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Tuesday, August 11, 2020

Foot Nerve Pain: Where does it come from?

Hi Dr. Blake,

I have enjoyed reading your blog and felt inclined to send in a question regarding my foot pain.

Background:
I developed a lot of pain right under my big toe in my left foot (not in the ball of the foot, but the underside of the toe itself) about a year and a half ago. The pain had first started cropping up with rock climbing and got progressively worse over time. I got a cortisone shot from a podiatrist that did not help at all and I could barely walk (was in a boot/using a knee scooter) for several months. I ended up having 2 more cortisone shots in that toe over the course of the next year (the 2nd two shots did help, they were from a different doctor than the first time and spaced 4 months apart). I had improved to the point that I was able to do my day to day activities, but still could only walk for about 10 minutes at a time without causing a flare up of pain. 
Dr. Blake's comment: Do you know what he was injecting? Ligament, joint, nerve?

At the one year mark, my right big toe started experiencing the same symptoms and the bulk of the pain simply switched over to my right foot. My left toe stopped bothering me and my right toe became the problem.
Dr. Blake's comment: The only explanation was a nerve problem from your back. The position of your toe in rock climbing put to much tension on the local nerve. This same nerve, typically originating from L3/L4 or L4/L5 nerve roots in the back, was painful due to double crush. This means the nerve is being irritated at the foot and back combined. A slight change in your spine would make the symptoms jump to the other foot. That can could be from limping or protecting for a year, or a primary back problem. 

I limped around and tried to manage it with anti-inflamatories for 3 months before deciding to get a cortisone shot in my right big toe. As soon as I got the shot, I had a TON of pain in the ball of my foot closer to my 3rd and 4th toes (probably an inch below the base of my toes). The doctor I was seeing at the time diagnosed it as a morton's neuroma.
Dr. Blake's comment: Cortisone is for inflammation, which many times there is none. Cortisone if injected into the nerve, a superhighway in your foot and leg, can cause pain in many nerves. Morton's neuromas take many years to develop. 

The big toe pain either went away from the cortisone shot or was masked temporarily, and this new pain in the ball of my foot became the main problem. It pretty much made it so that I could not walk for more than 1-2 minutes here and there to get around my house. It also became painful to drive. I felt some relief by using a metatarsal pad to offload the area, but was still in pain. After 2 months, the big toe pain started returning and it would just depend on the day what would hurt more, the toe or the ball of my foot. My guess is that whatever help the cortisone was giving had worn off. 
Dr. Blake's comment: Yes, but cortisone is not a predictable way of helping nerve pain, so please limit. 

I began seeing a new doctor who ordered an MRI. The MRI showed a "stress reaction" in my big toe, but did not show much for the ball of the foot problem. My new doctor advised me to take a vitamin D supplement and to immobilize the toe for a month in a walking boot. After the month was up, my big toe felt a lot better, but I still had pain in the ball of my foot. 
Dr. Blake's comment: It is hard to know if the boot helped the stress reaction, or just not moving the toe helped you not to irritate the nerve. Did you ever have an MRI of the left? 
The new doctor diagnosed it as "metatarsalgia". He said it was possible that it could be a neuroma, but it was unclear from my symptoms. He gave me a steroid injection from the top of my foot down in the 3rd-4th webspace. This definitely helped and the ball of my foot feel much better. HOWEVER, I now have a similar pain in the ball of my left foot (sort of below 3rd and 4th toe or 4th-5th...hard to pinpoint). I again am unsure if this new pain is metatarsalgia, morton's neuroma or something else. It is worse some days than others. Offloading with a metatarsal pad helps. My doctor has prescribed 6-8 weeks of physical therapy so I am planning to try that next. 
Dr. Blake's comment: You are making me a little dizzy!! LOL Only irritable nerves behave like this. Has your back or any other part of your spine, up to your neck, been an issue in the past? 

My questions for you are: 
What advice do you have to finally kick this pain? I feel like I'm playing a game of whack a mole....when one problem improves another one always seems to pop up!
Dr. Blake's comment: The problem with this is probably not finding the true source of the nerve issues. All of the pain would have to be primarily from the low back or higher. That would make the foot nerves sensitive, and as you favor one problem you then set off the other side. At least, this is the most common cause. I do like the "mole game" analogy. Research in your area PTs that are in the national neurologic physical therapy association as these peripheral nerves are not so mysterious to them. I am glad the cortisone is calming things down locally. 

