Diplomate, American Board of Podiatric Surgery

Fellow, American College of Foot and Ankle Surgeon

-- started at Wed Aug 20 17:49:15 PDT 1997

AlanSherman Welcome one and all to Celebrity Live Foot Chat, presented by Podiatry Online
AlanSherman Tonight will be our 3rd weekly Live Chat session
AlanSherman We hope that this programming will become a regular event and be embraced as a new way for Podiatrists in practice, in the classroom, and in legislative affairs to communicate with and learn from each other.
AlanSherman We have 2 more programs scheduled in this initial series,and they will take place 9PM EST the next 2 Wednesday evenings. The schedule will always be available on the FrontPage of Podiatry Today Online, at https://www.podiatryonline.com/footman/pdonline.html
AlanSherman Next Weds, Aug 27 at 9 PM Harry Goldsmith, DPM, perhaps the leading expert on insurance issues in Podiatry, will host a session with the topic "Pearls of Insurance Reimbursement"
SkaPod Hey - drop that Today :-)
MwaveMikeTran skapod... hehe..
AlanSherman The following Weds, Sept 10 Jon Hultman, DPM will runs a session with the topic "Current Survival Strategies for Living under Managed Care". John is a practice management expert and may be Podiatry's most prolific writer at the moment.
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AlanSherman As of Sept 4, "Today" is history..thank you
AlanSherman The word for word TRANSCRIPTS of all Live Chat programs will also be made available from the Podiatry Online home page. Simply go to the schedule and if the program has already taken place, there will be a link to it's transcript. The transcript of David Armstrong's program last week is already available there.
MwaveMikeTran Alan, uh huh.. :)
AlanSherman Last week, David's session was very interesting and, after reading through the transcript after the session, it occurred to me that what we're creating here is a new contribution to the medical literature that never existed before. The closest thing that I can compare it to is the dialogs done recently that appear in the back of the Journal of Foot and Ankle Surgery, where various experts are asked to critique each others articles. But here, we're live...
MwaveMikeTran harry, r u from NY?
AlanSherman Tonight, we have a compelling topic and an illustrious host.
AlanSherman I'd like to start off by telling you a few things about him:
Harry No, I'm from California.
AlanSherman Keith Kashuk has set a standard by which others in our field have measured themselves since graduating from NYCPM in 1969. By any standard, he has had an exemplary career.
MwaveMikeTran harry, okay...
AlanSherman We'll have some free chat later...
AlanSherman He was one of the early graduates of the 2 year surgical residency at Kern Hospital, known as Civic Hospital at that time. He is a Diplomate of ABPS, and a Fellow of the ACFAS, since 1976. He has taught countless Podiatrists surgery since establishing the Westchester General and Larkin Hospital Foot Surgery programs in the 70's and 80's.
AlanSherman His writings and lecture credits take up many pages and I am limited by how fast (or slow) I can type. He has been a valuable contributor to the American College of Foot Surgeons, has served as Scientific Chairman for their annual meetings, and has most recently been asked to serve on their Board of Directors.
AlanSherman He and a few others were really instrumental in establishing a place for Podiatrists in the hospitals in Miami, Florida back in the early 70's. He was truly a pioneer and had the confidence and drive to show the established medical community in Miami how HE thought Podiatrists should be regarded. All of that is now, of course, taken for granted, but now you know...the rest of the story.
AlanSherman I would only add that, since training with him 16 years ago, not a week goes by that I don't catch myself saying something or doing something that I learned from him. We learn more from our residency training than nuts and bolts, screws and pins. We also learn character, demeanor and how to communicate with other doctors and patients and he may not have particularly noticed, but I was watching him.
AlanSherman Tonight, Dr. Kashuk has agreed to host the topic of "Current Controversies in the Treatment of Heel Pain",
AlanSherman Good evening, Keith...thanks for agreeing to join us
Kashuk Heel pain is a hot topic. We as DPMs have been pre-empted lately in the lay press by our ortho colleagues
AlanSherman Does anyone want to start off with a question for Dr. Kashuk ?
MwaveMikeTran DrKashuk, what strapping do you recommend for a new pt who has heel pain?
Kashuk Also, in our literature, the procedure of endo plantar fascial rel has been quite hotly debated
Kashuk Still like the old reliable low-dye...with a moleskin T-strap
AlanSherman Keith, do you still inject heels in two parts, with the local separate from the steroid ?
