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Thursday, December 14, 2017

Sesamoid Stress Fracture: Email Advice

Hi Dr. Blake, 

I was wondering if I could get your input on my situation and whether I should pursue additional treatment for the hairline stress fracture in my left tibial sesamoid.

In February of this year, I started feeling an occasional sharp pain when training for sports and went to see a podiatrist in CT who took x-rays and diagnosed me with inflamed sesamoids. I rested/iced/took high strength ibuprofen for a while, but eventually decided to return to playing frisbee because the pain wasn't improving at all and it was my senior year (and we ended up making it to the National Championship game so I wanted to participate). After I graduated, I saw another podiatrist who took more x-rays and also said it was inflammation but thought I should be fine without orthotics or anything. Just continued rest.
Dr Blake's comment: Golden Rule of Foot: Create a 0-2 Pain Level for Healing. Rest however is very destructive overall in allowing deconditioning, swelling, nerve hypersensitivity, etc. I definitely want a more active approach to heal. 

After stopping all running and resting as much as possible for the summer, I still had pain and a lot of swelling. I saw my third podiatrist here in San Francisco and an MRI showed a hairline stress fracture in the tibial sesamoid (even though that spot never particularly hurt when pressed by any of the doctors).
Dr Blake's comment: Could be an over-read of the MRI for just bruising and inflammation. 

I have now been in a walking boot for 6+ weeks, semi-weight bearing with a crutch for the past 4. There is a pad on the bottom with a cutout for the sesamoid. The sharp pain is mostly gone, but I still get bouts of pretty severe swelling where I feel like all the blood is rushing and pooling in my foot. It gets red and hot and tingly. I also have noticed a general tingling when I touch the ball of my foot and big toe. I also developed more pain on the top side of my foot directly above where the sesamoids are and on the underside of my big toe where it meets the foot. Sometimes it feels like it is bruised there.
Dr Blake's comment: Pain, swelling, tingling, etc. that you did feel until after you went into the boot is probably caused by the immobilization and will get better once you leave the boot. Since your injury is so small, and we are not worried that it is a displaced fracture may be needing surgery, try to alternate environments with boot, hoka one one shoes, hike and bike shoes, and normal athletic shoes with orthotics and dancer's padding. 

To make matters more confusing, I am moving in three weeks and starting a new job right away in Hanover, NH. My podiatrist here hasn't really laid out a plan for me, except looking for a referral for me. I am worried that the walking boot may be causing more issues and the lack of PT or rehabilitation could be slowing my recovery. I am wondering what you think about my symptoms and response to treatment so far, and what my plan should be moving forward. I am also very willing to come see you in person since I will be in the area for the next few weeks.
Dr Blake's comment: Several weeks have passed since you emailed this, so you have probably moved. I hope the idea of alternating environments and daily working on the inflammation and nerve hypersensitivity is helpful. Good luck. 

I look forward to hearing from you and truly appreciate the time you take to help others like myself. Thank you very much!


Sesamoiditis: Email Advice

Dr Blake,
Thank you for the wonderful blog. If it wasn’t for your blog I would have had no idea to make any progress with my sesamoiditis.
The first podiatrist I went to diagnosed me with a fracture from the left foot x-ray, the second podiatrist (who is supposed to be the best in Denver) said there was no fracture on the x-ray and at my insistence ordered an MRI. The MRI also showed no fracture just inflammation in the bone and surrounding tissues