Do you think my ball of foot pain is morton's neuroma? 
Dr. Blake's comment: No! You can have morton's neuromas that have never bothered you, and normally never will, unless something like this happens. Morton's neuroma has a surgical side that I would avoid thinking about. Typically, it is merely a local neuritis that the cortisone great for. So, I would call this neuritis over neuroma from now on. Yes, I am opinionated!!
Nerve problems present 1/3 of the time as pain (you, unfortunately). 1/3 of the time as a mixture of pain and numbness. And, 1/3 of the time as numbness with funny feels of transient burning, bugs crawling around, tingling, vibration. The more pain involved, the more treatment, even though these scenarios present with the same pathology. Sad!

What do you think is the best way to heal the ball of foot pain that I have described?
Dr. Blake's comment: So, I would use 5 minute ice soaks, if tolerated, several times daily. I would get a pair of Hoka One One shoes or other stiff shoes that your toes do not bend alot. I would have the advice of a PT and Physiatrist about your back and peripheral nerve sensations. If someone agrees that you trust, then trying to calm the nerves down with topical medications like Neuro Eze, Lidoderm patches, TENS units, oral medications. Sometimes we are icing the back, and using warm water soaks for the foot. Find what predictably helps some, and stick with it for 3-6 months to slow down this roller coaster. The met pads seem to help for one so that should be part of your treatment. Come up with 5-7 times over the next month that have some positive affect. I hope this helps some. Rich 

Thanks so much!

Monday, August 10, 2020

Why Do I Watch Someone Walk?

My whole practice of Podiatry has gait evaluation as its foundation. I found this wonderful video last night on the components of gait, when things are right and when things are wrong. The happiness of a Podiatrist is somehow tied to the number of hours spent watching patients year after year walking and running. The happiness comes from truly helping patients with shoe selection, inserts, gait re-training, muscle stretching and strengthening, etc, all tied to injuries and preventing the same injury reoccurring year after year. Gait Evaluation can point to the Root of the problem, or at least one of its components. 


https://youtu.be/8kNo-cJcacU

<iframe width="560" height="315" src="https://www.youtube.com/embed/8kNo-cJcacU" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>

Sunday, August 9, 2020

Shin Splint Discussion: Part III

This is Part III of a discussion on Shin Splints. The links to Part I and II are attached. Here we will talk about treatments when the pain is all in the leg. Even though this discussion is geared for the podiatrist, patients can get a favor of what is important in their treatment.

https://www.drblakeshealingsole.com/2020/08/shin-splints-discussion-part-i.html

https://www.drblakeshealingsole.com/2020/08/shin-splint-discussion-part-ii.html


Common Mechanical Changes for Shin Splints

  1. Strengthening of Involved Muscle Group

  2. Stretching of the Involved Muscle Group

  3. Reducing the Suspected Pronation or Supination Tendencies

  4. Stretching the Achilles Complex

  5. Strengthening the Achilles Complex

  6. Custom Orthotic Devices particularly for Forefoot to Rearfoot Alignment Issues Involved

  7. Training Decisions

  8. Consideration of Bone Involvement


Strengthening of Involved Muscle Group is crucial in all 4 types of Shin Splints.

What is important is good muscle testing principles and you will need to learn

how to differentiate the muscles in each group. It is well taught how to

differentiate testing of the gastrocnemius (knee straight) and soleus

(knee bent) in the posterior group with the other groups *equally

challenging. It is important to know if it is the posterior tibial,

flexor hallucis longus,or flexor digitorum longus giving the medial ankle

pain. Or, if it is the peroneus longus or brevis that hurts when testing against

resistance the lateral compartment. Or, if it is the anterior tibial or another

one of the extensors producing the anterior shin splint. 

Stretching of the Involved Muscle Group is typically only done for the

anterior or posterior muscle/tendon groups. You should know the general

rules for stretching,but remember stretching should never hurt or the tightness

actually gets worse. I recommend stretching an involved group 3 times a day

so I can get to 100 stretches within a month for my next followup visit

generally. It typically takes stretching 3 times a day to gain.

Reducing the Suspected Pronation or Supination Tendencies with varus

or valgus wedges, taping, arch supports, shoe changes, custom orthotics,

and strengthening exercises occurs when youthink the pronation or supination

observed in gait or activity is related to the type of shin splint. 

Stretching the Achilles Complex is vital to most sports injuries when

there is equinus forces. However, it is so important to be able to reliably

measure for this equinus because over stretching a normal or hyper flexible

achilles tendon will do more harm than good. Tight achilles has been known

to be involved in all 4 shin splint types. 

