Michael A. Zapf, DPM, MPH, FACFAS, FACFAOM, LMI*
Perl168 ask about pain from wart removal è
Belinda asks about stump neuroma treatment è
Lisa asks a question about using Tagamet and "Beetle
Venom" for warts è
Jon asks: Physical therapy or Podiatry as a profession --è
The latest Dr. Zapf Acorn article on Gout -è
Pam has painful flat feet and asks about surgery
er
Letter from Stephanie about her recurrent neuroma
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A letter from Tracey about her neuroma -è
A letter from Ron H - very satisfied with his SHOCKWAVE
experienceè
A letter from Kay about her Shockwave Experience
è
Orthopedist versus podiatrist è
I received an interesting Morton's Neuroma question. See
è
For shocking photos of the Shockwave Day -è click here
A copy of my Clinical Guide to Wound Healing and a
suggested diet to heal wounds can be found at è
My April article was on the new use of Shock Wave therapy
for resistant heel spurs and plantar fasciitis. To read click here:è
My March article was about Operation Footprint, the club
foot surgery in Honduras. To read click è
My January ACORN article was on the performance of three
bunions in one week where not one of the three patients even needed to take so
much as one pain pill. To read this article click here: è
For more information about my recent trips to Honduras to
perform club foot surgery, please see è
The following letter was received on December 4, 2002 and
concerns Neuromas. Kristen's letter is in light blue
and my response is in dark blue.
Doctor Zapf,
I first wanted to tell you that I found more relative information on your web
site than I've been able to find anywhere else, including from my doctor.
Thank you very much.
I currently have an extremely painful neuroma in my right foot between my second
and third toes. As
you might have gathered from my page on neuromas, the area between the 2nd and
3rd toes is not a common location for a neuroma. They are usually between the
3rd and 4th toes. Yet this very morning I surgically removed one from a second
interspace and it was even larger than the one pictured on my neuroma page. What
I am getting at is that often pain and tenderness of a swollen 2nd
metatarsophalangeal joint 9the joint where he toe meets the foot) is the
responsible culprit and irritates the nerve. Make sure you do not have more pain
just under the second metatarsal head (your doctor can locate this for you) than
you do with palpation of the interspace.. I also have flat feet. My podiatrist is Dr.
P. I really like her but I am very frustrated with my treatment. I have
had cortisone injections
fine, taken anti-inflammatory medication
fine, again
and had orthotics made
I think orthotics help bunion pain very much. As a rule I do
not make orthotics for pure neuroma patient. If the second metatarsophalangeal
joint is involved, however, orthotics are the first line of treatment.
My neuroma pain actually feels like it
is getting worse - I'm in constant pain driving and walking in any type of shoe.
I realize that surgery should be a last resort but I'm at the point where I
just want the nerve cut out!
Surgery in your circumstance, with as much pain as you are
having, is not something to be afraid of. It can help you tremendously. Just
don't ignore sclerosing, as well. A series of 8 weekly injections of 4% alcohol
can often do the trick without surgery. Dr. P really advises against the surgery (she doesn't do the
surgery herself, it's performed by an orthopedic surgeon) as she feels that
there is a much greater chance of a stump neuroma occurring than previously
thought. I have had
2 painful stump neuromas in 16 years of doing neuroma surgery. As long as you
have tried the conservative methods, including sclerosing, the risks are well
worth the procedure. In some of
my research I found a few doctors who after removing the neuroma actually insert
the cut ends of the nerve into the! surrounding muscle to prevent a stump
neuroma from occurring. I haven't been able to find anyone locally who knows of
that technique though.I have herd of that as well, but do not do it. I pull on the
neuroma just before I cut it and snip the nerve as far back into the foot as I
can. When I cut the nerve it snaps back into the mostly muscle tissue from
whence it came. It is a similar technique but I do not cut a groove in he muscle
and tuck the nerve into it. I
was hoping that you might know or be able to recommend a podiatrist here in
____ that is as knowledgeable in neuromas as you
appear to be.
Honestly, nearly every podiatrist worth his
or her scalpel blade can do a great job on a neuroma. I suspect that your
podiatrist is just a bit more cautious than most, since she does not do the
surgery herself. The surgery is really quite simple and has a 95+% success rate.
Just visit the web site for the ACFAS (American College of Foot and Ankle
Surgeons) [put it into a search engine like Google] and find one near you who is
Board Certified. You will do just fine, especially if he or she can also
offer the alcohol sclerosing injections as a last, last resort.