-          This doctor has given me no advice on getting better other than insisting I get an orthotic made from him and take a cortisone shot (which I refused)
Dr Blake's comment: Good for you. It is the long-acting cortisone that we worry about in a joint. 
-          My pain started in mid-sept and I went to the doctors almost right away.
o   I was in the boot for 6 weeks.
o   I had zero pain in the boot 
Dr Blake's comment: Yes, you get injured and you do what it takes to create the 0-2 pain level for healing. The secret is to figure out how to keep it as you wean out of the boot and into normal activities. But, you achieved the first part well. 
o   My left ball of the foot still feels swollen and makes it uncomfortable to walk on barefoot
Dr Blake's comment: For most bottom of the foot problems, no barefoot walking until you have been completely fine for 2 months. The removable boots never get rid of swelling, and in fact, the velcro straps can trap the swelling in the foot by slightly cutting off the venous return back to your heart. 
o   I use Dr Jill’s dancer's pads and high-arch over the counter orthotics.
o   I bought Hokas and have been pain-free in them. I am able to walk for 30 minutes in them.
o   Yesterday I tried a spinning class and unfortunately I am feeling a bit of discomfort today ( I can’t tell if it is good pain or bad pain)
Dr Blake's comment: Spin should be fine. Initially do not get off the seat, and lower the resistance a little. Also, ice right after, and one more time that night for 5-10 minutes. 
o   I do contrast bath 2-3 times a week
Dr Blake's comment: If you are swelling, contrast baths starting at one-minute heat one minute ice for 20 minutes, along with pain-free massage and perhaps some PT to remove the swelling. 
o   I am naturally too pronated and my ankle rolls inwards
Dr Blake's comment: If your orthotics center your weight, then they are helpful. If you assess how you walk through them, see if you think you should have a higher arch. 

-          Questions for you
o   How do I get back to activity? I haven’t worked out in 11 weeks and I feel very unhealthy. I tried swimming but my work hours are crazy and it isn’t possible to swim other than the weekend
Dr Blake's comment: Typically it is mixture of impact (walking and advancing to a walk-run program), non-impact (elliptical or spin or stationary bike without the sesamoid on the pedal), and cardio (swimming is the best mixed with some spinning)
o   The spinning class gave me some pain – should I try it again? Yes, see above.
o   I am very unclear on how I try to get back on my feet and normal again and the doctor is giving no guidance
Dr Blake's comment: When you hurt your foot, you need to restrengthen your foot, but also condition your legs and core. Many people need the advice of a PT or trainer or both, to get the deconditioned feeling out and get powerful again. 
o   What physical therapy exercises should I try?
Dr Blake's comment: Try to find my description of the well you make to float your sesamoid when weight bearing. Typically four books of an equal height slightly offset to stand on with the sesamoid in a hole or floated. Then you can do your two positional calf stretches, your toe raises (start two feet only), your single leg balancing,  ankle therabands, knee extensions and flexions, and other core work.
o   I still have swelling but prior to the spinning class had zero pain, is it normal for swelling to stick around? Yes, see above, but you must work on it. 

I feel really depressed all the time with the lack of physical activity and the inability to wear normal shoes to work (I bought some vionics recently and will try them once this bout of spinning class pain subsides)

Is there a doctor in Denver, CO that you would recommend? I need someone who doesn’t try and force me into cortisone shots. 
Dr Blake's comment: I have heard good things about Dr Stephanie Parks. Let me know what you think. Rich

Any help and guidance from you would be much appreciated.

Thank you!

Tuesday, November 28, 2017

Podiatry Question #2

I hope you enjoyed the first question several days ago. These are meant to educate, but also to test your knowledge. Sometimes there is more than one way to answer, but I need to give you my personal best answer from a podiatrist viewpoint. Hope you all survived Thanksgiving. It is the start of an energetic and blessed, but exhausting, month towards Christmas. I love the Holidays. 

Podiatry Question #2: When we help patients through a rehab process, what pain level do we try to keep them at? 

When rehabbing athletes and non-athletes, working them through the various landmarks of recovery from injury, you must keep them between the 0-2 pain levels which are considered a healing environment. Initially, that may mean needing crutches and a boot, then various forms of taping or braces or orthotics, then some limits on what shoes they can wear, etc. But, in the pursuit of keeping the pain within 0-2, the patient learns what is needed to help them fully recover. I see so many patients spend too much time waiting for a test to be done, with no attention being made to the amount of pain that they have. Every day with high pain levels causes more muscle compensations and weakness to develop, more possible nerve hypersensitivity, and more gait changes to avoid pain. It may be impractical for some reason to reduce the pain this much, but when you do not, you are always delaying the process of complete recovery. I just had a patient that needs her dislocated 2nd toe fixed surgically. This will be the only way to completely eliminate her pain, but I am trying various shoes, taping, Budin splints, icing, and activity modification while the long process of finding a surgeon and the right timing in her life comes along. We must have that as our mantra: Keep the pain down between 0-2. Compromise is needed at times, but we should look for ways to lessen the compromises when we can. 

