Heel Pain

The following is an article written by Dr. Zapf featured in the Acorn Newspaper.  It discusses plantar fasciitis (say PLAN-ter fash-ee-EYE-tus), which is one of the most common reasons why people seek treatment from a podiatrist. 

“I hate putting my foot on the floor in the morning. It feels like a nail in my heel,” said Carolee when I asked her about first step heel pain.

She was describing a common symptom of the most frequently seem problem in a podiatry office: the first step pain after periods of rest seen with plantar fasciitis.

The pain is usually caused by the too-strong pull of connective tissue that stretches from the toes to the heel. At one time the plantar fascia was useful to its owner by making the foot rigid when climbing barefoot, but now it seems its most important job is filling podiatry waiting room chairs.

Like many patients, Carolee was worried about having a heel spur, imagining a boney spike on the bottom of her heel. I could see one on her X-ray, but she was skeptical when I told her that it was not the cause of her pain.

In fact, about 40 percent of patients without heel pain have a spur and half of all patients with heel pain do not have a spur. As proof that the heel spur is not the cause of pain, surgery, which is rarely done anymore, usually just involves cutting the fascia, leaving the spur alone. It is routinely successful.

Carolee demonstrated the most common causes of the overuse of the plantar fascia: being overweight, wearing flimsy shoes while working and walking on hard surfaces. She worked in retail in sandals and was walking to lose weight in flexible deck shoes. (This is not to say that underweight men who wear dress shoes cannot also have this pain.)

Carolee suspected, correctly, that her flat feet contributed to her problem by excessively stretching her fascia.

When she arrived at my treatment chair, I touched a spot on her heel where the fascia inserts on the heel bone and she jumped a little, indicating that she had pain in the correct location for plantar fasciitis. (Sorry, Carolee). I measured the thickness of the fascia with ultrasound, and it was an overly large and painful 7 mm thick. Her other heel, the one without pain, was a normal 3 mm in thickness. Normal thickness is up to 4.3 mm.

The ultrasound measurement has become the easiest confirmation method used and is especially useful for atypical plantar fasciitis, where the problem is not exactly at the insertion site of the fascia on the heel. Here it can be used to guide injections into the correct location for greater effectiveness.

The treatment provided at this first visit was a special, almost magical, tape strapping called a low-Dye, after Dr. Ralph Dye, who first described it. The tape will often stop the pain in its tracks. This works so well that I use a positive response to the tape as one of my four criteria to make a presumptive diagnosis of plantar fasciitis; the other three being first step pain, pain with pressing on the insertion spot and thickness of the fascia over 4.3 mm on the ultrasound.

Home instructions for Carolee included wearing stable shoes; using an over-the-counter arch support; reduction in the most forceful activities like the treadmill in favor of cycling, swimming or a healthrider; and the application of ice to the heel for 20 minutes several times a day.

For icing I recommend using a plastic bottle filled with water that has been frozen. Sometimes patients can learn to apply the low-Dye on their own; videos are available on YouTube.

Over-the-counter medications like two or three ibuprofen two or three times a day are often helpful. Wall stretches of the Achilles tendon and plantar fascia are also helpful. The technique is available on the Internet.

If the low-Dye strapping is consistently more helpful than over-the-counter arch supports, more effective custom orthotics can be made. If patients wear a stable shoe, they can often achieve pain relief with custom orthotics.

Unfortunately Carolee could not be talked out of her sandals and deck shoes because, as she said, her feet “get too hot,” requiring another approach. For immediate pain relief I injected a little cortisone near her fascial insertion site, and she received profound pain relief. Cortisone injections in the heel are safe and effective, and usually can be done with little to no pain.

For more resistant pain I can repeat the injections up to three times, and physical therapy can do marvelous things with the techniques and tools at their disposal. Our office has the luxury of two inoffice licensed physical therapists.

Statistics show that, on average, heel pain resolves on its own in 18 months. These techniques can certainly improve on that, so Carolee does not have to wait until 2014 for relief.

For those few that do not resolve in an appropriate time period, both high-energy shockwave therapy and surgical approaches that are described on the website below are available.

Meanwhile, three low-Dye strappings and two cortisone injections have helped Carolee become pain free. Now all she fears in the morning is her alarm clock.”