I understand that I'm not a patient of yours
(although I wish I could be) but any advice that you could give me would be
greatly appreciated. Thank you in advance for your time. Sincerely, Kristen S.
You are
most welcome.
For more on
neuromas see the link -->
This letter may or may not be
serious. I hope not. Maybe you will recognize this guy by the bandages on what
is left of his hand or the "red stuff" on the cars he works on.
I have been doing a lot of research lately
about warts since i have a few on my hands that i desperately wish to rid of. I
have very small ones growing under 2 fingernail tips and then 4 on my fingers
themselves. The doctors have froze them before but with no luck. I have heard
that the wart virus sometimes goes undetected by the immune system and needs to
be identified by damaging the wart so your body will recognize this. I read that
a lot of horse owners have crushed the warts of their horses with pliers with
great success of killing the wart. Have you ever heard of this technique on
humans? I know it sounds dreadfully painful but I am willing to handle it if it
will work. I am down to my last straw with them and want a do-it-yourself remedy
since all the doctors around me can't fix the problem. I have tried cutting them
out but did not know what I was doing and it was a very bloody experience that
failed horribly. I read on you website that you say warts prefer the body
temperature of 98.6 and that excess heat can kill them. Would the hotter the
temperature kill them faster? Such as maybe a cigarette lighter? I am not
worried about scarring since i am a mechanic and my hands are roughed up pretty
good already. I just want them gone and am willing to try anything short of
shooting them off. Thanks for any help you can give me.
Heel Pain in a 11 year old athletic boy. from November 23,
2002
Dear Dr.
Zapf,
My 11 year old son has been diagnosed with severs disease. After much research
on the web, your site was very comforting, you explain the condition very well.
I thank you.
My son is
not athletic, has been walking on his toes for 2-3 months now and the pain in
his heels have reduced him to crying. The doctor I am using has given us heel
lifts and a regimen of Advil 3x per day. This is not working well at all. I have
also advised the doctor that in the last year my sons shoe size has remained the
same.
Is there
anything else I can do to help my son, he hardly goes out anymore because he's
embarrassed to cry in front of his friends when the pain becomes UN bearable.
Thank
you for your time
Joanne
R.
Dear Joanne,
As you read elsewhere on my
web site Sever's is a short time limited pain that kids get in the back of the
heel (s). In the back of the heel bone (calcaneus) is a growth-plate like
structure that is quite vulnerable to injury or trauma. The plate will close in
a year or two but until then just running or jumping will aggravate it. First
aid steps include the following: 1) elevate the heel with heel lifts and the
corollary to that 2) avoid flat shoes (especially cleats) without heel
lifts, bare feet, socks only and slippers or sandals without heels - even
for the hour or so before going to bed, 3) ice massage of the heels three times
a day (before school ,after school and before bed) and 4) avoidance of
activities which aggravate the condition (running, P.E., soccer, etc). You can
also have your local foot doctor apply a tape strapping to the foot (called a
'low-Dye") to see if orthotics can help. Orthotics are custom made devices that
fit into the shoes and keep the foot from moving into positions that stretch one
of the ligaments that pu8ll on the heel plate. If these fail, I recommend using
oral anti-inflammatory medication for a time. If that fails you can try either a
night splint (see that section on my monograph A Patient's Guide to Heel Pain)
or a plaster, fiberglass or removable walking cast. Take heart, this only lasts
for a short time.
Dr. Zapf
Another
Sever's question
My son was diagnosed with this
about a week and a half ago. The growth plate even had a fracture in it. My
son is 11. The doctor did not want to cast it. Do you think this is the
proper thing to have done? Just curious. An 11 year old is not very easy to
keep down for the month he is supposed to stay off his feet.
Kim
Dear Kim, What sometimes looks
like a "fracture" of the growth plate is sometimes not a fracture. Ask you
doctor to compare the pictures in radiology text books on Sever's with your
son's x-rays. They are often "normal variants". As you see from the letter
above there are many ways to treat Sever's and you need to do whatever it
takes for your son to be comfortable.
Dr. Zapf
Neuroma Question from 11-4-02
I wrote recently
about foot pain which was found to be from bilateral Morton's neuromas. I
know you mostly answer questions for your patients, but I'm going to try to
bug you again because I am miles away in Tennessee and trust your advice
most. You have me curious about the sclerosing injections, but I have only
found one podiatrist here who does them, and not many patients here want
them. I doubt he uses all of your methods for easing the injection pain, but
I am still thinking of trying this. If it weren't eight weeks of injections,
I would be tempted to fly out to your office! Do Morton's neuromas ever
resolve without injections or surgery? What do you feel is the success rate
of the alcohol injections? Do you try cortisone first? Do you advise still
being careful with athletic activities and shoes after injections and
surgery? I know you are busy, but it is so scary out here where I can't be
your patient.