SkaPod I like to use an arch pad with an extension below the first metatarsal... in feet with forefoot varus..
MwaveMikeTran DrKashuk, yes one of the clinician at the Foot Clinics of NY recommends the Low-Dye also.
Kashuk Are you seeing more/less/same amt of heel pain pts?
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scott What is the substance of the debate? I wasn't aware of any major concerns.
scott debate of EPF
AlanSherman Heel pain is the 3rd most freq reason for people to see me
SkaPod What percentage of your PF patients go on to surgery?
Kashuk Controversies: How long conserv. tx? Inj or not? EPF or open or percut
MwaveMikeTran DrKashuk, I've been rotation for 3 weeks and have noticed alot of heel pain pts...
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AlanSherman Many people receive treatment in a haphazard way, without a protocol, and either don't get better or have reoccurrence
AlanSherman welcome to Live Chat, Podd and Blaze
Kashuk Heel pain is my second most common complaint
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AlanSherman Do you use strappings until the orthotics arrive, or preformed orthotics ?
Harry I think one of the most controversial areas of concern regarding the treatment of heel pain revolves around the wide number of therapies or treatments rendered patients. There does not appear to be a correlation between the specific treatments, duration of treatment, frequency of treatment, etc. Most practitioners report that with "conservative treatment" - whatever that turns out to be in the individual practitioner's hands - the patients respond favorably in 60% to 90% of the case
Kashuk Approx 3,000,000 new cases/yr
Podd I have participated in the USA Today phone in and at the local phone in at the last two national meetings and heel pain is the #1 concern.
SkaPod 60% sounds really really low.....
AlanSherman WE badly need outcome studies in this area
scott How long would you say conservative treatment should be tried (I guess everybody can respond)
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AlanSherman Welcome to Live Chat, Rob...please feel free to take part in the discussion
Kashuk My opinion-minimum of 6 mos of closely monitored cons care
Podd I use the baseball criteria of three strikes and you're out. Should see significant improvement in 3 treatments
Kashuk Podd---what then?
SkaPod Podd - have many malpractice cases active right now?
MwaveMikeTran 3 conservative tx?
Podd Will continue with good response and change with poor. I knew you would ask that
AlanSherman 6 months, hmm? Is most of that time just having mechanical support or getting active treatment ?(inj/pt)
Podd No mal practice any time.
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Kashuk What are your criteria for taking the patient to surgery?
Harry I assume the question of how long conservative treatment for heel pain should be tried before surgery? Essentially conservative treatment should be tried and modified as needed over a two month period (my opinion). The treatment program should be monitored every other week for status. If there is no improvement in a 2-3 week period using a specific therapy/treatment, the practitioner is obligated to review the case and consider a different course of care. Surgery is the last option
scott I've seen several journal articles that recommend against injection. Who here uses and does not use injections?
Podd I agree with Harry.!!
SkaPod ok - after 3 failed conservative treatments - you'd be right to change therapy, but surgery would be a bit precipitous.
AlanSherman Are patients "patient" enough to wait 6 months to get better ? I follow a similar protocol to Harry, for my patient's sake...but Keith is correct that 6 months conservative tx has been a standard
Podd Three conserv treatment then DIFFERENT concerv treatment. There are enough things to try to find something that works.
Harry I am impressed. Where is the research to validate that 6 months of conservative treatment is the standard?
AlanSherman scott...injections WORK..why not use them ? Morbidity is almost nil
SkaPod I start off with HVGS (galvanic) & Ultrasound twice weekly - with strappings.... Add non-steroidals if necessary. Usually have a positive response. Then go on to orthotics. If much pain remains - then I'll inject.
Kashuk What about injections? what substance, what approach?
Rob Type HEREHow many conservative modalities are there to take up six months worth of a patient's patience?
AlanSherman No research, Harry...just anecdotes...I think it is cruel to wait that long before giving a patient the alternative of surgery
SkaPod I go in at a 45 degree angle towards the medial tuberosity usually. Then directly below calcaneus if inferior calcaneal bursitis exists.
Podd Treatment better work sooner than 6 months or the patient is a goner
Kashuk How about PM splints, stretching,P>T>?
SkaPod Stretching - after improvement occurs
SkaPod Otherwise it can overstretch & retear healing tissue.