All 3 doctors at Agoura Los Robles Podiatry Centers treat this aggravating condition.  Please click on the link below to view Dr. Zapf’s “Patient’s Guide to Heel Pain”.  Please call our office with any questions.  (805) 497-6979 or (818) 707-3668.



Our Agoura Office Is Moving!

Our Agoura Hills office is moving locations. We will still have a strong Podiatric presence in Agoura Hills providing you the quality of care you have come to expect with Agoura Los Robles Podiatry Centers just in a newer, more updated office setting. Please excuse our mess if you have an appointment in our current Agoura office for the next week as we make preparations for the move. We will be opening our new doors at 5115 Clareton Dr. Suite 120 Agoura Hills, CA 91301, starting Monday, February 4th. Come visit us at our new home and thank you for your support!!

View Larger Map

Update 2014- we have been loving our new office- especially the WINDOWS! Here is a picture of the view we have of Lady Face Mountain:  

Venous Reflux, Or Why You Need Gradient Compression Hose

Legs that feel heavy, swollen and hot at the end of the day or after an airplane flight are common complaints in our office.

Usually the cause is the increasing inability of the veins to return blood from the feet and legs. If you recall from your anatomy lessons, blood travels to the feet by the arteries and returns by the veins. Gravity and a beating heart help the former get the blood down to the feet. Back pressure and, especially, a series of one-way valves in the veins of the legs aids the return of blood toward the heart.

As we, ah, mature, the valves frequently become less efficient (called valvular incompetence) and the surrounding muscular tissue loses some of its youthful tone (especially when overweight). The result is a condition called venous “reflux”.

The symptoms of “reflux” are leg heaviness, tiredness and swelling that gets worse as the day progresses and gets even worse with a lot of standing and sitting. Back pressure from the deep veins and valves often result in the visible swelling of superficial veins that called varicosities or varicose veins. Some authorities even blame night cramps of the feet and legs on varicose veins. If reflux and varicose veins are left untreated iron pigment from red blood cells can leak out of the veins producing a brown discoloration around the ankles. This is process if called “venous stasis”. The venous discoloration can damage the skin sometimes resulting in leakage of fluid out of the skin and the formation of ulcers  on the ankles and lower legs. Venous ulcerations are problems I will deal with in a subsequent article.

Good YouTube videos on venous reflux can be found here:



The first steps in treating the feeling of swollen, heavy, tired legs is to elevate your feet, exercise and the use of gradient compression hose (GCH) that help return venous blood to your heart. The word gradient implies squeezing  the forefoot with the highest force with less at the ankle and even less at the calf. This decreasing pressure gradient help the veins propel venous blood from the feet toward the heart.

GCH are ranked by the amount of pressure they exert at the forefoot compared to the pressure at the calf. The gentlest compression and the one easiest to wear will be labeled 8-12 meaning 8mm of mercury (Hg) pressure at the calf and 12mm at the forefoot. So-called “travel socks” that help prevent clots forming in the legs while on an airplane are usually 8-12.

Medical grade have compression is as high as 30-40. The highest are the hardest to put on but provide the most relief. In general the stronger the pressure the better the result but I glibly say that the best pressure for you is the one you will wear. Start with the lowest and see how you do. Keep increasing the pressure until you can’t stand it.

Some of the more famous brands of GCH have very informative web sites.

Jobst: http://www.jobst-usa.com

Juzo: http://www.juzousa.com/

Sigvaris: http://www.sigvarisusa.com/

There are a couple of local sources for GCH if you cannot find them at your local pharmacy. We have found them at:

Helping Hands

2955 E. Hillcrest Drive, Suite 106

Westlake Village, CA 91362

(805) 494-4402


A Private Affair

1321 E. Thousand Oaks Blvd., Suite 122

Thousand Oaks, CA 91362

(805) 374-2293


Higher compression levels may need a prescription. We will be happy to fax or forward one for any of our patients – just tell us where.


Michael Zapf, podiatrist and surgeon in Thousand Oaks and Agoura Hills, discusses a child's bunion.

A Child’s Bunion

Another surgery by Dr. Zapf today reminds us that even kids get bunions. This patient was less than 14 years old but her foot hurt so much in shoes when doing sports and P.E. that she couldn’t wait until she was fully grown to have her bunion done. All of her growth plates are not yet closed but on the metatarsal where the surgery was done the growth late is at the base of the metatarsal while the surgery is done at the head. She will be wearing a post-operative shoe for about a month and can then go back into athletic shoes.