Strengthening the Achilles Complex is vital when the achilles is weak.

The acid test for normal achilles strength is 25 single leg heel raises with

the knee straight (gastrocnemius) and 12 single leg heel raises with the knee

bent (soleus). These are typically done in the evening. 

Custom Orthotic Devices particularly for Forefoot to Rearfoot Alignment

Issues Involved is your classic Root design. Doctors not trained in Root

biomechanics tend to use more metatarsal pads and anterior orthotic bars and

posts, and combinations of all may be needed. Not only is forefoot support great

for the correction of pronation or supination tendencies, the metatarsal support

provided can be crucial for long flexor or extensor produced medial or anterior

shin splints. 

Training Decisions for shin splints is universally to lighten the load on the

injured tissue. And for those athletes who seek treatment, the chance of a

stress fracture is high. The runner must cross train with biking as the

mainstay alternative. Since both hill work and speed work are more stressful,

slow distance training is the first goal to accomplish. Each sport involved

will have different strategies at lightening the stress first, and then

gradually re-introducing these same stresses. 

Consideration of Bone Involvement is very important in shin splints.

There are yearly reported cases of compound fractures in runners ignoring

the shin splint symptoms only to have the stress fracture become a through

and through fracture. I have had 27 year olds with shin splints have the bone

density of 80 year olds. It is important to remember Shin Splints can be bone

pain primarily, and verifying the patient has good bone health is crucial. 


Heel Bursitis: Email Advice

Hi Dr Blake, 
I'm a former patient from years back who is active and actively working on improving my feet as well as the rest of my 61 year-old self.  

I have what I thought originally was plantar fasciitis in the L foot after some heavy lifting / carrying,  clearing out some old furniture for our "bulky waste pickup" over the July 4th weekend.  The following week the soreness came on, and I took it a little easy on the running.  Then it would feel better, so I would do a longer run (only 3+ miles though) and then it would be sore again.  

I'm wearing zero-drop shoes (Altra) exclusively now with splayed toe box so my  feet can get back to their natural shape. I love them for many reasons, but I realize they are not ideal for a sore heel.  
Dr. Blake's comment: This is very true, zero drop shoes make the knee slightly more stable, and take some pressure off the front of the foot, but add stress to the heels, ankles, achilles, and shins. I like my runners to alternate between shoe types to vary the stresses. We have wonderful choices for this option now. Rich 

An active tissue release chiropractor I see prodded around the foot and released a lot of tight hamstring and calf. He has confirmed that it's NOT the plantar fascia, so I'm left hoping for bursitis. I really don't think it's a stress fracture; I don't do a lot of any one thing.  I was running daily (1.75 daily, 3-4 mi on the weekend), and am able to continue floor Pilates, Zumba 3x weekly, and strength work 2x weekly. 


Dr. Blake's comment: First, here is a link to my video on heel pain. Secondly, running every day at our age is not advisable and may be the whole reason you are hurt. I always find that it takes 3 things (or more) to team up to produce an overuse injury: daily running (so no adequate recovery time), tight achilles which weakens the achilles and prolongs the time your heel is on the ground, zero drop shoes also increasing your time the heel was on the ground thus stressed, and doing something that irritated the heel in your cleaning project perhaps. 


I have not been to a podiatrist yet, as my Health Insurance encourages us to deal with some of these things at home.  I'm also off arch supports since I'm working hard to strengthen my feet.  But I would come in to see you in a New York minute. 

Apart from icing, contrast bathing and not running for a while, any additional suggestions for suspected heel bursitis?  I am playing with offloading using 1/8" adhesive padding in a donut shape around the sore spot and will (grudgingly) get some shoes with a little heel elevation to take the weight off if it doesn't start improving.  I am getting fretful with no running! 
Dr. Blake's comment: Heel bursitis hurts the most when you try to walk on your heels barefoot, and no pain at all walking on your toes. Heel pain is tricky with heel pads, some work and some do not. You are trying to cushion the heel, and transfer the weight forward. Some heel cushion do that and some just increase the heel pressure. I personally do not like the donut idea, as I am afraid the hole will allow the swelling to collect which it sometimes does. But, you have to experiment which what makes it feel better. Run every other day. Walk for several blocks first to warm up the tissue and then run a mile (or even a half mile) as rest does not help. You of course can not have pain during, and no limping. Ice after the run. Can you get some cardio some other way? Bike? Elliptical? Ocean swimming (avoid sharks)? To break down the bursitis, freeze water in a sport bottle. Initially fill half way as it expands when frozen. Put a towel on the ground to protect your floors and massage the heel area only, not the arch, for 5 minutes progressively pushing harder. This is done sitting and is the most useful thing for the home for heel bursitis. Straight ice packs, without the massage, just controls inflammation, but will not get rid of it. I like some sort of OTC arch support of course to transfer weight off the heel--a temporary help while you reduce the bursitis until you do not need it. Rich 