Thank you,
Dear
Kathryn, Sclerosing injections using a 30-gauge needle and a 1CC syringe
should not hurt much at all no matter who does them. I encourage you to let
your local doctor give them a try. He or she can even call me for any advice
if desired. Morton's neuromas can frequently become quiescent, especially
after a cortisone injection or two. I encourage my patients to try one or two
cortisone injections first for just this reason. If the neuroma were to come
back - we cal always sclerose it later. I find
that the alcohol injections relieve enough of the neuroma pain that more than
90% of my patients never opt for the traditional surgery. I do not advise any
special precautions after surgery or alcohol injections. Successful treatment
for neuromas should allow you to do everything your "sole" desires. Good
Luck,... Dr. Michael Zapf
Another Question about neuromas
from 10-26-2002
Hi
Dr. unfortunately my Dr. never game me the alternative and he perform a
neurectomy. I have developed a stump neuroma and the pain is worse than before.
I have pain in my entire foot know. I was wondering if I still have a chance of
getting better and being free of this problem. I have another neuroma in my left
foot and a stump on the right and I cannot do anything that involves walking.
This problem have taken over my life. I will thank you for any information or
advise you could provide.
Jennifer from Los Angeles.
Dear Jennifer, Every
once in a while, perhaps 1 in 50 neuroma surgeries results in a terribly painful
stump neuroma. Unfortunately for you that "1 in 50" is 100%. This rare but
problematic side effect is why I encourage patients to try sclerosing injections
before undergoing traditional surgery. I know that 8 visits to the doctor seems
like a lot of time but, in retrospect, wouldn't you rather have taken the time
then than have the pain now? I have had some success getting rid of stump
neuroma pain with sclerosing injections. Your job is to find a local doctor who
will be willing to work with you and try to inject this one (and the other foot,
for that matter) with the alcohol solution.
... Dr.
Michael Zapf
Question received 9-19-02
My question is I love to go barefooted and I haven't been able to find any
cream or lotions for my dry skin and especially my feet. I
have type 2 diabetes and my feet are really dry to the point of
cracking and I have corns as well as warts what do I do?
Answer -->
Question received 9-16-2002
Will publish news and answers to questions on this page. Come back again.
September 11, 2002
I received a comment from Breanne H. of Texan on the use
of Tagamet for warts. â
January 5, 2002
My first letter of 2002 is from Monica from England and concerns her mother.
To read the letter and my answer please see .â
October 22, 2001
A question about bunions from Holland See
a
The
question is:
To begin with: I am a man (age: 36) living in
Holland and just discovered your website. My story is the following: I bruised
my left foot very badly about 4,5 months ago due to a heavy fall in my own home.
First I went to the First Aid (they did nothing because my foot was swollen),
after 2 weeks my own doctor examined my foot (the bunion was already visible)
but didn't do anything, after almost 2 months I finally got
"permission" for an X-Ray (nothing broken, no furthermore comment),
after 2,5 months I went to a second doctor (my complaints were growing : pain in
my left hip, muscles hurting, stiffness in my left leg that feels like missing a
shock absorber) who finally for the first time diagnosed a Hallux Valgus. I'll
had to go to an orthopedist (waiting list: 6 weeks) who "prescribed"
me (within 5 minutes) standard (!) orthopedic soles under my shoes (which I'm
still waiting for). In the mean time I developed also a beginning of a callus.
I'll have a few burning questions for you because I'm getting a bit desperate:
- Are there similar podiatric clinics in Europe like yours ?, I cannot find them
in Holland and I don't trust a surgeon who operates a foot once a month or so. -
Is it possible (as a Dutch citizen) to undergo an operation in your clinic? (my
health insurance will never pay for this of course, but money doesn't matter to
me, I want to do everything to get my ambulant capacities back).
Hope to hear from you soon :),
Sincerely, R van der W (once a walker by heart...........)
See
the above link to Holland for the answer.
July 25, 2001
Another question from Australia. this time about NEUROMAS.