Michael Zapf, podiatrist and surgeon in Thousand Oaks and Agoura Hills, discusses a child's bunion.

Michael Zapf, surgeon and podiatrist in Thousand Oaks and Agoura Hills, discusses the presence of a bunion and tailor's bunion.

Bunions and Tailor’s Bunions together!

One of Dr. Zapf’s surgeries today reminds us that there you can have a bunion on BOTH sides of your feet. Most everyone knows that the joint behind the big toe can form a bunion but the one behind the little toe can also form a bunion and hurt. In fact this surgery was on a 27 year old woman who had more pain from her little bunion, called a tailor’s bunion or a bunionette, then she did from her big bunion. They were both corrected with a surgical procedure over at the Thousand Oaks Surgery Hospital. The surgery took less than one hour for both bunions to be corrected. This patient will be wearing a post-operative shoe for about a month and then tennis shoes. Since her left foot was done she can drive as soon as next Monday.

Michael Zapf, surgeon and podiatrist in Thousand Oaks and Agoura Hills, discusses the presence of a bunion and tailor's bunion.

A Very Special Thank You

We just wanted to share a thank you that was given to us recently. Our practice is very lucky to have such amazing people as our patients, and we hope to give the best care we can all the time. Getting something like this helps us know we are doing a great job, so thank you again.

Patient thanks Michael Zapf, podiatrist and surgeon in Thousand Oaks and Agoura Hills

Caring for Your Feet

I found this article and thought it was well worth sharing with our followers, as a fair amount of our patients have diabetes. Maintaining your feet is an greater task when you have diabetes, and if left unchecked it can cause a considerable amount of problems. We cover the risks and complications of diabetes on our website, but this article gives you an outline of various things to keep in mind while you keep your feet healthy. Remember too, these guidelines do not JUST apply to people with diabetes, a majority are good to keep in mind for anyone. We hope you enjoy it and learn something!

Click Here to Read the Article!

Special thanks to Rita Weinstein and Diabetes Self-Management.

Gout Update 2012

Gout Update 2012
By: Michael Zapf, DPM
January 8, 2012 – Special to the Acorn


It has been a relatively warm winter yet our office has already gotten over 20 calls from patients with the same complaint: a sudden onset of redness, swelling, heat and, often, unbearable pain, originating from the foot without any history of injury or change in routine. After the diagnostic workup I will describe below, these patients, like some 6-8 million fellow Americans (mostly male) ended up having gout. In the past, gout was almost always in the big toe joint. Most patients still seem to picture in their mind a painting of Old’ King Henry, some number or other, with a chunk of meat in one hand with a flagon of wine in the other, resting his foot on a pillow with heat waves rising from the area of the big toe. “But, Doc, I don’t even drink” some of our patients say. Let me try to clear some of this up.


All gout has the sudden onset without precipitating factors in common. But what is surprising is the number of anatomical locations we have seen it this year. Personally, I have seen this season’s gout not only in the big toe, but the second toe, the 5th (baby) toe, the second metatarsophalangeal (toe-foot) joint and the outside, middle and top of the foot and, in one case, the heel. One patient had so much gout in his little toe that it broke the skin causing a wound. Yes, it can get that bad. I have read that the general incidence of gout is on the rise, especially in men.


Gout is caused when a normally dissolved material, uric acid, comes out of solution forming crystals. If you remember your chemistry, this happens when the fluid cools (like salt water evaporating in a glass). If you have more uric acid circulating in your body than you need, the crystals form in the coolest parts, your feet. The higher your uric acid levels (measured with a blood test) and the colder your feet get the more likely you have solid crystals. The seasonal factor is winter where it is just colder. Add surfing and snowboarding and you see why two of my patients developed gout.


Genetics, increased caloric intake, being overweight, having kidney trouble, high alcohol intake and, ahem, maturity, all seem to increase out load of uric acid.


The diagnostic work-up usually involves a careful history and physical examination, x-rays of the painful part and a measurement of the uric acid level with a blood test.  The two most likely competing diagnoses are an injury, which usually has a corresponding history with the resulting damage often seen on x-ray, and an infection which is usually accompanied by a break in the skin. Sometimes it is very hard to tell gout from an infection and, in those cases, we often treat for both conditions to be safe.  Since cooling the body makes more crystals form, it is wrong to put ice bags on a gout foot, even though it is good for an injury.


