Plantar Fasciitis and Cortisone Shots: Email Correspondance

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I am so thankful to the Golden State Warriors for the great enjoyment they brought to the San Francisco Bay Area and fans spread around the world.

In the last few years I've increased my activity level significantly, taking up running and power lifting. After about a year of running, I started having horrible pain in my heel and achilles, which my PCP and Chiropractor diagnosed as Plantar Fasciitis. I spent about six months doing everything I could to take care of it. Icing, massage, rest, adjustments, you name it. In this time, my physical activity has been extremely limited, as I haven't been able to put any weight on my heel without pain.

I finally saw a podiatrist today, who decided to do a cortisone injection and gave me a boot to wear for the next three weeks. Somehow, with all of the questions I had, I forgot to ask what has been at the forefront of my mind for the last six months. I imagine that I should ease back in to physical activity, but how soon? I'm willing to do whatever I need to prevent future injury, but am REALLY missing all of the activities that I had grown to love. Any suggestions for the best way to get back to normal? Thanks!

Dr Blake's comment:

     Thank you so very much for your comment to the post on cortisone shots. After a cortisone shot, you must wait 2 weeks to see what the overall effect is. I always consider that I may have to do up to 3 shots minimum of 2 weeks apart in an effort to bring the pain level down to 0-2. Remember with each shot you can not do anything that hurt before the shot for 2 weeks. Then, at 2 weeks you gradually start adding what hurt before the shot and see where you stand. This is how you decide on the 2nd and possibly 3rd shot. Continue to ice 2 times daily because it really helps the shot (s). I have many patients in your boat to have to wear the boot completely for 3 months, with another 6 weeks of gradually weaning out of the boot. So, now that you put yourself in the Immobilization/Anti-Inflammatory Phase of Healing make sure you do it right!!! And, I always love MRIs to tell me where I am at, but you need to wait for 2 weeks after a shot to do the MRI. Good luck my friend. 

Neuropathy: What to Do?

Dear dr. Blake

my friend  saw you a few years ago with a broken ankle, recommended I write to you about what happened to me recently that resulted in neuropathy in the soles of my feet and toes.  She says you are wonderful.

Well, cheap footwear from a drugstore apparently had some toxic substance in or on the shoes.  These were a pair of flipflops, boy's size 4/5, with fabric covering the foot-bed.  Being chemically sensitive, I chose this model over all the plain plastic ones (which often reek of plastic fumes), thinking fabric would make them safer -- plus the fact that none of the other models they had available fit me anyway.

 I wore the shoes for about one hour total, and about 2-3 hours later began to notice the sensation of numbness in my feet.  This happened on Sunday April 21st, and there has been zero improvement.

That evening (soon after I noticed the problem) I soaked my feet in epsom salts dissolved in warm water, for about an hour.  Still had the problem, so next two nights I packed clay on my soles and toes (a friend suggested this detox method, and I was glad I had some clay ready to use).  I felt after these two nights that the toxins had been removed but that I was left with lasting nerve damage.  My right foot is worse, the first 4 toes and the sole of ball of my foot feel numb, sometimes there is a burning feeling, and if I stub a toe just a little there can be a sharp pain.  There is nothing visibly wrong, but the sensation I have when walking around is as if I am walking on wadded up kleenex.  I also noticed the skin of my toes felt clingy, as if the toes were sticking together, and my feet seemed to cling to my old plastic flipflops with a very unpleasant sensation.  I have found some relief from this by  putting cornstarch between my toes and wearing loose socks (no flipflops of course). Fortunately I have a pair of Aerosoles w cushiony insoles, which I discovered make it possible for me to go for walks -- and get some exercise.

But now I am scared to buy shoes of any kind.  I wonder if you can recommend some footwear known to be safe (even for the especially chemically sensitive).  I feel kind of ridiculous even asking such a question, but there it is.   Actually I think those shoes from the drugstore would be toxic to anybody but maybe the non-sensitive might not have an acute reaction.  The fact that these were a child's size gives me real concern for the intended wearers.

Dr Blake's comment: Here is a blog posting on this topic.

http://tipsforcs.blogspot.com/2013/04/shoes-for-chemically-sensitive.html

And if you have further suggestions what to do for neuropathy beyond:  I see that you recommend a lot of vitamin D, which I already have been taking for a long time now, so that should be covered.  I started taking B12 and other Bs, plus lecithin and various herbs that I saw recommended online.  I have the impression that massage is NOT a good idea.  Deep probing of the affected areas seems to hurt and not be helpful.

Any ideas appreciated.  Thank you.

Dr Blake's comment: 

     Thank you for the email, and I am sorry for your suffering. One of my medical assistants getting allergic reactions to the dyes in leather shoes and now uses only vegetable based shoes. She went to an allergist who tested everything, and it really helped her begin to control her symptoms and live more normal. Below is my nerve pain outline and so much can be used in your situation. I have highlighted in red the most common things you can do. Also see the video emphasizing exercise, healthy diet, sugar restricted diets, and no smoking or alcohol. 