Sunday, November 26, 2017

Podiatry Question #1

I created this blog to teach. I wanted to teach my patients first of all to be smarter in the rehab course, and perhaps to prevent injuries in the future. But, I also created this blog for podiatrists, podiatry students, and all in health care with an interest in feet and biomechanics and overall health. I am in my 6th year of teaching the podiatry students at Samuel Merritt University’s California School of Podiatric Medicine. They are wonderful, and I am blessed. I am starting this series of questions with the hope they will all know the answers by the time they graduate, or even as they begin their practices. Many of these questions will be for lay folks, sports store personnel, coaches, or just students of good health. I will ask the question, followed by a photo to gap the answer by some space, and then the answer. Shall we begin?

#1   When treating tendinitis in any form, what mnemonic is commonly used to think through the possible treatments?

Answer: The mnemonic B.R.I.S.S.  Biomechanics  Rest.  Ice.  Stretching.  Strengthening. These are the 5 key components to treating all types of tendinitis. Of course, there are so many other treatments of tendinitis out there that have helped, but BRISS gets the process started. The Biomechanics are concerned with the forces that caused the injury, and the forces that can be changed to help the injury. Rest is a four lettered word for everyone, especially top level athletes in competition, so we tend to shift the attention to Activity Modification. We need to rest the area, but we need to cross train. Ice is universal for Anti-inflammatory measures, but we are getting better at knowing when to ice, and when to heat, when to use contrast bathing. This also applies to anything that decreases the inflammation including oral medicines, injectables, topical, prescription or OTC, physical therapy, or acupuncture. Stretching is key to relaxing the tissue, and many tendinitis cases do not get better until you can find the way to stretch that makes the area feel better. And finally, Strengthening, is so crucial. We must assume that any tendinitis is caused by weakness of the tissue, or surrounding tissue. Start strengthening to some degree the day you hurt yourself. 

Tuesday, November 21, 2017

Post Bunion Surgery Suggestions from a Patient

Dr Blake,

Hi, things are really progressing for my toe! Pain is about 0.5 and it’s becoming more and more flexible. I’m in normal shoes with dancer pads—seems to be a good combo at this stage. In a few weeks, I’ll try some orthotics again. 

Anyway, if I had feedback for other patients it would be: 
  • Go to Defcon 4 of a healing program for yourself—it won’t get better unless you’re really doing the work. If you do the work, though, it will get better. 
  • Contrast baths are much more effective than just icing. Do it front of the TV at night. Easy.
  • Physical therapy to strengthen muscles and loosen up the joint. This really works.
  • Self-mobilization 3x per day works wonders. 
  • Elevate whenever possible.
  • Protect your toe from bumping into things with a toe guard or shoe.
  • Wear a post-op shoe when you sleep to protect it from injury at night. 
  • Take your time and remember that you’re injured—whenever I started feeling better I went too far with my movements and set myself back.
  • No pain meds—for me that would just mask injury and not give me feedback about progress and possibly further injure the toe without me knowing.
  • Lose weight to put less weight on your foot.

Wednesday, November 8, 2017

Ankle Pain with Email Advice

Hello again, dr Blake

I hope you are well. I am sorry to bother you once again. I am sure you are a very busy man. Since last I contacted you, I can report that I have gotten hold of the exogen stimulator, and taking Vitamin D and Calcium supplements (right foot sesamoid problems).

However, I am not writing about my right foot metatarsal problem now. Unfortunately, I have a more acute problem with my left foot. 

Originally, after my running injury 2 years + ago, I ended up with very bad pain in both feet. The pain got so bad that I ended up using a wheelchair for 4 months. About a year after I was diagnosed with sesamoiditis in the left foot after MRI (oedema in both sesamoids). I suspected that I actually had had a sesamoid stress fracture in the left foot too and that it was healing ok. But I also had strange aching pain in all of the left foot and continued difficulty wearing shoes and tight socks. This pain got better very slowly but seemed to get worse every time my right foot metatarsal pain flared up, and I focused on offloading that with more "flat walking". I mentioned it to several doctors, but it seemed to be written off as pain connected to my forefoot-issues. But all the time I had a feeling that while my pain level matched the diagnosis of my right foot, it was not so with the left one.

