPS4X41r4 http://www.cga.ct.gov/2014/SUM/2014SUM00145-R01HB-05337-SUM.htm http://www.nejm.org/doi/full/10.1056/NEJMp1101959 http://well.blogs.nytimes.com/2011/04/14/what-big-medicine-means-for-doctors-and-patients/?_php=true&_type=blogs&_r=0 http://www.nytimes.com/2012/12/01/business/a-hospital-war-reflects-a-tightening-bind-for-doctors-nationwide.html?pagewanted=all http://www.mondaq.com/unitedstates/x/205782/Healthcare/8+Key+Issues+For+Hospitals+And+Health+Systems+2013 Current Conversation Add your questions, thoughts, and commentary to our current conversation below, I dare ya!](https://static.wixstatic.com/media/d6b712_48092926766d405286c744a2426ca4a9~mv2.jpg/v1/fill/w_265,h_265,al_c,q_80,usm_0.66_1.00_0.01,enc_avif,quality_auto/Image-empty-state.jpg)
The Bad Rap on Inflammation- Part 1
Somewhere along the way the term inflammation got a bad name. Inflammation can’t be good, right? At least this is what most people think. Inflammation is actually an essential part of every reparative process. It is how our bodies heal and fight back. It is how we recover from trauma, surgery (organized trauma), cuts, broken bones, infections, etc. Inflammation is a good thing. You have to admit that when you hear the word “inflammation” you think bad thoughts. “Oh God, did I hear you say I...
Morton’s Neuroma Revisited
Thank you all so much for your comments and support. I have received a lot of feedback and fantastic questions about the Morton’s neuromas (MN) post and your problems with diagnosis and treatment of such. This area of the foot can indeed be terribly confounding and difficult to diagnose. I want to help you all as much as I can with this conundrum, and I would love to answer each and every one of you individually, but I just can’t and shouldn’t in this setting. If you have been labeled with...
The Rescue Patient: Part One
First and foremost I am declaring that I am the first to use this term: “The Rescue Patient.” I have now made my mark. My fifteen minutes of fame may be over. If you can’t stomach tough love, stop reading here. If you are a rescue patient or you know one and you/they want to get better, read on. You know who you are. You’ve had a bad, no, a very bad experience with the medical profession and you have lost all trust and faith. You’ve been beaten down like a political candidate. Your...
The Rescue Patient: Part Two
In my last blog, The Rescue Patient: Part One, I coined the term “The Rescue Patient.” While I am not always successful, this experience has given me great satisfaction and the insight to make some useful recommendations to the rescue patient who is contemplating “coming in.” Keep in mind, most of my colleagues don’t embrace this challenge, thus you will need to be equipped during your encounter. Also, keep in mind that you have a very real problem, but its elusiveness creates a sense that it...
Six Weeks: Part Two
In the last AO entry, Six Weeks: Part One, I shared how as much as docs council our patients prior to an elective surgery, patients continue to only hear what they want to hear. Ultimately, I see these misguided — and unrealistic – expectations time and time again. In this entry, I want to share my five simple rules to the best surgical recovery and eventual outcome. 1. Have the lowest expectations possible. The journey will always be better and who knows, you might be pleasantly surprised in...
![As mentioned before, 20% of my patients come to me seeking relief from plantar fasciitis. After I came across this TV news piece on the subject, I knew I had to address it because it’s filled with the kind of flawed, “easy fix” information I’m fighting. (Thanks to @DrHurless for sharing this on Twitter.) While it may appear to be a story with good information, most of it I disagree with. Not because the information presented is bad for you, but because it represents the usual incorrect, status quo rhetoric people continue to be given — whether it be from the news, the Internet, or even from their doctor. And unfortunately, these recommendations only continue to steer people away from meaningful and effective treatment. About the only thing I agree with is the importance of daily stretching, which I can’t emphasize enough. Scientific literature has repeatedly shown how regular stretching of the calf is what will eliminate heel pain by getting to the source of the problem. Take care of your body and it will take care of you. One of the first things I disagree with is how the doctor recommends the use of orthotics. Orthotics simply do not do anything about the cause of the pain, calf tightness. Don’t get me wrong, orthotics may in some cases give some relief from the pain of plantar fasciitis, but they don’t fix a thing. Then there’s the idea of shockwave therapy. The anchor throws in that Dr. Kase “has [had] good success with acoustic shockwave therapy. It helps break up some of the scar tissue,” he argues. After posting this clip on Twitter, @cathysucher asked me my opinion of this kind of therapy. What’s being referred to here is ESWT, or Low-Energy Extracorporeal Shock Therapy. EWST is merely a flashy placebo. There’s no conclusive evidence to support its use, but it certainly helps doctors make money. Treatments can get pricey, and insurance may not cover it. Therefore, patients who wish to have these treatments – which don’t even work in the first place – often end up paying out of pocket for them. At least it’s not an unwarranted surgery. A kissing cousin to ESWT is PRP, platelet-rich plasma, and I will have more on PRP soon. Again, you will see better results from stretching – in combination with a little patience — than from any of the other feel good treatments. Archived Comments A collection of comments from previous versions of the blog, preserved for historical context and the richness they add to our discussions. Current Conversation Add your questions, thoughts, and commentary to our current conversation below](https://static.wixstatic.com/media/d6b712_ee972d0133254704b3136dace358a300~mv2.png/v1/fill/w_265,h_265,al_c,q_85,usm_0.66_1.00_0.01,enc_avif,quality_auto/Image-empty-state.png)