3.      Topical Medications/Applications (should be gels for ease of application)

§         Warm Compresses

§         Non Painful Massage

§         Parafin Wax

§         Chinese Herbs

§         Lidoderm Patches

§         Neuro-Eze

§         Multiple Compounding Medications which include (usually not all of these):

ü      Ketamine 10%

ü      Clonidine 0.2%

ü      Gabapentin 6%

ü      Baclofen 2%

ü      Nifedipine 2%

ü      Lidocaine 2%

4.     Alternative

§         Biofeedback (Thermal to increase circulation)

§         Hypnosis

§         Meditation

§         Accupuncture (can be to opposite limb or ear)

·       Nutritional (next 3-12 months)

1.      Lipoic Acid 300mg 2x/day

2.      Acety-L-Carnitine 2000 mg/day

3.      Inositol 500-1000mg/day

4.      Vit B6 50mg/day

5.      Vit B12 1000mg/day

6.      Vit E (up to 1,600units/day)

7.      Thyroid Natural Supplements

This Mayo Clinic article gives a good overview. I hope this points you in the right direction. 

http://www.mayoclinic.com/health/peripheral-neuropathy/DS00131/DSECTION=treatments-and-drugs

Sesamoid Fractures with Slow Healing/Reflares: Email Advice

Hi Dr. Blake,

Thanks so much for your past responses; they have helped tremendously (physically and mentally).  Though all the ups and downs, I seem to be on a downward slope again.

A few months ago (January 2013), you had replied to my below email regarding a reflare/set back of my left tibial sesamoid fracture (initial injury September 2012). Per your advice, I put myself back in the boot and I was out of it in 1.5 weeks and have been (left foot) pain-free ever since (so between 3-4 months).  THANK YOU!  I took your advice and never stopped icing, have been using the bone stimulator daily, and taking vitamins.  About 2 months ago, I starting removing the carbon fiber plate from my shoe and have been using primarily a toe spacer (occasionally), a dancers pad (all the time), and custom orthotic with arch support (most of the time)... sometimes all three together.

The last x-ray taken was in March and the top view of the sesamoid basically looked like a snowman (so two connected balls... key being fairly connected).  Last week (7 days ago), I reluctantly decided to walk to/from lunch (0.75mi total) without any dancer's pad or orthotic.  This was really the first time I walked any distance without the dancer's pad as I regretfully thought I was healed enough to walk without it.  It absolutely the classic "too much, too fast".  I did not feel any pain while I walked to/from lunch, but rather it progressively got worse over the next 1-2 days.  It also was unseasonably hot that day/night in Chicago, so both feet were pretty swollen that evening.  

Anyway, I'm SUPER worried that I reinjured my sesamoid as I'm having varying pain from a constant 2 and occasional throbbing up to a 5-6 (keeping in mind it was at a constant 0 for months... I might be hyper sensitive right now). 

Dr Blake's comment: Unfortunately, with all injuries, we have to test them. You did nothing wrong, and the force produced by that walk would have irritated, not reinjured the sesamoid. I am sure you will be fine. Just, once again, back in the boot, etc to create that pain free environment. 

 I notice in the shower that it doesn't hurt so much when just standing barefoot, but when I lift my foot up, I get pain.  Also, the cause of the reflare in January (riding bike) vs this current one (walking 1st time without padding), indicates more potential for reinjury (from my perspective).  Anyway, yesterday, I put myself back into the boot and have been aggressively contrast bathing (3 times a day) and icing.  Given your extensive experience, it also helps to know what you have historically seen with people who have had sesamoid fractures and have felt NO pain whatsoever for 3-4 months (actual injury 7months ago) and did everything initially correctly.  

Dr Blake's comment: Unfortunately (sorry I have to use this word), I have too many patients like you with flares, but they seem to 95% get through them the way you are. There is hope, and it is not false hope. If your last MRI was over 6 months, get a new one. If not, wait until the 6 month interval. 

After going through your blog in the past 7 months, I have not found any exact similar circumstances.  Should I be getting an MRI? (never had one on the left foot given the positive progression of symptoms and x-rays). 

Dr Blake's comment: Yes, MRI crucial to follow this. I would rather follow symptoms than X-rays at this point. 

 Would an x-ray in the next few days reveal any bone damage indication or give us much to compare back to in the March x-ray?  Should I cut out the contrast bathing and just ice?  

Dr Blake's comment: I love three times a day of something. Try three times a day of a simple 10 minutes ice pack under your foot, and compare how you feel with that vs how the contrasts made you feel. Some version of icing and contrasts should feel the best. 

Should I concentrate on off-loading?  I know I should probably give this 2 weeks in the boot and go from there, but it's hard to face this music right now.  I feel like I totally screwed up here and am looking for your guidance, thoughts on potential harm I may have caused, and future plan of action.  

Dr Blake's comment: I know this sucks, but do not be so hard on your self. Off weighting with orthotic and dancer's pads are fine if they create our pain free environment, or back in the boot with you for 3 days longer than you think you need it. I find that the length of time you have to be in the removable boot with each flare, is a strong indicator (better than X-rays) of how much irritation you caused. Remember each day from the initial injury this bone is getting stronger, and less fragile, so it takes alot more to reinjure it. I can not imagine you re-injured it, only irritated it. 

Thanks so much Dr. Blake,

Luke

Nothing to do with Feet: Just Unbelievable!!