Podd I have heard that pm splints work but I have not used them yet
Blaze but you need to hold the stretch for at least 2-3 minutes
AlanSherman I still follow the Kashuk approach (of 16 years ago)....a 2 part injection of 3 cc's of marcaine (I threw out all my lidocaine after reading Bret Robotskys study) followed by 1 cc dex acetate
Rob If you are getting a patient into a good stretching routine, you should see results in less than 6 weeks, not 6 months.
Harry I will inject a heel 3 times (maybe 4 if I honestly feel that there will be a significant long-term benefit for the patient's symptoms. My injections are generally spaced 7-14 days apart. The patient's have reported, in my practice, that the injections, stretching, short term course of strapping and possible therapy have been most beneficial in controlling symptoms.
Kashuk How soon should a patient be offered an orthotic? What about cost? What kind of orthotic?
Podd Harry--I like what you say. (that is because it is very close to what I do
AlanSherman The worst "complication" of steroids in the sub-calc bursa is spontaneous detachment of the plantarfascia...and THAT cures the condition
SkaPod so rumour has it
Rob Cost should never be a factor in comprehensive care of a patient
AlanSherman Rob..what community do you practice in ....Shangrala ?
Kashuk Once the decision to bring the patient to surgery has been made, what is the pcd of choice?
SkaPod Allan - Have you had a spontaneous detachment of the PF after 3 injections. I've never seen one occur, only read about it :-)
scott firm, thick, heel lifts for immediate relief and rest, and strapping during stretching to prevent reinjury. Treat runners different from those on their feet alot or those who are overweight. Also Superfeet orthotics. Birkenstocks have helped a lot of people who are on their feet all day. Of course NSAIDS.
Podd Good point Rob--results should be. But if cost is NOT considered you may never have the patient around to get results
Rob My point is you should always think of the best care of the patient
Rob Cost is a concern and that is where all options should be presented to the patient
AlanSherman No, I've never had one...it's just theoretically possible...Incidentally, another complication can occur if you are not in the sub-calc bursa..that is, atrophy of the plantar fat pad. That's why I still measure each one on a non-wt bearing xray before injecting. You CAN estimate, too.
Harry I find that immediate initial use of OTC doctor prescribed supports is very beneficial in controlling the biomechanical problems which either led to the symptoms or continue to irritate the plantar fascia/plantar calcaneal region. 75% of my patients or more never need anything more. Orthotics are used in follow-up to OTC supports when I feel that the patient will be better served or need the specifics of individually measured and fabricated devices.20%
Kashuk In 26 yrs I have known of three spontaneous plantar fascial ruptures in my exp of thousands of injections
scott Harry, specifically what kind of OTC supports?
SkaPod I'm usually lucky enough to usually see only those who have already failed with OTC supports & heel cups
Podd I agree Keith. In 30 years I haven't seen any or heard of any
Blaze how can an OTC device correct a BIOMECHANICAL abnormality?
Podd Spenco makes the best products I have found
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Rob Don't forget that the spontaneous rupture will save you the trouble of performing anepf
Harry I can't imagine throwing out steroid injection therapy for plantar fascia/bursal pain - with the significantly positive results obtained with the injections and the very low complication rates.
Kashuk Alan, you brought up the important issue of outcomes study.
scott Superfeet is more rigid than Spenco, with a much wider range of sizes. But harder to find.
Harry I also agree that Spenco arch supports are inexpensive and have resulted in favorable responses from my patinets.
AlanSherman I like the Podothotic made by Northwest...it has a plastic shell under a plastizote top
scott Sports or outdoors stores sometimes have them.
Kashuk Heel pain has been targeted as an important area for future res. by ACFAS
Blaze Spenco with plastic arch supports work well...albeit with many modifications to meet the patient's needs
AlanSherman Are there major or multicenter outcomes studies being done in Podiatry ? I thought I remembered reading that ACFAS was planning this..
Blaze The Podothotic does not have a plastAzote topcover
AlanSherman Blaze..what is the topcover made of ? Soemthing nice, anyway
Kashuk This could be a fruitful area for online data gathering
Harry In reading the comments, I am impressed with the number of providers who also feel that OTC or pre-made support devices are beneficial. I would add that they should be attempted on the initial go-round treatment for the heel. Orthotics can always be fabricated at a future date.
Blaze It is made of a closed-cell polyurethane foam...breaks down quickly
scott Important point: the particular Spencos that have the moldable plastic support. I think there is a problem with any research into supports and lifts because of the wide variety of choices.