Many thanks for your book (which is on my Kindle) and your blog. I'm a big fan. 
Dr. Blake's comment: Thank you, and I honored to help!!

Best, 

Saturday, August 8, 2020

Healing from An Injury: The Physical Stress Theory


As many of you know, I love sports medicine. Helping patients through an injury is very rewarding, and very challenging. I am constantly learning. I just heard a great talk by Dr. Javier Pascual, Spain, and he recommended the below article as a must for rehabilitation. It is going to take awhile due to its length, but a first review it seems excellent. In podiatry, we are either decreasing stresses to help an injury recover faster, or we are improving stability of the patient, or just making sure that they are maintaining a healthy life. As I read through this article, I will use this post to add the key points. 

https://drive.google.com/file/d/1Snm9_fQ138rB5yybayWrmG04DoTSTOZZ/view?usp=sharing


Key Points brought out by Mueller and Maluf when presenting the Physical Stress Theory include:



Shin Splint Discussion: Part II

This is Part II of a discussion on Shin Splints. The link to Part I is attached.

https://www.drblakeshealingsole.com/2020/08/shin-splints-discussion-part-i.html


One of the number one causes of shin splints that do not seem to improve is undiagnosed stress fractures. The young inexperienced cross country runners (or other athletes) who are not responded to shin splint treatment should be worked up for tibial (anterior or medial shin splints) stress fractures or fibular (lateral shin splints) stress fractures. This is still a version of the same process of overload. The overload in shin splints goes to the weakest link in the chain: the bone and a fracture occurs, the periosteum of the bone (which is the classic shin splint), the muscle belly, or the tendon.


The five most common types of stress fractures which are mistaken for shin splints are: posterior tibial (posterior or medial shin splints), distal tibia (medial shin splints), anterior tibial (anterior shin splints), fibula (lateral shin splints), or proximal tibial (either medial or anterior shin splints). Of course, if you do make the diagnosis a stress fracture, always think about the overall bone health. Did this bone break not only due to the mechanical overload of hills, pronation, supination, tight muscles, etc, but is the bone actually healthy? An unhealthy bone becomes the weak link in the chain. 


I mentally use the Rule of 3 in overuse injuries. The Rule of 3 means look for at least 3 legitimate reasons why a certain structure started hurting. Overuse picks on the weakest link in the chain, and many times a structure is weak because of 3-5 factors working against it. For example, since we are talking about stress fractures, remember that 40 years ago they were thought only to be related to impact shock. Then, article after article came out regarding stress fractures related to muscle contraction or bony torque. And, recently, the role of overall bone health has been more publicized. Therefore, if we use the common example of lateral shin splints actually being undiagnosed fibular stress fractures, the common rule of 3 includes:

  • Inadequate bone health with eating problems or low Vitamin D

  • Excessive supination causing excessive peroneal strain or simply increased lateral body weight

  • Weak Peroneal Tendons increasing the strain or pull on the fibula

  • Old lateral ankle sprains increasing the supination moments of force

With shin splints, the game for me is trying to figure out what muscle group is involved and what could be the cause of the overuse of that muscle/tendon. If we take the extensors as a group, they give us anterior shin splints. What causes general overload of the extensor group? The extensor group is again overloaded with a very tight achilles tendon complex which makes it work  harder to flex the ankle joint. Also running hills makes you use the extensors differently than what you are used to, especially eccentrically as you run downhills as they avoid foot slap. Typically our bodies will get used to the activity, so shin splints are usually from new activities or changes in some routine. When shin splints occur in a seasoned runner for example, I think bone over tendon, therefore I want to rule out a stress fracture first. And, to add an extra twist, there are 4 individual extensor tendons. The anterior tibial tendon can cause a shin splint particularly if the foot pronates too much. The anterior tibial is straining to decelerate contact phase pronation. The peroneus tertius and extensor digitorum longus get painful with over supination especially in midstance or propulsion. While the extensor hallucis longus is fairly neutral to the subtalar joint, it can overload in functional hallux limitus as it tries to lift the big toe off the ground, or in painful big toe joints (perhaps hallux rigidus) as protection. 