Biertijd.com // Media » Britain's Got Talent - Charlotte & Jonathan


     What is life about? It can be the relationship of us to our friends, family, neighbors, strangers, and a Higher Being. Jonathan would not have been there without Charlotte. Jonathan stood firmly with her under fire. She had his back, and he hers. A team was born way before the song was sung. A music teacher off in the shadows. It was this teacher that allowed them to fly. I say Teacher of the Year!!! I bet Jonathan will remember that teacher always with gratitude.

     Charlotte and Jonathan represent a TEAM--Together Everyone Achieves More. I disagree with Simon. This team has magic, and they support each other. There is no "I" in team. I wish them well.

   

Sesamoid Fracture: Email Advice

Dr. Blake,

I was recently doing some research and came across your orthotic blog. About a year and a half ago I was diagnosed with a stress fracture in my right foot sesamoid bones. I ran cross country in college freshman and sophomore year and was running about 45 miles a week. In the middle of the sophomore season the bottom of my foot began to hurt but it wasn't bad enough to stop running. By the end of the season it was very painful so I went to see a doctor.

 An MRI revealed that I had bipartite sesamoids as well as a stress fracture. I was in a walking boot/cast for 8 weeks. After that I did not run for at least a year. I did other activities like spin class, elliptical, and aqua jogging. In December of 2012 I began to run again. I started with 10 minute bouts and that was painful but eventually got better. I slowly began to increase and at first it would be painful but after a few weeks at the same time and speed it began to get better.

 I am emailing you now because I seem to have gotten stuck  at about 30 minutes. I usually run 3-4 times a week. The pain is mild when I run but afterwards is about a 7/10 on  pain scale. I want to increase my mileage but am afraid I will be doing more damage. Is it okay to have pain? Can I make it worse by running?

Dr Blake's comment: You have to listen to your body and honor the pain. The worse pain is when it occurs during the later stages of a run, but the second worse is when it occurs afterwards. You must manipulate the running to have the pain stay at 0-2 afterwards. This can be running more flatfooted, making sure your shoes and inserts adequately take pressure off the sesamoids, running shorter time or every fourth day, avoiding hills, icing for 30 minutes as soon afterwards as possible, etc. If this fails to make a significant change, a repeat MRI to compare with the old will always help. 

 My physical therapist said that if it was a fracture it should have grown back stronger and that I can't damage the bone anymore.

Dr Blake's comment: I kindly disagree. That general rule does not work with sesamoids since it is a weight bearing bone with poor blood supply.

 I forgot to mention that I am seeing a physical therapist. We are working more on mobilizing my mid foot, I have very high arches and a very rigid foot.

Dr Blake's comment: Rigid feet pound more, and high arch feet have more metatarsal and sesamoid problems. This is due to the fact that the metatarsals point downward more in the high arch foot leading to more pressure on each of the metatarsal heads (where the sesamoids are). 

 Other things that I am doing are: wearing custom orthotics, icing after every run, not wearing heals, and taking NSAIDS when the pain/swelling gets really bad. I've been thinking of switching to altra-zero drop shoes to see if that will help any. I keep looking at sites and seeing that this pain should be gone within 6 months-year after the fracture and yet mine is still hurting.

Dr Blake's comment: You can not use time to judge since everyone is different. You need to create this pain free environment by manipulating each aspect of treatment. I agree you should be running some to help find out what works. Can you make your orthotics better? Do you feel that the arch support puts your weight off the big toe joint when you run? Do you have a dancer's pad within the orthotic device? If so, is it high enough to off weight the sore area? You should be icing 3 times a day for ten minutes minimum, and probably use the evening icing time to actually do a full contrast bath to flush inflammation. I agree to keep the NSAIDs as needed. Look at when you are irritating your foot. Is it only running now? Or how bout barefoot? Dress flats? 

 I don't want to have surgery because I know that the chances of being able to run again after that are slim-none. 

Dr Blake's comment: Not running after sesamoid removal is due to a surgical complication, not in the nature of the surgery itself. I always expect my athletes to run after sesamoid removal, and I presently have a 4:10 miler doing just that. However, surgery has a 20% failure rate for return to running, and even though great odds for surgery, not great if you are the 1/5 that can not run. Goal: Have surgery only if you have done everything else and waited until the MRIs (at 6 month intervals) document no longer any healing. The more sports medicine learns about this problem, the fewer patients have surgery. We get smarter. 

I'm not looking to be running 45 miles a week again. I'd love to be able to do 20-25 miles/week. So I guess my main questions are:

1.) Should I keep running? Yes, with modification.

2.) If I keep running can I damage my foot further? If you keep running with level 7 pain, yes. 

3.) Is there anything else I can do...should I be going back to see a doctor? If MRI is over 6 months, get another one. If PT can do the rest for you, including orthotic modifications, stay there temporarily. You are in the Return to Activity Phase of your rehab, and you are having problems. This is when we learn the most to individualize the treatment, no cookbooks. Make sure the bone density, calcium, Vit D3 is great. You want a D3 level around 55 or you will break something else when you start running. Hope this points you in the right direction. Rich

Anything else you think might me would be greatly appreciated.