About a month ago, my left hind foot had gotten quite painful again, and then I felt a sudden stinging pain at the back of my ankle/over my heel. It then felt like I shouldn't place weight on my heel afterwards. In the following week, the pain got worse. After negative x-rays and being written off by my doctors once again, I decided to pay for an MRI myself. This was the description I got:

"Mild tenosynovitis in peroneus tendon sheaths with possible small longitudinal spilt of peroneus brevis tendon distally to the lateral malleolus. The tibial posterior tendon is a little thickened distally against the attachment to os peroneum. Very mild tenosynovitis in the flexor tendon sheath." I have excluded the rest of the description, which was of normal findings.

I have read a lot about these tendons afterwards, and today I was at a physiotherapist with diagnostic ultrasound expertise. He confirmed that it looks like a split right below the malleolus, although a very short one. I have a history of 2 ankle fractures and following sprains (with a major knee injury after 1 sprain) in the left foot since my childhood, so I am thinking there might be a connection there. 

My question to you now would be, what now? I feel that the pain gets very bad with any weight-bearing at the moment. I tried offloading with crutches for a week, but my right foot cannot handle the additional weight. I also have gotten some new pain in the ankle area of the right foot. It doesn´t feel nearly as serious as the in the left, but I suspect some inflammational tendon issues there too. I have used a wheelchair at home for 10 days now, and I feel a lot of pain reduction when offloading the feet.

I read that some use cortisone to get rid of the inflammation, but others say it can damage the tendon more. I see some statistics that look very bad for conservative treatment of tendon split, and that many end up with surgery. Others claim that conservative treatment could work well, after all. Do you have a position on this? Or any advice on how long to offload the foot, before attempting to walk again? 
Dr Blake's comment: I need you to send me the MRI for review, at least a copy. Your symptoms do not match the findings of the MRI. If the physio tests the tendons, do they hurt? You can try resting the ankle in an AFO custom made at a local brace shop. They are prescription items. I see these split tears in some, with absolutely no pain in the area, and no pain on the contraction of the tendon against some resistance when you are testing the strength. I think for some people they are normal variations of that tendon--to not present like a hold piece but to present as multiple strands. Yes, I do not like cortisone for tendon inflammation as there can be some weakening. The 9 classes of NSAIDs could be tried first to find one that works well. Ibuprofen in one class, diclofenac in another, Celebrex in another, and so on. It sounds almost nerve tension, so consider neural flossing, Neuro-eze gel massage, and neurological eval by a doc or neuro PT. Hope this helps some. Rich

Hope for a response from you, yet again.

Kind regards,

Friday, November 3, 2017

Calmare for severe nerve pain: More news

A Pilot Trial of Scrambler Therapy for Pain Associated With Pancreas Cancer - Full Text View.

Doctors seek new paths toward pain relief amid an epidemic of addiction and death.

Calmare Therapy
Four months after a botched podiatric surgery, Ridgewood resident Marilyn Green started to experience intense pain in her right foot. She was diagnosed with reflex sympathetic dystrophy (now largely known as complex regional pain syndrome type 1), a neurological disorder in which pain from damage to the soft tissues and/or peripheral nerves can spread to other parts of the body. Leery of narcotics, she self-prescribed a combination of B-complex vitamins and exercise that had proven beneficial to her mother after a case of shingles. The treatment offered some relief, but the gnawing pain persisted and began to spread. Green came across an article describing a rare procedure known as Calmare, designed to treat neuropathy, the nerve damage and concurrent chronic pain that can arise after chemotherapy, a shingles outbreak, or surgery. In cases like Green’s, says Michael Cooney, a chiropractor who is one of the few practitioners in the state to use the therapy, “we think there’s a hypersensitivity that’s developed within the pain center of the brain.” The Calmare device uses electrodes to move what Cooney calls “a no-pain signal” through the area of pain in order to “reboot” the brain, so that it’s no longer aware of the pain.
Cooney treated Green with 10 sessions of Calmare, and she is now pain free. “When I went in there, my pain level was at nine,” she says. “On day five of the treatments, it was down to zero.”
Calmare is effective only on true neuropathies; it appears to offer relief ranging from 6 to 18 months or longer.