The lateral shin splint syndrome is commonly caused by over firing of the peroneals to protect the lateral ankle. Common causes of normal lateral or foot overload are: laterally worn shoes, running on banked road (foot held supinated), shoes laterally unstable (70% of all supination problems are not in supinators structurally), and foot types like pes cavus that overly supinate. One of the exceptions to this concerns the function of peroneus longus tendon to raise the medial arch by plantar flexing the first metatarsal. Here lateral shin splints can develop from over pronation when the peroneus longus is strained. 


The posterior shin splint is typically the soleus fibers or a tibial stress fracture. The pain is deep to the calf muscle belly, so given the name shin splint since it does not seem to be a calf strain. The stress fracture may never show up on xray, and not seem serious enough to get a conclusive MRI or Tc99 bone scan. 


In Part III of our discussion on Shin Splints, I will talk about general mechanical treatments


Friday, August 7, 2020

Modifying Boot with Metatarsal Fracture

Oblique Fracture at the Head of the Fifth Metatarsal Left Foot

2 one quarter inch felt layers to place in Removable Boot 
to off weight the 5th metatarsal fracture. It goes under the 
lining of the boot

Shin Splints Discussion: PART I

                         Shin Splints 

 

     I love shin splints for the academic challenge to figure out

what is wrong and what muscle/tendon is involved. Since shin splints are so common at the start of cross country season, it is easy to get a little lazy with treatment since most get better. You have to take the approach that the athlete will not get better without your treatment, and that should inspire you. I breakdown shin splints into medial, lateral, anterior, and posterior. The muscles and tendons involved are summarized below for each. This discussion of shin splints will be broken down into 3 parts, today PART I.


Medial Shin Splints

Involves the posterior tibial tendon, flexor hallucis longus tendon, or the flexor digitorum longus tendon


Lateral Shin Splints

Involves the peroneus longus tendon or the peroneus brevis tendon


Anterior Shin Splints

Involves the anterior tibial muscle, extensor hallucis longus tendon, extensor digitorum longus tendon, or the peroneus tertius tendon


Posterior Shin Splints

Involves the gastrocnemius muscle or the soleus muscle


Common Location Anterior Shin Splints

Common Location Medial Shin Splints


Shin splints actually can be defined as pain between the ankle and the knee. There are a lot of structures that can be involved which are important when treating these symptoms. When we treat shin splints, we can simply use activity modification, some ice, general leg strengthening, cross training, and most patients will do fine. However, if will treat it will a little more zest, we can prevent it from reoccurring. This can mean an athletic will have a longer running career. For the patient who does not respond to simple measures, they could have compartment syndrome or tibial/fibular stress fractures. Muscle testing sometimes helps, but most cases of shin splints are related to the muscle fatiguing when tiring. This is hard to test in the office when the patient is rested, although I do normally have patients workout hard, or workout to the threshold of pain, before their appointment last in the day. One muscle testing principles is to test the muscle in two basic positions: patient has advantage and examiner has advantage. You can pick up subtle weaknesses this way. 


A thorough understanding of shin splints starts with you defining it as one of these 4 types and then delving into the function of the muscles and how the patient may have overused that muscle or muscle group. Today, this blog post, will focus on medial shin splints.


If the patient presents with medial shin splints, the muscles involved are posterior tibial, flexor digitorum longus, and flexor hallucis longus. We then have to look for overuse in one of its functions. So, what do these muscles do actually? These tendons have many functions, but let us look at what they do at the ankle. Since they all arise from the deep compartment, they are ankle plantar flexors and ankle invertors. What is the primary ankle plantar flexor? That is the achilles tendon, but anything that makes the achilles tendon weak can cause you to overuse one of the 3 muscles causing medial shin splints as they try to help the achilles perform its job. Typical weakness in the achilles is simply fatigue from the new sport they are engaging in, or just adding hills to their running program can fatigue the achilles. But, an over stretched achilles or excessive tight achilles, is considered weak by force length physics. With the recent craze of zero drop shoes, I have also seen more achilles and anterior or medial shin splints. 