Thank you for your time,

Mari (name changed)

First Toe, First Metatarsal, and Sesamoid Injury: Email Advice

X rays notoriously misdiagnose sesamoid injuries. I can see irregularities in her tibial sesamoid, but is that really what is causing pain? We see normal joint space in the big toe joint denoting no significant arthritis. You can see the first metatarsal head is longer than the second. It needs to be 3 mm or so shorter than the 2nd or jamming of the joint can occur. This is a major cause of big toe joint pain, and mechanical changes with arch support and dancer's pads are very important. 

Dear Dr Blake,

I have been reading your blog and have found it to be an amazing resource - and by far the best on the seemingly incredibly tricky area of sesamoid issues.

My story: I have had pain in my right forefoot ever since snowboarding in Feb 2011. Initially this centered on the distal interphalangeal joint in my big toe. I had an x-ray which purported to show a fracture on the outer extremity here and treatment to relieve the pain was a cortisone shot in August 2011.

In March 2012, the pain returned - both in my big toe joint, and now around the sesamoid region. An MRI showed edema in the sesamoid region, but no apparent reason for this. I had an ultrasound guided cortisone injection into the site of the edema. This did not relieve my pain at all.

Dr Blake's comment: Even though the pain is in the same area, this sounds like a new injury. However, long acting cortisone can mask pain for 6-9 months, and patients can be worse when the cortisone wears off. Overall, try to stay away from cortisone shots into joints for this reason. Just using cortisone, without understanding the injury mechanics/cause, can be a dangerous proposition. 

Over the months the pain worsened. After going horse riding, which placed a lot of friction on the sesamoid area, my entire joint swelled up massively. I had a further MRI in Feb 2013, diagnosis this time was sesamoiditis.

Dr Blake's comment: Sesamoiditis rarely causes massive joint swelling. There is definitely something wrong with the joint, but it is not the sesamoid.

Unhappy with this I got a 2nd opinion on my scans which has recently come back as a fractured tibial sesamoid. In April 2013 I had a further cortisone injection (bringing my total to 3 in this area!) and am now in an aircast boot.

Dr Blake's comment: Hopefully you are not getting long acting cortisone which is contra-indicated in fractures. 

My questions...

1. Given that I have gone undiagnosed for so long, I am understandably keen to confirm that I do indeed have a fractured tibial sesamoid - are you able to identify this on my attached scans?

Dr Blake's comment: Thanks for sending me all these images. You did injury your tibial sesamoid, but that seems to be doing well. You still have some major healing to occur on the first metatarsal fracture, and perhaps some mechanical treatment of the first metatarsal to help you speed up the cure, and prevent relapses.

2. The pain in my distal interphalangeal joint is now insignificant in comparison to my sesamoid pain, but I wonder if you can see anything on the scans to confirm a fracture here? Could it be that my seasmoid fracture resulted at a later date after walking differently to compensate for this pain?

Dr Blake's comment: Yes, the distal phalanx (under the toenail) was injured and is still showing inflammation. Hard to know if it all occurred at once, or were separate injuries. Has is your Vit D3 levels and overall bone density? 

3. Will the multiple cortisone shots I've received have done any irreparable damage and act to prevent my healing? I assume you would advise absolutely no further shots now a fracture has been identified.

Dr Blake's comment: Probably not, and yes try to avoid. 

4. If I sustained the sesamoid fracture so long ago in Feb 2011, is it now unlikely to heal whatever efforts I make?

Dr Blake's comment: Your sesamoid fracture with it's resultant inflammation is probably less than 5% of your overall pain right now. Most of the pain is from the inflammation within the first metatarsal head (very obvious on the MRI images below).

5. My doctor advised just 6 weeks in the aircast boot, I am assuming you would recommend much longer?

Dr Blake's comment: There is no fracture displacement necessitating casting or surgery. It is going to take a long time to have the first metatarsal feel better based on the present inflammation. You need to wait 6 months to check on the first metatarsal head inflammation process, a sign of healing. You should be creating your pain free environment with the least immobilization as possible. Right now, if the joint is swollen, contrast baths, no NSAIDS, bone stimulator if your insurance will allow, spica taping, orthotics, dancer's pads, Vit D3, Calcium, occasional boot, stiff shoe, rocker shoes, etc.

6. I am now trying to follow the advice on your blog and create a pain free environment - spica taping, icing, contrast bathing, orthotics inside my aircast boot. Yet my joint is visibly still quite swollen and I believe the aircast boot my even aggravate it from rubbing. Would you advise removing the boot whenever sedentary?

Dr Blake's comment: The swelling will be there for a long time, and immobilization makes it worse. Base your treatment on gradually increasing activity, while you protect the joint, and keep the pain level between 0-2. Do not base your treatment on swelling. Good luck my friend and so sorry for the delay in responding. Rich

The saga of my foot injury has brought me quite low. And I am quite devastated to learn after all this time that there has been a fracture lurking. I hope that by following your advice I can finally access some real healing.

Many, many thanks,

Cecilia (name changed)

On this view, like the above X-ray changes within the tibial sesamoid suggest a tibial sesamoid stress fracture. The tibial sesamoid is closest to the skin, the fibular sesamoid is closest to the 2nd metatarsal. See the dark area in the center of the first metatarsal head suggesting bone remodeling. This area is highlighted in the T2 image below which emphasizes swelling. 