Thursday, November 2, 2017

Fat Pad Atrophy: Email discussion

This patient has fat pad atrophy post cortisone shot one heel and sesamoid area other foot. Here is a discussion we recently had regarding a procedure to move the fat pad placement and inject stem cells to encourage fat regrowth. The doctors are up in Pittsburg, Pennsylvania. I have reviewed the MRI for her noting tremendous scarring of the fat pad at the heel called panniculitis. 

Hi Dr Blake,

I wanted to get your opinion on this procedure. I have lost fat on the lateral side of my left heel as well as under my big toe (same foot) due to a cortisone injection for plantar fasciitis and sesamoiditis. Unfortunately, I haven't found any shoes that help or inserts, taping, etc. I've been doing a lot of research and found 2 doctors performing the Foot Fat Grafting. They're married, the wife is a podiatrist and the husband is a plastic surgeon. It seems like they've had good results for far in their pilot and research study.

What are your thoughts, do you think it's worth trying? I'm only 28 years old and the pain is unbearable. I just want my freedom back.

Thank you!

Dr Blake's comment:
      I reviewed and found the articles interesting and hopeful. They would, of course, recommend it if you went there. You would need a doc near you to followup, and hopefully, someone independent to think your pain is from the fat pad atrophy also. But, it sure makes sense. Rich

Thanks, Dr Blake. I've had one doctor say it'd atrophy but then others haven't. It's hard because I hear so many opinions, a lot of "plantar fasciitis" but I have the scarring in my heel fat pad that is shown on the MRI. They will do ultrasound prior to the procedure to confirm the thickness 

Dr Blake's comment: 
     I read their reviews. Also, see if you can talk to one of their patients. 

I spoke to one of the patients yesterday and it sounded promising, she only had it done 3 months this ago so hard to say if the fat stays and if the stem cells from the fat help with new growth of the fat pad

Dr Blake's comment:
     I was thinking the same, but as long as we get good results probably does not matter!

They are doing a volunteer study for the heel which I'm going to apply for so it's free. Worth a shot. I'll keep you posted in case it might help others. 

Tuesday, October 31, 2017

Saturday, October 28, 2017

Possible Tarsal Tunnel Syndrome: Email Advice

Hi Dr Blake,

I hope you're well.  

I am wondering how to know if the pain in my foot/ankle/lower leg is coming from the FHL, FDL, or Tibialis Posterior? They all seem to have the same location and trigger points from the muscle are also close together. I would like to do self-massage to release whatever is trapped/tight if possible.
Dr Blake's comment: These are the 3 tendons that run together in the tarsal tunnel. 

Some history:

Two and half years ago, I injured my FHL tendon where it meets my sesamoid (imaging showed inflammation and swelling at 1st metatarsal, fracture of sesamoids ruled out) on my right foot.  I developed nerve pain as a result (in right foot and leg, and mirror nerve pain in left foot and leg), as well as piriformis syndrome in my right glute from the gait changes.  Tendon eventually healed, but different kinds of nerve pain/patterns and piriformis muscle pain remained, sometimes mild sometimes more severe.  Additional imaging ruled out lower back/SIJ issues.  

Two months ago, I developed an intense tension in my right foot, very close to my Achilles tendon, between my Achilles tendon and ankle bone on the inside of the leg, when walking.  Tension would feel like somebody was pulling my heel back whenever I tried to take a step forward, as if one of the tendons/ligaments was too short and bouncing back each time.  Pain could not be reproduced on pressing the area of the pain, just when stepping forward. Pain only appeared when I put on my shoes and took a step, when at home in flip-flops I could walk pain free. The pain came and went for about 10 days, then disappeared.  
Dr Blake's comment: This is classic tarsal tunnel (nerve) symptomatology, not tendon. 

A week ago I started feeling pain in my right foot, starting from the bottom just in front of the heel (between heel and arch) and shooting upwards towards the back of my ankle bone on the inside of my leg.  Not a nerve pain feeling, but a tension again, less severe than two months ago, different spot (but nearby), and sometimes starts tingling sligthly when I press on it.
Dr Blake's comment: It is called neural tension, and definitely neurological. 