The crystals, by themselves, are not vary harmful but the body’s reaction to them causes an immense inflammatory response that hurts like crazy, sometimes requiring patients to use crutches to keep their foot off the ground. This is the stage where anti-inflammatory medication seems to be helpful, either doses of a strong ant-inflammatory pill or a cortisone injection.  Other self-help remedies that seem to work include drinking 2-4 liters of fluid daily, avoiding alcohol (especially beer), limiting  protein intake, especially fish, meat and poultry to 4—6 ounces per day and, an anecdotal folk remedy, eating 1 ¼ cups of dark, red fresh cherries a day. Cherry juice is a weak alternative.


A quick response to the high dose of anti-inflammatory medication we prescribe is almost diagnostic for gout, much to the relief of the gout victim. I stop my initial care of the patient at this point, sending them back to their primary care doctor for medication to lower uric acid levels. He or she will usually use medications that can lower the production of uric acid, increase our body’s ability to clear it out of your system or slow down your body’s overenthusiastic attack on the crystals. You might have seen one of the newest medications, Urloric, advertised on television. The gout blogs say it is effective, but, expensive at $200 a month if you do not have insurance. These medications are recommended for people with recurrent attacks or who might be developing uric acid kidney stones. Another risk factor is the blood pressure medication hydrochlorothiazide (HCTC). Many combination blood pressure medications, such as Diovan, Lopressor, Monopril, and Ziac and about 30 others, contain HCTZ without patients being aware of it. If you have chronic or recurrent gout and are taking a HCTZ medicine, you will need to talk to your doctor about switching.


There are a lot of uric acid lowering diets on the Internet (look for a low purine diet) and we have a couple in our office as well. All of the diets lower the protein that leads to uric acid by reducing meat, poultry and fish, increasing plant proteins, avoiding simple sugars and alcohols, especially beer.  I am not sure how well the diets really work but when the pain is bad enough, most of us will do anything to make it go away. While it may be fun to fantasize you are royalty, this is certainly one aspect you can do without.


List of medications containing HCTZ
  • Apresazide® (containing Hydralazine, Hydrochlorothiazide)
  • Accuretic® (containing Quinapril, Hydrochlorothiazide)
  • Benicar® HCT (containing Olmesartan Medoxomil, Hydrochlorothiazide)
  • Diovan® HCT (containing Valsartan, Hydrochlorothiazide)
  • Dutoprol® (containing Metoprolol, Hydrochlorothiazide)
  • Exforge® HCT (containing Amlodipine, Hydrochlorothiazide, Valsartan)
  • Hydrap-ES® (containing Hydralazine, Hydrochlorothiazide, Reserpine)
  • Hydro-Reserp® (containing Hydrochlorothiazide, Reserpine)
  • Hydropres® (containing Hydrochlorothiazide, Reserpine)
  • Hydroserp® (containing Hydrochlorothiazide, Reserpine)
  • Hydroserpine® (containing Hydrochlorothiazide, Reserpine)
  • Hydra-Zide® (containing Hydralazine, Hydrochlorothiazide)
  • Inderide® (containing Hydrochlorothiazide, Propranolol)
  • Inderide® LA (containing Hydrochlorothiazide, Propranolol)
  • Lopressor® HCT (containing Metoprolol, Hydrochlorothiazide)
  • Mallopress® (containing Hydrochlorothiazide, Reserpine)
  • Marpres® (containing Hydralazine, Hydrochlorothiazide, Reserpine)
  • Monopril® HCT (containing Fosinopril, Hydrochlorothiazide)
  • Quinaretic® (containing Quinapril, Hydrochlorothiazide)
  • Ser-Ap-Es® (containing Hydralazine, Hydrochlorothiazide, Reserpine)
  • Serathide® (containing Hydralazine, Hydrochlorothiazide, Reserpine)
  • Serpazide® (containing Hydralazine, Hydrochlorothiazide, Reserpine)
  • Serpex® (containing Hydralazine, Hydrochlorothiazide, Reserpine)
  • Tekturna® HCT (containing Aliskiren, Hydrochlorothiazide)
  • Teveten® HCT (containing Eprosartan, Hydrochlorothiazide)
  • Timolide® (containing Timolol, Hydrochlorothiazide)
  • Tri-Hydroserpine® (containing Hydralazine, Hydrochlorothiazide, Reserpine)
  • Uni Serp® (containing Hydralazine, Hydrochlorothiazide, Reserpine)
  • Unipres® (containing Hydralazine, Hydrochlorothiazide, Reserpine)
  • Uniretic® (containing Moexipril, Hydrochlorothiazide)
  • Ziac® (containing Bisoprolol, Hydrochlorothiazide)