This is really why you hurt. You can see that the tibial sesamoid is lighter than the fibular sesamoid suggesting some fluid retention, but healing uneventfully. The center of the first metatarsal is full of intense swelling signifying cartilage or bone injury to the metatarsal head. You will not feel a lot better until that inflammation goes down with further healing.

Here the sesamoid and the first metatarsal look fine, however injury is noted in the distal phalanx (under the toenail) with inflammation seen on this and the next image.

Normal middle of the joint from the side

You can see the center of the first metatarsal head is still remodeling. Definitely here looks like a slow healing fracture.

Here there is a suggestion of bone edema into the first metatarsal shaft away from the sesamoid area.

You can see the old tibial sesamoid stress fracture that is in one piece. You can get some symptoms, but the injury to the first metatarsal head is worse, and still has aways to go to stop giving you symptoms.

This is a hard image to read but implies normal sesamoids

This is another great image showing that the sesamoids at this stage are not your problem, but the swelling above it.

Neuropathy or Referred Pain from the Low Back: Email Advice

Hi Dr. Blake,

I have a few symptoms that I will be telling my doctor about at my annual physical in two months. In the meantime, I thought I would ask you about them.

For about a year or so, I have a hard time with walking around the house barefoot. It is especially difficult first thing out of bed. Recently I have been having numbness in the corner of my right big toe. I thought this was just and old ingrown toenail thing acting up again, but it seems to be more than that. I have pain in my arches-just below the ball of my foot. I bought some arch inserts from Germany, and now have to put them into almost any shoe I wear, except my dansko clogs.

Dr Blake's comment: I have linked this with my video on foot nerve pain and it's relationship to the back. You can see how the corner of the big toe is related the L4 Disc as well as the pain in the ball of the foot into the arches.

Sometimes I imagine I get relief after stretching my hamstrings. I have one of those green stretch nylon ropes with loop holes I got after rehabbing from my knee surgery(right knee)  I got a little freaked out tonight after standing in a rite aid store. There I was getting dental floss and the auto message over the loud speaker was warning customers of their possible undiagnosed diabetic neuropathy. They listed off some sensations that sounded like a few of my symptoms.  Of course, walking home, I kept thinking.."what if this is something I have?" I don't have diabetes, that I am aware of anyway?

My questions are:

Why would the upper left corner of my big toe feel numb and burning on and off? Not just at the toenail, but under it on a callous pad and at side of toe bone.

Why is it so painful to walk barefoot? As if I need the support of a shoe or else it feels like my bones crunch with each step. As though not enough muscle in my arche to hold myself up?
Dr Blake's comment: The video above should explain what nerve root in your back is probably effected. Pressure on a nerve can cause both abnormal sensations and abnormal muscle function (ie your muscles are not supported the bones and they complain mightily.) 

Should I be concerned about diabetic neuropathy?
Dr Blake's comment: This does not sound like neuropathy, but, in the early stages of development, the symptoms can be atypical. If you were in my office, I would send you to our back doc to check if this was coming off your back. 

How can you tell the diference between foot weakness symptoms  - foot neuropathy -- Morton's neuroma - plantar fascia pain ?

Also what type of doctor would I want to be seen by. Is this for a podiatrist or a neurologist?
Dr Blake's comment: Both a podiatrist to treat the local symptoms and a neurologist or physiatrist to evaluate and possibly treat the back. The MDs would definitely help in pinpointing the diagnosis better, but the lion's share of the treatment can be left with the podiatrist. Sure hope this helps. Rich

Thanks for your time.

Bursitis vs Neuritis: Questions following Cortisone Injections

Hi Dr Blake,

I have intermetatarsal bursitis (2-3 and 3-4) following an incident with my foam roller 8 weeks ago. Last Tuesday I had ultrasound guided cortisone injections in both bursa and my ankle (for chronic synovitis following bad sprain last year). My ankle felt great within 24 hours but the bursitis is still worse than before the injection. Is this likely to be a prolonged flare? Is it usual for pain to be worse this far along or is there still potential for it to make a difference?

I'm not sure what preparation it was but have been icing regularly since reading your blog, using padding and now taking diclofenac. This helps but obviously don't want to have to take it long term. It's an intense sharp, electrical shock type pain in my forefoot, worse with walking. I rested my foot for the week after the injection but I'm once again on my feet all day now. Do you think I can resume elliptical and recumbent bike at the gym?

Your advice would be much appreciated.

