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Wednesday, November 26, 2014

Initial Workup Hallux Limitus for potential surgery

This wonderful young lady (my age) presented to the office to discuss surgery on her big toe joints. She has a bone spur on the top of the joint that is painful to wear shoes (especially non athletic). A surgeon had recommended removing the bone spur in a relatively simple procedure by shaving the top of her joint. Where this may be perfect, I have had too many patients that have problems when the joint itself is damaged. Removing the spurs from the top of the foot removes bump pain, but can increase bending pain. The shaving procedures typically cause scarring of the ligaments on top of the joint permanently limited the range of motion further. It is rare that patients get more range of motion after surgery, typically less, so jamming of the joint with bending can occur easier. 

Here are the x rays that she brought into the first visit. We are now going to get MRIs to look at the internal nature of the joints and see if they are damaged. Can you guess what joint has more damage and what joint has less range of motion because of that fact from looking at these photos? First 3 are the left side, and the second 3 are the right side.

It is the left side that is worse in range of motion and pain, but the x rays really can not say that for sure. There are suggestions that both joint surfaces will have too much damage (osteoarthritis) to qualify for this bone shaving. The decision may be to implant or fuse. I prefer to implant these joints, since there is no going back once it is fused. The patient has over 40 degrees of range of motion now on the left and 55 degrees on the right. 

Sunday, November 16, 2014

Foot Pain without An End in Sight: Email Advice

Dear Dr Blake,

It has been over a year since I contacted you last, and what a long journey I have been on.

First I want to express my profound gratitude AGAIN for your Blog, and all you do to serve us. Thank YOU!!!!!!!!

I am so very grateful for your Blog, I honestly think it's the only thing that has kept me going at various times over this last year.
Dr Blake's comment: Thank you. I am so glad it has helped. We are all in this together in many ways. 

I had to stop working over a year ago, I received SDI for a year ($1100 a month, yikes), and now I have no income. I have wanted to see you and called your office to find out the cost, but the cost out of pocket is so high, it just has not been possible for me. Do you ever work with people on a sliding scale? I would really appreciate your feedback about what someone in "my shoes' (grin, gotta keep a sense of humor!) options are around receiving your guidance. And if you don't offer any sliding scale options - do you think you can make a difference in my treatment plan that would make it worth the cost for me, period - to see you? Or not really at this point?
Dr Blake's comment: All my self pay fees are extremely low, but I work in a hospital which has facility fees. For the initial visit, between me and the hospital you are looking at $250. You should call Mr Jim Houser, CEO of Saint Francis Memorial Hospital. Ask him if you can apply for pro bono or sliding scale, and I would honor that, for a one time consultation. 

Please let me know your thoughts. In the meantime I would be so very VERY grateful for any guidance you might offer about how best to proceed and receive support from a podiatrist, etc in my process now. This is a lot of info I know, I have poured my heart and soul into this email. 

On Monday I am seeing Dr Eric Fuller who is familiar with you and your work. I have seen him twice over the last 5 months. I get to see him at no cost at my clinic because I have medi-cal now. I live in Berkeley. I don't know when you will be able to respond to this email, and I thought I would send it off now and simply look forward to your response :) :) :)

I have gone through such a journey with this injury, I want to give you the brief summary of the main points so you can hopefully provide feedback :)

Some important facts:

****Important to note - I worked 2 times a week on my feet for many hours taking care of a disabled woman for a few days after I injured myself on March 2012, until I could no longer bear weight, walk or drive at all June 5, 2013.

****Also important to note, I was an extreme vegan for 13 years, and a year after I injured myself I got blood tests and found out I was EXTREMELY low in vitamin D (a level 6) and I began taking vitamin D and slowly reintroduced meat into my diet, which I eat on a daily basis now. My vitamin D is now 75 - from my diet alone (I stopped taking the vitamin D oil supplement).
Dr Blake's comment: With the normal being 32-87, it is good you are back in normal ranges, but your bones will need a lot of time to regain your strength. You definitely need a bone density test so that we can get a feel of where you stand now. 