The ankle inverter function is probably the more common cause of medial shin splints. What taxes the inversion strength of these muscles? Excessive pronation can cause these 3 muscles to fatigue and strain as they attempt to decelerate the pronation. As the arch collapses in pronation, the medial 3 are strained, but especially the posterior tibial and peroneus longus (a cause of lateral shin splints). 


So, what are some of the causes of excessive pronation? Running itself with landing on the lateral side of the heel will cause 2-4 times more pronation than walking in many runners. Another one of the common causes of severe foot pronation is achilles tightness called equinus. This tightness can be the cause of posterior shin splints, but also anterior and medial shin splints. This is why a complete understanding of achilles strength and flexibility is crucial. If the achilles is tight, it is harder for the anterior (extensors) to dorsiflex the foot (thus causing anterior shin splints). If the achilles is tight, the foot can pronate and the arch collapses (medial shin splints), both putting strain on the functions of the deep posterior compartment. If the achilles is tight, the forefoot is forcibly loaded by ground reactive force, making it difficult to bend the toes in propulsion. Stress is placed on the long flexors (medial shin splints) and long extensors (anterior shin splints).


So when a patient comes into my office with shin splints, I need to see what type they have (medial, lateral, anterior, or posterior) and if I can figure out what they did wrong other than add a new sport. I need to check if their pronation is excessive (and you have to watch them run since running and walking for a patient can be totally the same or different). I need to measure for achilles tightness or over flexibility since the achilles tendon can be the source of both power and problems for athletes. I need them in their normal running shoes. If they are a pronator, I also want to categorize them as mild, moderate, or severe, so I can determine what level of support needed in my treatment to lower the tissue stress threshold so they can heal. This is where podiatry usually excels since proper shoes, custom or OTC insoles, appropriate strengthening exercises, and taping can speed up the rehabilitation and prevent re-occurrences. PART II will discuss stress fractures, anterior and lateral shin splints, and other general rules.


The video below is on posterior tibial strengthening when a weak muscle is found in medial shin splints.


https://youtu.be/w3FXx4OFqec


Thursday, August 6, 2020

Tissue Stress Theory Discussion with Dr. Javier Pascual (English Subtitles)

https://youtu.be/sOthQIPzCLw

<iframe width="560" height="315" src="https://www.youtube.com/embed/sOthQIPzCLw" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>

Wednesday, August 5, 2020

Sesamoid Injury: Email Advice



Hello!

I have been having sesamoid pain for over 1 year now. Originally, I injured the outer sesamoid bone on both feet while playing basketball. It was an overuse injury rather than a one instance injury.  Over the past year or so I haven’t played basketball, but the bones seem to be healing extremely slowly. I never wore a walking boot, but about 7 months ago I did have custom orthotics made with sesamoid offload. My doctor never came out and said whether I have a fracture or not.. would you be able to tell from the attached xrays? Also, is it still possible to heal via walking boot, etc.

Thanks!!


Both xrays show irregularities of the tibial sesamoids, but to develop pain at the same time a irritated bipartite sesamoid is the most likely. If you look really close, there are many pieces of sesamoid there so a multi-partite sesamoid is most likely versus fracture. 


Dr. Blake's comment: 

You have to create the 0-2 pain level for the next 6 months to allow for healing. Yes, they look like fractures or just multi-partite sesamoids, but only an MRI would tell for sure. In fashioning a 0-2 pain level over a prolonged time, I usually have my patients ice 1-2 times daily, contrast bathes 3-5 times weekly, and alternate from bike shoes with embedded cleats, Hoka One One rocker athletic shoes, and anklizer removable boot. The patient typically can feel when they can use each (but the boot should be on 4 hours minimum of each day. I also get a bone stimulator to use when insurance allows me to speed up the process, make sure that their Vit D levels are fine, and eat healthy. Injuring both makes me wonder about your biomechanics (do you have a high arch?) or bone health issues (which your PCP may want to investigate). You take it one month at a time. Also very important to learn spica taping and cluffy wedges, and always feel that the dancer's padding is the right amount (it can vary by shoe gear). When patients have soft sandals for home, and can walk flatfooted (no bending the toe), they can quickly get to shuffling around the house. Just no barefoot. I hope this helps. Rich 

And the Patient Response:
Doc, thank you so much for your reply!  