Thanks and best regards,

Sara (name changed)

Dr Blake's comment:

Sara, please find out exactly what they injected. This is nerve pain, even if you have bursitis on ultrasound imaging. When you irritate the nerves with the deep massage/pressure of a foam roller, you have neuritis which can take awhile to mend. Cortisone is a weak help for neuritis at times, and the injection itself can irritate things. Typically, you should create a pain free environment with shoes, inserts, removable boots, crutches, whatever it takes. Have the doc help you decide on Extra Strength Tylenol (nerve pain) vs Diclofenac (inflammation pain). Also, ice can be irritating to nerves, long warm soaks can be soothing to nerves but irritating to inflammation. Acupuncture seems to help nerves alot. Elipticals are bad on this area, stationary bikes are okay if you can put the weight off the sore area. Ask some more questions. But, I got to run. Rich


Thanks very much for your message. Just to clarify, I was foam rolling my left ITB and the right (injured) foot was supporting on the floor. As I rolled there was a loud crack across the metatarsal heads (it would have been a pro/supination injury mechanism). The bursitis was found initially on MRI and I have a mulder's click as well. I wondered if there could have been a hidden neuroma alongside the possibly cured bursitis, which is now responsible for what would presumably cause similar neuritis type pain.

Best regards, Sara

Dr Blake's comment:

Thanks for clarifying. Can you send me some images with your phone of the MRI in T2 images (bone is black) which showed the bursitis. Definitely a neuroma can be hidden by the bursitis swelling. Does your foot look swollen, or discolored, from the other foot? If so, send a photo of the top of both feet. Rich

Hope these are okay - I assume the bursitis is visible as the bright white between the metatarsal heads but MRI interpretation is not my forte! On the ultrasound, the 2-3 bursitis was worse than the 3-4 although my pain was only attributable to the latter.

Thanks and regards,

Sara 

T2 MRI image noting white fluid between each interspace diagnosed as bursitis

Dr Blake's comment:

     I agree that you have some bursitis, but this may be normal for you. Bursae are noted in all 4 interspaces, with none being brighter than the others. I would guess that you irritated the nerves leading to neuritis with your foam roller and you should look at the various posts on Morton's neuroma treatment. Especially, for right now, creating that painfree environment and then advancing from there. Hope this helps. 

Low Lying Rainbow from my office Window

Plantar Fasciitis and Achilles Tendinitis: A Common Duo

Dr. Blake, I found your blog online and found them a fascinating read. I wonder if you can shed some light on my foot problem. I have plantar fasciitis on both feet and Achilles tendon insertional micro tear (insertional Achilles tendonitis?). I have had them for more than a year, been seen by my podiatrist 4 times. I am still in pain from both problems.

• Nov. 2011.       started noticing pain in bottom of right heel at the first steps of the morning

• Nov. 2011.       took Ibuprofen for 2 weeks per primary doctor’s advice and stopped daily 2-mile run since then on

• Jan. 2012,       while the condition of right heel is getting worse to 8 out 10 pain scale, I started noticing pain in bottom of left heel at the first steps of the morning. I started wearing orthotics since then.

• Feb. 2012.       seen by a Podiatrist. Was told to do regular stretching.

• Mar. 2012.       over stretched the Achilles tendon/heel bone insertional area. Having pain in the insertional areas of both feet since then. Stopped stretching since then.

• April-Sept, 2012, elevate my feet as much as I can during the day. Ice them before I go to bed at night. Symptom is getting better. Pain level improved 5 out of 10 scale.

• Dec. 2012.       Started arch stretch. Plantar fasciitis pain appear to get better, but very slowly

• Feb. 2012.      Started to massage calf muscles, plantar fasciitis pain appear to get better, but very slowly

• March, 2012. Started to have a lot more pain, new pain, in the lateral side of the heel of both foot.

• My doctor told me to stretch the calf muscle. But even a very gentle stretch will cause the insertional area quite painful.

I wonder whether there is any cure for me? Thank you.

Dr Blake's comment:

     Thank you so very much for your email. I am gradually catching up from before my little Hawaiian vacation, so I apologize for my delay.

Sunset from Waikiki Beach, Oahu, Hawaii

Most people know that the plantar fascia on the bottom of your foot originates from the achilles tendon fibres that engulf the heel bone. If you are lower on the evolutionary change, there is a greater connection between these 2 structures. Apes can use their ankles like hands so need these two structures connected. So, no matter where you are at  in the evolutionary process, you can develop pain in one structure first, then another. This, in your case, is what is being treated. But, is it correct? You can consider the achilles tendon fibres grabbing the heel bone from the back, both sides, and bottom (like a hand), ready to lift the weight equivalent to 10 times your body weight. And, it is hard to stretch the insertional achilles fibres into the heel bone since they are attaching into the bone. Typically stretching and massaging, if not done perfectly, can irritate the fibres more than bring them relief.

As you are being treated for tendinitis/fasciitis, and it is not working well, there are 2 logical explanations. The treatment is just not tailored enough (individualized) to you or the treatment is not addressing the correct diagnosis. First of all, both the plantar fascia and the achilles tendon attach into the heel bone (calcaneus). This could easily be an injury to the heel bone with pain from protection or compensation in the  plantar fascia and achilles. So, I would look into obtaining 3 tests that can greatly help with the diagnosis: x rays, an MRI, and a bone scan. The x rays have the least likely chance of helping, but they may point to something important. Even if you had to self pay for these tests, the $1200 (San Francisco Bay Area prices) would be worth it. This would 100% rule in or rule out a bone problem that needs to be dealt with differently than you are treating yourself. 