 Tried rolling foot on tennis ball at point of pain and felt tingling on bottom of foot towards big toe (similar to pain from FHL injury 2.5 years ago but much less intense). Did not continue rolling on ball.  Being familiar with trigger points, I press my lower leg up from ankle (on inside of leg) to calf and get some referred pain into my foot between the heel and arch.  Pain is felt when swimming, walking, and stretching body when waking up (tension/soreness) and when not moving (dull throbbing ache).
Dr Blake's comment: It is half neurological, and half tendon, the way you describe. When the 3 tendons are individually stressed, how do you feel? Rich 

Any ideas of which tendon this could be and suggestions of how to release whatever is pulling on the tendon would be much appreciated! I would rather not go to doctors and physiotherapists all over again, but would not want to leave this if it might get worse.  I got used to the residual/chronic nerve pain and piriformis muscle pain but would not want to start shifting gait again.
Dr Blake's comment: If you were in my office, and I tested the 3 tendons without problem, I would put you on a tarsal tunnel protocol of neuro flossing, neurological-eze gel top massage, no stretching, active ankle range of motion, warm soaks 20 minutes twice daily, orthotics or sole wedges if you pronate, and consider lyrica  for evening at least. Rich

Thank you,

Foot and Ankle Pain Post Surgery: Email Advice

Hello, Dr Blake. 

     I have suffered with foot pain for 2.5 years now.  I have had MRI, and X-rays which show no tears, showing a heel spur, inflamed plantar fascia, inflamed post tib tendon, and the nerve that runs through tarsal tunnel area.  There is fluid around the tendons as well.  

     Approximately 4 months ago I opted for a Hyprocure stent that is supposed to help with these problems.  The Doc also ground down my heel spur at the same time.  My heel pain is much better now, but I still have arch pain and post tib pain, and what I think is a bit of tarsal tunnel or nerve pain.  I have tried everything that I could imagine. 
Dr Blake's comment: This device helps with pronation like orthotics on a permanent basis. It will help the mechanics, but not the inflammatory or neuropathic pain. 

     I had to drive out of state to do the Hyprocure so that doc is a very long drive.  I went to a more local (1.5 hr away)  doc 2 weeks ago and he gave me a Trilok brace and injected traumeel and did a 3 min shockwave.
Dr Blake's comment: Why not normal physical therapy? Have you tried it? Where was the Traumeel injected? The brace looks good, does it help some of your symptoms? 

    I believe the only thing that helped at all was the brace.  Went back 2 days ago and ended up doing 2 cortisone injections.  One towards the plantar fascia, and one near the tarsal tunnel area.  It seemed to help so far.  The problem is, 2 years ago I had a cortisone shot that worked but only for 4 or 5 weeks.  I have a home ultrasound and an afx machine which is for strengthening the foot for plantar flexion, dorsiflexion, inversion, and eversion. 
Dr Blake's comment: Please be cautious with the shots. Could not find reference to afx machine, but definitely, continue to strengthen your foot and ankle so you do not de-condition. 

    I have really considered buying an AFO such as the Deroyal Element Sport Ankle Brace. 
Dr Blake's comment: This is not an AFO, so not sure if any better than the other brace. I hear from your email that you are trying all these things, but what about starting all over with a removable boot placing yourself at least part of the day in the Immobilization Phase with daily foot, ankle, and leg strengthening work. This should include core work and some cardio (can you swim, use an elliptical, or ride a stationary bike?) Main question is what does it take to get you to 0-2 pain level and then maintain that? 