AlanSherman Absolutely...it would be a simple matter to create a password protected page that contains a form that all centers could simultaneously enter data into...the results would instantlyavailable for all to see, too.
SkaPod Yes, The spenco with the plastic shell is the better one...for OTC orthotic
Podd Strapping, heel cushions, heel cups, Sorbothane, Spenco, US, injections, etc... What other conserv. treatments you use??
Kashuk Getting down to basics---what really causes heel pain?
scott lose weight
AlanSherman Durability is a big problem with all premade orthotics, I think...any exceptions that you know of ?
Podd Tell that to a patient and you can say good-by at the same time
SkaPod Alan - I like your idea for a page for data entry...
Blaze begin with a premade, and then "beef" it up...especially with crepe
Podd I have my standard way of explaining heel pain to a patient. I would be interested in how others do it
Kashuk Is there a profile for the "typical" heel pain pt?
Harry The orthopedic "study" on OTC support devices was flawed in many ways, but it did show in those that participated in the study that a wide variety of devices whether OTC or custom orthotics do help control the biomechanical problems and symptoms. I'm not sure that one specific device is the absolute choice. If it was you would see orthotic labs capitalizing on the idea.
AlanSherman I joke with patients and tell them that the typical pt that comes in for the first time with heel pain is an overweight woman who just took her grandkids to Disneyworld
scott and does aerobics
AlanSherman Oi !
SkaPod In my office the typical patient is a runner who has increased their mileage & gotten older at the same time....
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AlanSherman If we could only stop that aging thing...
Podd Heel pain , to me, is an overuse problem.
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scott rec.running newsgroup has the largest and most knowledgeable postings about PF. Running know PF
Rob Has anyone found any of the computerized devices to be beneficial: I have attempted the Benefoot device and the Bergman and have had poor results thus far. Any suggestions?
AlanSherman Certainly, it's an overuse problem...an effective but inpractical tx is staying nonwt bearing for 2 weeks...always works
Podd If a patient could go from the 30,000 to 40000 steps a day to half their normal, thing have to start to get better
MwaveMikeTran scott.. i am going to check the newsgropu out
Harry The age range of heel spur syndrome patients varies from about 35 to 70 in my practice. Some are runners, others work on cement flooring, others are overweight, some are weekend athletes - there is no specific prototype patient in my practice.
AlanSherman The is also an excellent review of web info on Plantar fascia done by a bright fellow named scott Roberts, referenced on the frontpage of Podiatry Online
SkaPod True Harry, everyone gets it.... younger people can get Seaver's disease.
scott try scott.home.mindspring.com it has the rec.running and more. It's my plantar fasciitis web page.
scott that's me
AlanSherman We have 11 people signed on here at the same time...that's a record for us...thank you all, Gentlemen
MwaveMikeTran scott, great
kashuk What hurts? Bone? fascia? Nerve? Bursa?
MwaveMikeTran alan, and ladies? :)
scott 140 visitors per day. My most popular site
Podd How do you know one is not a lady??
AlanSherman Scot ? Is that you, scott ?
scott me
Podd I think it is the bursa Kashuk
hankypanky Does the PF night splint at 10 degrees dorsiflexion work and if so .. hoe does it work
SkaPod micotears at the fascia/bone interface
Podd That is why it is so painful in the morning
scott I think we should treat my page as a controversy because I'm not a doctor.
AlanSherman Nice to have you joining us...Everyone..scott is the fellow that did the excellent web research for us, referenced on the front page of Podiatry Online
Harry Fascia at the bony attachment, periostium, nerve, bursa - could be any of the above. A thorough H&P is essential in determining the specific etiology.
kashuk Have you dissected the heel and identified an anatomic bursa?
AlanSherman What % of heel pain is caused by calcaneal neuroma or neuritis ?
Harry Interestingly in surgery, I rarely fine a true or adventious bursitis; or neuroma.
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MwaveMikeTran alan, good question
Podd Makes sense it is a bursa. Pain first thing in the AM--gets better after ambulation--worse again after sitting.
kashuk What about Don Baxter's notion of an entrapment of the first branch of the lat pl N?
AlanSherman Don't you "feel" a potential or real space when you inject in the correct spot ?
Rob Harry, when doing surgery is your incision large enough to find a bursitis or neuroma?
hankypanky upon taking epf course, we dissected heel with fish mouth incision on several heels,
SkaPod I've got to leave - guys - kids still up & have to get ready to treat bunches of this tomorrow...