Second of all, the plantar fascia and achilles have fibres of the sciatic nerve running through them. I have personally misdiagnosed sciatic nerve problems as plantar fasciitis and achilles tendinitis numerous times. It is easy to do, but when the patient does not respond to normal treatment, you look deeper. Neurologists and physiatrists are the nerve test people. See if they can make some correlation to your pain and the sciatic nerve. This may require a nerve conduction test. Treatment for this syndrome also quite different. The sciatic nerve hates to be stretched, but the technique of neural flossing may work. 

Finally, perhaps the treatment you are getting for achilles/plantar fasciitis is not correct. When you have any type of tendinitis, see my post on BRISS. This stands for Biomechanics, Rest, Ice, Stretch, and Strength. It is the 5 areas that should be addressed simultaneously in treating any tendinitis like achilles tendinitis and plantar fasciitis. You make changes in the biomechanics of shoe gear or activities, you use rest or activity modification principles to keep the pain level between 0-2, you use ice and other anti-inflammatory measures to calm the tissue down, you do pain free stretching, and you begin arch and achilles strengthening the day you begin to have pain. Go back to square one with your rehabilitation. See the link on BRISS. Read all the posts regarding achilles and plantar fascia. Get some of the above mentioned tests to rule in or out other causes of heel pain. I sure hope this points you in a good direction. Rich

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

     

Bunion Pain or Not? That is the Question

Hi Dr. Blake, I emailed you about a year and a half ago about a sesamoid bone that I broke and then had removed after about a year of it not healing. Now I have another issue I would like to ask about.  On the other foot I think I may have a bunion forming, but I am not sure if that is what the problem is. At first I thought the other foot hurt because it had to work harder to make up for the first broken one. Now I am still having issues and tenderness in the ball of my foot, but I don't think my other foot is compensating now.  Since I found a lot of information about my first foot issue on your blog, that is the first place I decided to look now. I am wondering how to determine if I have a bunion or not. I have a painful area below the great toe and today it began to turn red. The great toe is not turning toward the other toes yet. Since I have been healing from my sesamoid injury I have begun to get back into martial arts and I am not sure if something like that, since it is a barefoot sport, would encourage this to come on.  Neither of my parents have had bunions and I am not sure of my grand parents, but much of the information says it is hereditary. I looked at the information you posted for the different items from Foot Smart, but I am not ready to buy them before I know for sure that is my issue. Can you give me a suggestion of where to find information about diagnosing this or if I need to visit my doctor for x-rays to decide. I appreciate all your information you have for us and for any help you could offer me. Thank you! Dr Blake's comment:       I attached my You Tube video on Bunion diagnosis. I hope it is helpful. Rich

Peroneal Tendon Surgery Rehab: Email Advice and The Role of Over Supination

Hello Dr Blake,

I am writing to you for I failed rehab after peroneal tendon repair (approx 20 mos ago)

I finally got fitted for custom orthotics at Davis shoes after an unsuccessful attempt at another orthotic place the last two months
  Arnie n Michael fix up my presurgical orthotic so that I have something while they work on my real one which will be ready in several weeks.
My problem is not just fallen arches; now I understand why I struggled everyday after returning to work  post surgery in superfeet

My question is what is a bad pain? My first day with this  orthotics; I am better than I have been since 1/2012.
Dr Blake's comment: See my post on Good vs Bad Pain

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

Tonight, my legs are achy (deep) after rolling
The temporary orthotic seem to help my surgical ankle -no burning up laterally to my butt; just stings in ankle joint, but I have pain in nonsurgical inner ankle which I started to experience back in 4/2012; post tibial tendinitis

They tell me to ease into this but I am a Neonatal ICU nurse who is on her feet 8 hours (duration of my shift)

I need some help in making better choices to heal my body

Thank you in advance

Amanda (name changed)

And here was another early email

Good Morning Dr Blake,

I am writing to ask about gait training ...
I had peroneal tendon surgery 7/1/11(slipped in water n fell onto my ankle bone on 12/20/09; didn't know about torn tendon til 8/10)
5  mos (12/1/11) after surgery I returned to my job as a neonatal ICU nurse/12 hrs shift; I had problems almost immediately; I decreased my hours to 8 hrs shift at end of 1/2012 and I continue to struggle all of 2012.  My surgeon recommended superfeet before n after surgery
I used superfeet n presurgical custom orthotic through out my journey. I did not realize that my problem was more than just fallen arches n  lack of strength

I was at my worst by winter of 2012.  I could not bear weight on my L side.  My surgical ankle showed it's problem by sending burning pain up to lateral calf as well as to hip n butt
I now have a temporary orthotic from Davis shoes  n can see that I don't push off with my big toe; burning to hip only happens at 6-8 hours

My podiatrist thinks it's time for EMG
I don't have auto immune disorders; just chronic pain from shoulder injuries a decade ago
I don't believe I need Lyrica
I started a PT program for core strength ( Pilate on reformer) in Jan 2013; has help me some
I think that I am doing something very wrong
So, this am I am thinking gait retraining is important

Dr Blake's comment:

Amanda (name changed),

      Since you are in a painful state, you really should be in some form of brace for standing/walking, and then gradually restrengthen your peroneals. You probably have some nerve pain, but does icing at least temporarily calm down the pain? Watching you walk and then prescribing the right shoe inserts is crucial. But, you will still need to get very strong. Do you have alot of scar tissue? What does the PTs say is the reason you hurt? What do your doctors say? Any information is appreciated. Rich