    I'm just not for sure when I need to strengthen and stretch, vs just keeping it immobile.  I have studied on these issues for many many hours and finally came across your website.  AWESOME!  Thanks for all you do.  I am seriously depressed for the first time in my life and I'm running out of options.  The only other solution from one doc was a complete reconstruction.  That seems like too much considering nothing is torn.  I am a very healthy 43 yr old male, normally pretty active (not now) 6 ft, 225 lbs with quite a bit of muscle.  I am even losing weight just to see if that will help.  Any suggestions on the timing of strengthening or bracing after cortisone injection?
Dr Blake's comment: You are asking all the right questions. You should have supportive orthotics to rest your foot, it is in a new position with your surgery only 4 months ago, and needs a year to re-strengthen. You should immobilize some time of the day in a removable boot, because I need to know what pain relief that gives you. Important info. If the immobilization does not bring you to 0-2 then you have too much inflammation or neuropathic pain, and there are many ways besides shots and surgery to help that. I hope this helps some. Rich

Thank you,

The Patient Response:

    Hello, thanks for the response.  I did try physical therapy and didn't have much luck.  After the hyprocure surgery, I did the physical therapy on my own using ultrasound and ankle foot maximizer (afx).  I also used a blood flow stimulation therapy wrap (electromagnetic heat).  For some reason, any orthotics custom or otherwise seems to aggravate the arch area now. 
Dr Blake's comment: When the posterior tibial nerve is irritated, off the tarsal tunnel, patients have an intolerance to orthotics. Which means to me that the primary direction of your treatment has to be neurological and not mechanical. Read my postings about nerve pain, they are some the same treatments we use for CRPS (like the meds and Calmare or Quell). 
    I am finding that cushion seems to help.  The only shoes I can wear at the time are Asics Kayano, which is a stability cushioned shoe.   The traumeel was injected into the post tib insertion, which really wasn't where the pain was.  When I went back, we got more specific with the cortisone as to the exact location of the pain with 2 shots(that was my choice to switch to cortisone.) 
1)  I believe I have the Ossur air walking boot from the hyprocure surgery, would this work for part day immobilization?
Dr Blake's comment: Yes

2)  Orthotics seem to aggravate now, any suggestions
Dr Blake's comment: If we want arch support without pressure on the nerve, you need to experiment with the many arch or posterior tibial tapings available. See my video on posterior tibial taping with leukotape and coverlet 

3)  Should I start strengthening exercises immediately, and what frequency.  (ex 1x/day for 3x/week)
Dr Blake's comment: Only in the evening. Never through pain that does not get better with 10 minute icing after, or sharp. It can be sore due to the nerve irritation. Start with active range, then isometrics, then progress to progressive resistance. May want PT to guide you. See my video on Posterior Tibial strengthening for the order. 

4)  Icing, ultrasound, or bfst wrap?
Dr Blake's comment: May be time for a new PT to guide you. When you are dealing with strength, nerve irritation, and inflammatory issues, along with taping, etc. a PT should be very helpful to find the balance. Rich

Thank you so much!!!

Sesamoid Healing: Patient's Account of Healing

I have emailed with this wonderful patient for quite some time. He got into a terrible state of deconditioning and nerve hypersensitivity when a physical therapist (true healer) decided to help (and I mean really help). Everyone's story of healing will be different. What works for one, may not work for another. You have to keep trying, doctors may give up, but you can't. You have to assume that there is an answer to your problem that is around the next corner. This is a heart-wrenching and wonderful story. I know how hard he worked. Here's to continual healing. Please be kind to leave comments. Thank you. Rich

Dr Blake,

Hope all is well for you!  Thought I would share some thoughts on my battle with sesamoiditis 