Harry If it was an entrapment of the 1st branch of the lateral plantar nerve, why does a complete or partial plantar fascial release result in reasonable elimination of the pre-operative symptoms?
SkaPod nice to see so many people here.
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AlanSherman BYE Sks..thanks for participating
MwaveMikeTran time to BAN hank...
kashuk The fat pad of the heel is complexly septate, very stable, has viscoelastic properties, and is firmly attached to the calc, except for a central are4a
Harry As far as the bursitis explanation, I think the symptoms of pain after rest is usual and customary for any acute or even chronic inflammatory process on a weightbearing or active segment.
kashuk What about EPF?
Harry It does not have to be a bursitis.
kashuk Who does it?
Harry It works. So does traditional surgery. They both have their supporters. I like the minimal disability in EPF.
hankypanky is it true bursa with incapsulation?
kashuk How are your outcomes with EPF?
Podd You are right, Harry, it doesn't HAVE to be a bursa I just think that it mostly is
Podd Only my opinion Harry
AlanSherman I took a break for ice cream. I'm back now...
Podd You didn't offer alan-- I'm tasting it now
Rob Overall, outcomes similar to open procedure with the big advantage that patient is comfortably weightbearing in 2-3 weeks.
scott Here in Motgomery AL, Dr. fletcher does it. He uses shots liberally. 1 in ten get surgery. He reports 98% success for those who get EPF surgery.
AlanSherman Healthy Choice Cappachino..mmmmm
hankypanky has fluid from plantar calcaneal pocket or bursa ever been aspirated and analyized
Podd Stuff it!! Alan
Harry Besides EPF, there are surgeon's who are using fluoroscopy to guide scissors or blades; there are other surgeon's who for years have thrust a scalpel blade through the plantar area of the foot at the anterior calcaneal region, dorsiflexed the digits and in a side to side motion cut the plantar fascia blindly. All these people report success. Who is to say, especially without outcomes data, which is the best or if they are equally good?
AlanSherman I'd estimate 90% sucess with EPF...but only 15% fail conservative tx
kashuk The only significant fluid return I get is from rheumatoid pts
MwaveMikeTran alan, hhhe...
scott he missed on one patient and now they have no feeling in a toe or two.
AlanSherman Or can't plantar flex their Hallux
Harry I haven't experienced a loss of plantarflexion in a hallux.
kashuk Have you had lateral column pain, instability with any type of PF release?
AlanSherman I guess you haveb't severed the FHL..that's good
Harry I have had one or two patients who report lateral plantar numbness - usually lasting months.
Rob Of the 10-25% that don't respond to conservative care; do any of you research into the possibility of tarsal tunnel syndrome?
AlanSherman TTS has to be considered in the intiial workup and it CAN mimic plantar fasciitis
Rob For the lateral pain that is sometimes seen the cuboid plug onto the orthotic works very well.
AlanSherman A + tinel's sign can be a pretty subtle thing
kashuk Heel pain is usually the least common sequel of TTS since the Med calc N usually comes off so high
Harry Although TTS could exhibit some common symptoms as heel spur syndrome, I usually rule it out clinically during the initial work-up. I can't say that I have had failed plantar fasciitis treatment (conservative or surgical) which turned out to be TTS.
scott I wonder if patients stop seeing their doctor after a painful injection and the doctor assumes they are better. I get a surprising number of emails about the ineffectiveness of shots. . . but if the shots had worked they wouldn't be emailing me about their PF
AlanSherman Shots are psychologically difficutl(scary) for patients, Scot
hankypanky what does cubod plug really do to alleviate lateral column c/c joint pain?
kashuk I really don't think we have a true handle on outcomes, since many pts are probably lost to follow-up, frustrated, shopping,etc
Rob I recently had a patient who showed no signs of a TTS and did not respond well to injections, orthotics, etc. and had no Tinel's sign. The patient was sent for an NCV which was positive and patient did will with TT release.
Harry I agree with scott that there are many patients who "disappear" after not only injections, but other treatments which do not appear to them to be beneficial. I do believe in the value of the injections. I also believe that technique, medication and dosage are very important. As an aside, I love the family practitioner that injects the heel plantarly with an 18 g needle - steroid without local anesthesia. Those patients love me.