I'm suspicious that I injured both due to unfortunate circumstances (no bone health issues in the past and I have fairly neutral arches).. I weighed about 310 lbs (height: 6,1) when I initially felt "injured", so I'm wondering if it was due to being overweight and pushing my feet too hard for too long.. I was playing basketball 3-4 times/week so I was definitely pushing my sesamoids at that point.  I'm feeling much better on a day-to-day basis now (pain level ranges from 0-3 most of the time).  I am currently wearing tennis shoes with a full length metal plate insert under my custom orthotic which includes sesamoid offload.   This combination seems to be working pretty well.  I'm able to walk 1-2 miles/day with minimal discomfort (daily exercise).  From your advice, I may decide to take it a little more easy for a few months and see how I progress.  I've always been pretty active and even kicked field goals for the better part of my life without any sesamoid pain.  It wasn't until I reached 300+ lbs that I started having problems.  Weight loss is in full affect, so hopefully that helps as well :)

Thanks again for your advice!


Achilles Tendon Taping

I love John's achilles taping video for my patients. 

https://youtu.be/thCltEiB2T0

Tuesday, August 4, 2020

Sesamoid Fracture: Email Advice

Dear Dr. Blake,

I came across your blog when I was researching the internet for resources on sesamoid fractures.  There is not a ton of information out there and sometimes advice seems to be contradictory across different sources.  Your blog has been a blessing!  Thank you for sharing your advice on foot injuries.  I wonder if you could share some advice based on my experience...

About 2.5 years ago, so early 2018 I think, I started experiencing limited mobility in my right hallux and discomfort in the ball of my foot.  The great toe was stiff and I felt the need to pop it frequently.  Often my right arch and great toe would cramp up.  I didn't think much of it, so I just ignored it or tried to rub/roll/stretch my arch whenever this happened.  Then after a week or so of this, I was walking into work one day and could not put any weight on the ball of my right foot without severe pain.  So I immediately went to the podiatrist.  She took an X-ray, did not see any fracture, and diagnosed me with sesamoiditis.  They gave me a foam dancer (J-pad) for my foot and told me to wear that at all times.  I also took some naproxen for 10 days.  She said if the pain persists I could get steroid injections or have the bone surgically moved.  At that point, I had absolutely no idea what to ask the doctor and I just took her word for it.  I didn't want surgery or steroid injections, so I thought that the solution must be to just power through the pain since it was now tolerable with the pad in my shoes.  And it couldn't be that bad, right?  No one told me about any underlying issues that needed to be addressed, either...and no one recommended an MRI even though the X-ray didn't show a fracture.  At the time I didn't know that I should have asked for an MRI. 

Since then, I decreased (but didn't completely discontinue) running until one year ago.  I just ran much less frequently and for shorter distances (3 mi. or less).  Now it has been over a year since my last run.  I kept doing pretty intense weight-bearing workouts including lifting weights, squats with and without weights, using the elliptical, going on long walks, walking on the treadmill with an incline, etc.  All of these things were done with the pad in my shoe which helped relieve some of the pain but the low-level pain still persisted. 

Fast forward to early this year and I realized that I may have a problem since my foot pain has continued.  I went to a different podiatrist on March 5, 2020, and he took an X-ray that revealed a fracture shaped like an "x" in my fibular sesamoid (that's the one on the inside, right?).  Again, he encouraged me to wear a dancer pad, buy shoes with a stiff sole and rocker bottom and wide toe box, and stop doing activities that caused the pain.  He also advised taping my toe and getting an orthotic with a metatarsal extension.  And again, I had no idea what kind of questions to ask so I took that advice (sort of).  I stopped the hard workouts and started doing completely non-weight bearing workouts (thanks to Caroline Jordan fitness on youtube - chair cardio and floor barre).  However, I kept going on long walks even though this was pretty uncomfortable (I just wasn't willing to give it up!)  Then I realized that the long walks also needed to stop if this was going to ever improve.  My orthotics are STILL not delivered yet.  So finally after some more research I asked my podiatrist if it was time for a walking boot and he said yes.  So now I've been in a boot for a week and a half. 

For some additional background, I'm a 26 year-old female. I was an athlete in high-school and played softball and volleyball.  I have Osgood Schlatter's in my right knee and still have a protruding bump that is uncomfortable when I sit on my knees.  I have high arches, tight arches, and tight calves and hips (I never really made stretching or warming up and down a priority until just very recently).  In 2012, I began training for a half-marathon (probably running very poorly...never really taking much time to stretch or learn proper form).  In 2013 I ran a full marathon, and 2014 another half marathon.  Then I cut down on the distance running for a while.  I went on a 60 mile, 4.5 day hike on the Colorado trail in 2016 (hiking the majority of it in Chacos), and climbed the Manitou Incline in 2017.  In 2017-2018 I began running shorter distances on the treadmill but I pushed myself very hard, sometimes ran and walked on an incline, and didn't stretch well. 