See ->
June 29, 2001
I received a question about ingrown nails from Amber. Look for the answer
here: -->
April 28, 2001
I discovered I did not write anything on Neuromas. Follow this link to see
what I spent the early morning hours writing on this nervous topic. -->
March 17, 2001
I received the following letter
Dear Dr. Zapf,
I found your information on pre-dislocation syndrome on
the Internet,
and am very grateful for your explanation of the condition. I would
greatly
appreciate if you could answer a few questions. For the past 19 months, I
have been trying to get help for this problem. I have had injections,
which
only seemed to aggravate the condition. I have tried total rest, a walking
cast, orthotics, physical therapy, ice, various metatarsal pads. Still, my
second toe is lifting, and my big toe is moving over to the left,
underneath the second toe. I have been advised at this point to have
surgery: flexor tendon transfer, to stabilize the second MTP joint, and an
Akin procedure to get the big toe out of the way. Do you have any thoughts
on this as an appropriate solution? Any thoughts on other possibilities
that may have been overlooked? Thank you so much for your time.
Sincerely Judy F.
Dear Judy, For your answer go to -->
March 5, 2001
I received the following letter after Dave visited the web page talking about
heel pain.
Dr. Zapf: Just happened on your web page. Your article on flat
feet--my
feet look just like your pilots, right down to the bulge on the side.
They have looked like that since I was 9 years old and started getting
leg pains. My legs and feet hurt so badly I became very inactive and
gained over fifty pounds. Converse gym shoes were terrible. But I
discovered a pair of old cowboy boots in the basement. They were
wonderful and I wore them to the chagrin of my parents who said the high
heels would ruin my feet. However, I went off to school, the Navy etc.
and didn't wear boots for almost 20 years. When I was nearly 40 my wife
came home with a pair of boots much like the old ones. I went nuts and
had to have a pair. After wearing them about three months I realized my
feet and legs didn't hurt. A number of A-B tests proved it was the
boots. A resulting trip to a pedorthist confirmed that heels were for
me. Now at age 61 my leg pain is gone and so are the calluses and corns
on my feet. I am also able to walk four to six miles a day in good
walking shoes, all I have to do is wear my heeled boots otherwise. Your
article is the first one I have seen which verifies my experience, over
20 years worth, everyone else says I'm nuts. Dave
February 28, 2001
What is the biggest QUACK device in all of podiatry and how is it related to
the weinermobile? Visit -->
February 27, 2001 - A question from a web reader answered.
Question: We are away from home and I think I have a soft corn
on the inside of the big toe, I wear an orthotic for a foot problem and
don't think it breaths as I recently got 3 bad toe nails all within 6 mo.
The other foot I do not wear an orthotic and that foot is fine. I will be
at this address for another week and half or 2 weeks. Thanks.
Answer: Regarding the soft corn on your big toe, try getting a
toe separator from your local drug store (or podiatrist) to prevent the big toe
and the second toe from coming together. Regarding your bad toe nails, I do not
think the orthotics are to blame. Athlete's foot fungus is ubiquitous and is
just waiting for the right environment to spring up. It is unlikely that the
orthotic changed the environment of your feet. It is possible that the orthotic
wearing results in your being in shoes more of the time which could, in turn,
increase the humidity in your shoes which, again, in turn, set you up for a
fungus infection. My suggestions are the following: see someone about your nails
and get a professional opinion on the presence of fungus, 2) change the
environment in your shoes by wearing a sock that 'wicks' moisture from your feet
and 3) spraying your feet each morning with an anti-perspirant spray (not merely
a deodorant spray) that keeps your feet from sweating. In my opinion over the
counter anti-fungus therapies work only anecdotally and not in real life. You
can try a prescription level anti-fungal nail medicine like PENLAC. I would
avoid any oral anti-fungal medicine until a professional has assured you that
there is fungus in your nail.
I hope this helps. And what are you doing wearing only one
orthotic? They come in pairs, usually.
February 28, 2001
I answered some interview questions posed to me by Kristi -->
February 20, 200
I answered a question from Sylvia about bunions -->
February 15, 2000 - Valentine's Day
I answered a question to Minh To, a high school student regarding the life of
a podiatrist, I answered it on this web page for all to see. Feedback welcome.
To see the answers go to -->
January 29, 2001
CRAMPING: The Alabama Sports Medicine Institute reports that mustard
ingestion is useful for treating acute muscle spasms in athletes. The athletes
ingest a packet of mustard, washed down by water, every 2 minutes until the
cramps are gone.. It is believed that the vinegar in the mustard does the trick.
Let me know if you try it.
January 2, 2001
I added a page on the reasons why my injections are thought of as being so
very gentle.
For this see
December 29, 2000
I re-wrote the page on ingrown nails.
December 21, 2000
I updated the page on warts
and created a new page with great close up pictures of a wart surgery
.
* Lots More Initials