Dr. Michael Zapf is board certified podiatrist in private practice with offices in Agoura Hills and Thousand Oaks. For more information, including the complete list of medications containing HCTZ, please call his office at (818) 707-3668 or visit the practice web site www.ConejoFeet.com

Vitamins to take for better brain health

4 Vitamins and an Oil for Better Brain Function in Later Life

Reported by Michael Zapf, DPM
January 4, 2012
I don’t know if you caught the recent New York Times article (*) that pointed out a study reported in the January, 2012 issue of the journal Neurology noting that older adults are often a little low on five nutrients that can sustain brain function as we age.  The report stated: After controlling for age, sex, blood pressure, body mass index and other factors, the researchers found that “people with the highest blood levels of the four vitamins scored higher on the cognitive tests and had larger brain volume than those with the lowest levels” :
The five important nutrients are:
Omega-3 oil
Vitamin B
Vitamin C
Vitamin D
Vitamin E

Omega-3 oils are found in fish, plants and nuts. In addition to aiding brain power they also help reduce cholesterol levels and blood pressure, reduces the risk of heart disease and lowers the damage of diabetes, osteoarthritis and osteoporosis and may even reduce depression.
Vitamin B – The B complex includes thiamine, riboflavin, niacin, B-6 and B-12 as well as biotin. Some are found in vegetables and some only in foods of animal origin. Biotin is a B-vitamin that strengthens finger and toe nails so it is often suggested to patients by podiatrists.
Vitamin C- Found in fresh fruits, broccoli and Brussels sprouts, is needed for tissue repair, including making strong skin, tendons and ligaments, cartilage and bones and it is a strong antioxidant. Because you do not store Vitamin C you need a steady input of this vitamin. Contrary to popular misconception, Vitamin C does not prevent a cold but it might shorten the duration and make the symptoms somewhat milder.
Vitamin D – Research has shown Vitamin D useful in many other facets of metabolism, especially in strengthening bones, as well as the possible reduction in breast and prostate cancers. It is important to ask your doctor to measure this vitamin in your body with a simple blood test. The minimal nutritional amount for this vitamin is likely to be raised to 1000 IU per day with an 8-oz glass of milk containing about 300 IU. If you doctor finds your levels low in D-3, a recommendation to supplement your diet with 50,000 IU a week is not uncommon. 10,000 IU capsules are available.
Vitamin E –   Higher levels of this vitamin also help lower heart disease, some vision problems and some types of cancer. One research study showed that 2000 IU a day slowed some of the effects of Alzheimer’s disease. The highest source of this in nature is wheat germ but liver, eggs and dark green vegetables are other sources.
As always, the best sources of nutrients are from a well-balanced diet of fresh food.
A good source for vitamin and nutrition information is from the web site of the University of Maryland Medical Center at http://www.umm.edu/altmed/ -Just put your favorite vitamin or topic in the search box. Now, where did I put those vitamin pills?


Update on Laser Treatment of Nail Fungus with the Cutera Genesis Plus

There was a recently a  report released  by Dr. David Weiss of Hammonton, NJ on the effectiveness of the Cutera laser to treat nail fungus that I found interesting.

The beginning of the report outlines the current treatment options available, discussing the pros and cons of each before he launches into the summary of his testing.  Using the Cutera Genesis Plus, an Nd-Yag laser that produces a 1064nm wavelength, he found that on the laser had a 70% efficacy rate when used twice on a nail with a 6 week interval between treatments.

This stays in line with other numbers we have heard in the podiatry community regarding efficacy rates on visually improving the nail.  Unfortunately, his sample pool was very limited, with only seven patients, however we are all very excited to see more studies come out on this topic.

Our in office efficacy rate is matching up exactly with these numbers, and we would love to find ways to get them even higher,  please take a look at his report which is below in PDF form.

3 Month Clinical Results using Sub-millisecond 1064nm Nd: YAG Laser for the Treatment of Onychomycosis By: David Weiss, DPM