Thank you so much for writing back and your advice on bracing/getting the peroneal stronger

Some how that did not cross my mind.  I will go back to using the figure 8 brace.  I have reviewed your blog for the exercises. I don't think I was ever doing them like your video. I was using yellow and red for point n flex.  PT had me doing lots of point n flex; towel pulling n activating quads; soleus on weight machine; two calf stretches. I had about 15 PT Postop. I  work on balance  very minimally ( after my 3th 12 hours shift my right foot got caught in a wrinkle of a carpet as I was exiting the hospital. I didn't react I just fell onto my knees n hands

Last w/e i found out I still don't like to react with the right side

I have been told that my R hip is tighter but I feel more pain in my left 

I stopped the therabands when I started to have more and more problems  as I returned to work
Dr Blake's comment: Therabands are a very difficult exercise to do correctly and can take a skilled podiatrist and/or physical therapist to help you do it correctly and safely. Here is the link most likely to help.
http://www.drblakeshealingsole.com/2010/08/video-on-ankle-strengthening-eversion.html

I also have the donjoy brace but it got too uncomfortable the last time I used it (about 10 days ago)

My podiatrist continues to just say my R ankle is structurally  sound.

  He is planning for me to get EMG testing even though the burning pain goes away the next day or after contrast bath.  I knew about flashing (contrast bathing) from previous dequevain injury

But I have been doing them differently from your blog; works quickly n well all the way up to the thigh.

I will do the warm n cold then elevate after as well as writing the alphabets

http://www.drblakeshealingsole.com/2010/09/swelling-reduction-video-on-contrast.html

He asked me to see a rhumatologist last year and I did and to get Pilate txs for my core.  

He wrote for acupuncture txs when I told him that I was not going to take lyrica;  it has helped some

He finally wrote for more PT to treat my lower exts as well as hips; I am to use my own insurance for Work comp has denied all tx as of 10/2011 so I have not seen s PT til this Jan.

After 20 sessions she did say I am using my hip more n not my shoulders; she did work on my incision at my last visit

My AME said I don't need any PT for I had too many and I just need myofascial therapy for my symptoms have spread all over ---laterally up 

So, my myofascial therapist has elbow massaged from ankle up to the butt because I was sore in my  thigh after a shift

I have some scar tissues 

I am working on it as much as I can

I can now balance on single leg for 2mins; I could bearly do 1 min last October

L Post tib tendinitis is better; I just massage the soleus trigger points 

My L side really suffers qoday unless I stay off my feet

R side pain was gone for about 7 days after I begged another doc to inject my peroneal trigger points because I don't want cortisone injection from my podiatrist

I am seriously looking for a new rehab plan;  rehab was what I was worried about before committing to surgery n I somehow got derailed.  At the time I  spend so much time in the pool because I was worried about my core n spine ...

now I am stiff all over but glad that Gail and Carol have given me your name and have found your blog

Thanks again 

Amanda

Good Morning Dr Blake,

I spent  Sunday reading your blog, contrast bathing and trying the peroneal L/B Thera band exercises, stretching my Achilles w excercise band for 45 mins, compression sleeves and staying off my feet,  etc

Is it normal/ok to have this slight pain at the end range of exercise behind ankle bone?
Dr Blake's comment: Yes, and it is totally fine. You should avoid the end range of motion in either direction as you do the therabands. It is where the internal tissue is either too stretched (in one direction) or too compressed (in the other direction). 

Is it okay to kick in the pool by swimming or be in water exercise class if I am having pain?
Dr Blake's comment: Again, the article on Good vs Bad Pain should be memorized. You must know the difference to rehab correctly.

I had no/minimal symptoms on R (surgical foot) when I wake this am
Burning pain left me during class  but left side  flared after deep water exercise class/ after my 8 hour shift on Sat; from ankle to ribs. Inner ankle to outer ankle  like where perineal would be  contrast help some but too uncomfortable for compression after so i just try to roll; stretching the Achilles for 45 mins at midday on Sun did help all the symptoms from my mid back/ribs/ inner thigh/knee pain
Does tight Achilles cause you pain straight down around your ankle  bone?
Dr Blake's comment: Yes
I don't feel much stretch when I try this prolong stretch to my surgical ankle
I think that I am not getting it deep into or behind that bone
I have always had that problem
I also did not tell you about my bunions; R worst than L
Only had pain in that joint when I wear high heels which was very rare


Thanks again

Amanda

Dr Blake's comment:

     I had the absolute pleasure on seeing Amanda as a patient, since she lives locally. Amanda has what 10% of the population has, over supination. This motion was not really helped by her orthotics, so I adjusted them. Excessive supination as shown in the links below is devastating on peroneal injuries since the peroneal tendons must stabilize the ankle and resist the over supination. By controlling the excessive supination, the peroneal tendons should not have to over work and her symptoms should improve. I was able to see that she had Peroneus longus weakness, no achilles tightness, no scar tissue issues, and stable shoes. She should do just fine. 
http://www.drblakeshealingsole.com/2011/09/supinators-various-gait-videos.html

Another Hawaiian Sunset