AlanSherman Outcome studies will be our most effective tool in convincing decision makers that we should be doing their foot care
Harry There are a number of "entities" getting into the outcome study business. From first hand experience, heel pain is a high priority to get data on.
AlanSherman Yes, Harry...those guys don't get good outcomes
kashuk Alan, I agree, and re-iterate that outcomes research is an excellent app of online tech
AlanSherman It's been an hour..how are your fingers hold up, Keith ?
Podd Again I agree with Harry who agrees with scott. I think we have much more to offer than the primary care providers
Harry NOBODY DOES IT BETTER THAN PODIATRIC PHYSICIANS DO.
hankypanky patients appreciate a pt block before steroid inj in pf
Harry NOBODY.
scott There are 140 posts from patients to my guestbook about PF. Might be interesting.
scott many of them have had it for years
Podd Where do you practice Harry?
Harry I mix steroid and local after a Medajet wheal.
Harry California
kashuk I think that this has been a very provacative chat .
Podd Where in CA?
Harry This was my first "chat" I truly enjoyed the interaction.
Harry Southern Califonria
hankypanky recent seminar .. steroid w/o mix is more effective
AlanSherman scott..understand that the visitors to your site represent people for whom tx has failed or isn't available..they are the bad ones..a scewed sampling
scott very much so . . . I need to make a comment about that on the page. People email me very worried
Podd Celestone is still my choice. with xylocaine.
AlanSherman The were MANY excellent quotes that can be taken from this chat...that would constitute a good course on current tx of Heel pain
Harry I found that if I increased the amount of local with my steroid my results were not as good and patients developed post injection pain after the local wore away.
kashuk Mixture of anes & steroid will precipitate due to methylparaben in anes.
Rob If celestone fails, you may want to try some kenalog
kashuk Use them separately.
AlanSherman That's why I like the 2 part injection...
Harry I use Kenalog 40, or Aristocort, or Depo-Medrol 40.
scott the psychological benefits of the page to the visitors is enormous. they often thinbk they are alone or just going crazy from disbelief
Harry I had too many "steroid" reactions (relatively) with Celestone. Maybe it was me.
hankypanky thanks for info on steroid precipation in presence of anes.
Rob Harry, how is your success with aristocort?
scott they are happy to see fellow sufferers. It gives them relief that they are not alone or crazy.
kashuk Long acting, highly halogenated steroin xtls stay around a LONG time
Harry Aristocort was my best result.
scott One thing we forgot to mention: a good conservative treatment ....
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AlanSherman What is Aristocort ? an acetate ?
Harry Kenalog 40 was my next best.
scott inform the patient. Hence my web page. Doctors need a good, standard brochure to give patients with specific recommendations for inserts and heel lifts and the Strassburg sock (night splint alternative)
scott and details about stretching (maybe the mpost important) in the briochure.
AlanSherman You've made an excellent contribution, scott...Thanks
scott thanks
kashuk Alan, I think the well has about run dry...Great experience!
Harry Aristocort is a diacetate.
AlanSherman I have a question...stretching REPRODUCES the mechanism of injury..how does that help ?
Rob Thanks for the info, i've got to run.
AlanSherman Thank you, Harry
Podd WHAT EVER WORKS FOR YOU
AlanSherman Bye, Rob..thanks for coming
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Harry The stretching program has to be graduated over a period of time.
scott Protect the fascia during stretching with TAPE
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hankypanky when stretching, stj must not pronate
AlanSherman Sorry scott...what are you stretching then, if you're ptotecting the plantar fascia ?
Harry Congrats on an interesting forum. I've got to run. See you next week.
hankypanky waiting for scott to ans.
AlanSherman Thanks harry...you made a great contribution tonight
scott The calf muscles silly! That's usually the underlying cause: tension in the calf muscles tranfering to the bottom of the foot when the trailing leg lifts off the ground!
Podd Thanks Alan for this forum
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MwaveMikeTran hmm...
scott sudden increase in activity strengthnes and shortens the calf muscle. Hence the need for a heel lift!
AlanSherman You can sign off anytime you'd like now, Keith...We always have a tough time ending these things..sort of like a woman's mah jong game
hankypanky Any opinions about Dannenburg's logic?
scott It's a common them in the journal articles
kashuk I bid two bams and three cracks
scott theme
Podd Nite all
AlanSherman I raise
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AlanSherman Gentlemen..thanks for your help in making this a great session tonight. We'll end the formal chat now...feel free to continue. I'll keep the room open

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