I'm realizing now that I REALLY have not cared for my body very well or listened to my pain.  This fracture could have been an unidentified stress fracture back when I had the first x-ray 2.5 years ago and I didn't even know it!  I wanted to run and work out really hard because I thought that was "good for me," but in reality it was hurting me.  I also had no idea how to advocate for myself in this process.  I feel pretty helpless when it comes to this injury and I really want it to heal without surgery.  Do you have any advice?  Is this injury too old to heal properly?  I plan to stay in the walking boot for 8 weeks and continue safe non-weight bearing stretches and light non-weight bearing exercise.  I ice my foot once a day.  Is this a good approach or should I be doing something else?  I've been removing the boot at night but taping my foot and I sleep on my stomach so my toes are pointing down instead of up.  Even after wearing the boot, the ball of my foot still aches at the end of the day most days.  Should I be sleeping with the boot on and elevating my foot?  Should I use a bone stimulator?  Should I request an MRI or is that pointless since the X-ray picked up the fracture this time?  I'm a little curious if there has been any scar tissue forming that is also causing some neuroma in that area. What do you recommend post-walking boot?  I really want to find someone in town (Tulsa, OK) who will take a holistic approach to my body (probably a physical therapist?) to identify what may have led to this injury so that I can address those things and prevent re-injuring this in the future, but I don't know where to look or what to ask. 

Thank you again for being willing to answer questions and offer advice.  I look forward to hearing from you. 

Dr. Blake's comment: Thank you so very much for your email. I will try to help. Sesamoid fractures are difficult to both diagnosis on xray and follow any healing progress. So, I would advise an MRI, and if it documents a fracture, begin 9 months of bone stimulator treatment, followed by another MRI. The boot you are using now should be worn for 3 months, and not while sleeping, and then there is another 2-6 weeks of transitioning from boot to shoes (like Hoka One One and orthotics with dancer's pads). We have to have you create a 0-2 pain level for this next year, while the above is happening. It is in creating the 0-2 that you make orthotic adjustments, shoe adjustments, activity adjustments, tape, ice, contrast, PT, etc. Ask the podiatrist to take some photos for the best sesamoid views on the MRI and send to me and link that to this post so I can look back. I hope this helps. Also, make sure bone health is good with Vitamin D levels and good diet. You want 5 servings of food that has calcium (like diary or tomatoes per day). Rich 

Monday, August 3, 2020

In the eyes of a dying Steve Jobs, these were the most important aspects of life!! Thank you David Baudrez

In 2011 Steve Jobs dies at the age of 56 of pancreatic cancer, leaving a fortune of $ 7 billion and these are some of his last words...
′′ Right now, lying in bed, sick and remembering my whole life, I realize that all the recognition and wealth I have makes no sense in the face of imminent death.
I have the money to hire the best at homework but it's not possible to hire someone to carry my illness.
Money can get all kinds of material things, but there's one thing you can't buy: ′′ LIFE ".
As I grew up I noticed a $ 300 and a $ 3.000.000 watch show the same time.
That with a $ 150,000 car and a $ 15.000.000 car we can reach the same destination.
That $ 150 or $ 1500 wine generates the same ′′ hangover ".
That in a house of 300 square meters, or in a 3000, loneliness is the same ".
′′ True happiness does not come from material things, it comes from the affection that our loved ones give us."
So I hope you understand that when you have friends or someone to talk to, it's true happiness
Five undeniable facts
1 1 Don't educate your kids to be rich. Educate them to be happy. - Then when they grow up, they'll know the value of things, not the price.
2 2 Eat your food as medicine, otherwise you will have to eat medicine as food.
3 3 Who loves you will never leave you, even if you have 100 reasons to give up. He / She will always find a reason to cling.
4 4 There's a big difference between being human and being human.
5 ️ If you want to go fast, go alone! But if you want to go far, go with it.
And in conclusion...
The top six doctors in the world are:
1 sol The Sunlight
2 Descanso The Rest
3 Ejercicio The Exercise
4 Dieta The Diet
5 mismo Confidence in itself
6 Afectos The Affects
At whatever stage of life you are in now, thank and enjoy the little things to the fullest and treasure the love of your partner, your family and your friends, so that when the day comes when the curtain comes down, you can carry with you the true wealth of this world.