A recap - about 18 months ago I began to have swelling in the ball of my foot which soon showed up in my other foot.  Went to many doctors who kept telling me to rest and if I had pain it would not heal etc.  After an MRI the doctors said I had stress fractures in the Sesamoids in both feet.   Went to multiple physical therapists that could not help either and I kept getting weaker and weaker.  I lost about 30 pounds, started having pain all over my body.  I got so weak I struggled to even take a shower.  If I had to walk much I used a wheelchair.   I went to doctor after doctor and tried OTC orthotics, custom orthotics, walking boots, cortisone shots, opioids, antidepressants, tons of different shoes but nothing seemed to help.    I went to many PT sessions over 4 months with two different physical therapists and that did not help either.  Finally, after 10 months a lady from my church suggested I contact a physical therapist that she had used with success.    She saved my life!   I began therapy and the first day she had me cancel my appointment with a particular Orthopedic surgeon and had me schedule with a different one.  Obviously, a PT knows which surgeons to go see since they have to help everyone rehab after surgery!  We had several sessions and after a few weeks I was getting stronger but the pain was getting worse.  I went to my appointment with the Orthopedist and my PT went with me!  (That should tell you how bad of shape I was in!)  I had seen Psychiatrist, psychologist, Internist, Podiatrists, Orthopedic surgeons, Rehab specialist and the Physical therapist helped me more than anyone had so far!  The doctor said I had AVN but told us that I had to fight this and I was basically released to full activity.  From that point, the therapy got a bit more intense and the pain for two days after each session was terrible.  The PT kept telling me I would get better and to just push through it.  I was now more active but my feet hurt and got much worse as the day progressed.  They had gotten so weak from all the resting that I heard comments like your feet feel like baby feet.  Well the PT was right - I'm still doing the exercises she showed me and I'm able to do anything I want to do.  I still have some pain when I sit for a while but once I get moving the pain goes away.  The PT expects I'll still have some discomfort for the next 6 months but expects it to totally go away by then.  I wanted to share some of the things I did that helped me the most.   I'll never know for sure what caused all my issues but I suspect shoes were a part of it.  

  1.  Never stop moving - that led to weakness all over my body and hip, back, knee and foot issues.  
  2. Find a good PT no matter how many you have to go to to find one - make sure the PT knows all about strengthening feet and hopefully has experience specifically with sesamoiditis
  3. The PT suggested Asics shoes - I tried them on and immediately they were wide enough to take pressure off the sesamoid area.  I had tried Altra, Hoka, New Balance etc and the Asics were the only ones that were wide enough for my feet and did not have too much cushion.  Initially, a stiff shoe was OK but later I needed to have flex back in the shoe.  
  4. Cushion is not necessarily a good thing in shoes - My feet really don't have much cushion on the fat pad so I thought that a more cushion shoe would help but it actually made things worse.
  5. Took Vitamin D - my counts were low around 30 initially - also spent more time in the sun
  6. Took Calcium supplement
  7. Used an Exogen bone simulator as Dr Blake suggests using
  8. Specific exercises that helped -  Wobble board (stretching and strengthening), Busu Ball (marching),   foam wedge (stretching while standing), Side lunges, riding a stationary bike, Walking (making sure to walk normally), Marbles (pickup with toes), Standing on one foot and planks.  Also used a Total Gym to help with upper body etc during this time.   
  9. Orthotics are not necessarily good for your feet - I think they actually caused more damage than they helped.  Once my feet got strong again I really didn't need them. Dancer pads caused all kinds of pain for me- I think I may have needed them in the first month but after the bone healed they had to go!
  10. Lots of stretching will help - use the foam wedge mentioned above and do the gastroc stretch.  It doesn't seem to do anything quickly but over time will help.  make sure to do a warm-up before stretching or you'll cause more issues.
  11. A spikey ball will give a deep tissue massage.  You can find them on Amazon and it really helped me early on.  

If anyone is having trouble like me my thoughts are with you.  I wouldn't wish this on my worst enemy but thank God the worst seems to be behind me!  

Monday, October 23, 2017

Unresponsive Plantar Fasciitis: Email Response

Dear doctor,
    I came across your blog while I was searching for my chronic PF's cure and I have enjoyed reading your great insights.on foot problems. I have been suffering from PF for the past 5 years and I had been to 5 or 6 different podiatrists here in Tampa area and tried both custom and over the counter orthotics for my PF relief but to no avail. During this process, I found that each doctor has their own protocol to treat PF and I got very vexed with these doctors after failing to get any relief from the last doctor's multiple steroid injections(7-8) which were given to me more than a year ago! 

    I have also been icing and doing calf stretching and strengthening exercises as humanely as possible. During a recent trip (3 months) to India, I also went through PRP injections which gave me no relief yet. Kindly suggest a good podiatrist who can put me out of this misery. 8-)

I sincerely wish I am living in the bay area (SF) so that I can come to your office.


Dr Blake's response. 
Sorry for your problems, please get an MRI because it sounds like it could be a tear. Also, 2 podiatrists to see: Gerald Cosentino, DPM in Tampa and Matthew Werd, DPM in Lakeland. You can also go to the AAPSM website and look for other members of this great organization that live in this area. Rich