****I am a generally very health woman - 43 years old. I have always prioritized my health. Now of course I am very atrophied from almost 3 years of being so limited in regard to my mobility from this injury.

The events:

March 2012 - I whacked my right foot on the bathtub while showering, and hurt my toe next to the pinky toe. It was a sideways impact.
3 weeks later - I whacked the same toe on my metal bed frame. After that I got x-rays - they determined it to be a sprain. No sign of any break. Podiatrist showed me how to buddy tape.
July 9, 2012 - the toe still did not look right and hurt more than it seemed it should, I went and got more x-rays, and the tip bone had become dis-located, which it was not when I received the previous x-rays. The podiatrist manually put the bone back into place and made me a little splint to wear.
Dr Blake's comment: So, you probably originally did not break, but sprained the joint 3rd degree. 3rd degree is a complete tear and should not be walked on. It is rare in this location, so easily missed. If you walk on a 3rd degree sprain of the toe, the bone could dislocate, which I guess it did. Splinting and taping is too weak a treatment for the toe to properly heal. Removable boots, post op shoes, can be made with accommodations to off weight the area enough to allow healing. 

The pain continued in the tip joint of that toe, and then the joint at the base of the toe at the head of the metatarsal bone began hurting. More and more.
Dr Blake's comment: I am sure you continued to sprain the joint walking on it daily. Many patients need this surgically fixed. 

January 2013 - I got an MRI - the report said nothing distinctive.
The pain continued. This whole time it hurt to bear weight, and it also hurt when I was off my feet.
Dr Blake's comment: The sprain is too far from the injury so some healing, even incomplete healing, can mess up what the MRI says. Also, MRIs on such a little area is close to impossible to read correctly. Too small, too close to the skin for artifact. Physical examination of the injured area seems better. Chronic pain, even if mechanical and inflammatory at first, can cause neuropathic pain to set in. 

May 2013 - I began doing stationary biking to get blood flow in my feet, and the pain had gotten better enough to do this. However, I did a little walk barefoot at the gym and went up on my toes barefoot as I walked, which did not hurt at all at the time, but later that night I was in a LOT of pain and that walk on my toes was the only thing I had done differently.
June 5, 2013 - I put my foot on the floor to get out of bed and experienced sharp pain. That was the end of my walking. Got more x-rays immediately - they showed nothing. 
About a week later - a Podiatrist gave me a cortisone shot -  1cc total of 0.5cc of 0.5% Marcaine plain and 0.5cc of kenalog 40.
June 24, 2013 - got another MRI (non-contrast) later in June - this time the report said: The insertions of the second, third and fourth plantar plates appear degenerated with minor splitting and frayed appearance. I am including a copy of that report. - considering that I wonder if the cortisone shot was a terrible decision?
Dr Blake's comment: Hopefully not. Did it help with your pain? Where was it injected? Why Kenalog 40 for feet? Most patients over 40 have some plantar plate irregularities, typically no big deal, part of the aging process, and not part of your injury. Definitely know that osteopenia can cause peripheral nerve symptoms which can be painful, numb, or combination. 

July 23, 2013 - got PRP and prolozone therapy (Dr. Monagle did a combo of the 2 in the same treatment).
Dr Blake's comment: What are those treatments trying to accomplish? 

2013 - Got 2 more MRI's in 2013 - both saying little to no change.
Dr Blake's comment: Little to no change in what?? In normal??

Have seen MANY podiatrists, they disagree about what is going on. I have never had a clear diagnosis.
Many docs and pods have thought I also have CRPS - I saw a neurologist and she did not think I had/have CRPS - but I still wonder...
I basically spent a year unable to walk, in a wheel chair and crutches. Bearing weight in a boot would start causing sharp bad pain. The pain was so intense I could not have a sheet on my toe, I had to sleep with my foot hanging off the bed.
Dr Blake's comment: CRPS or not, this is neuropathic pain, not inflammatory or mechanical. You have so far indicated no normal treatment for neuropathic pain----compounding creams, oral meds, local blocks without cortisone, sympathetic blocks, heat, pain free massage, biofeedback, meditation, etc. 

Now I am very slowly weight bearing again with the assistance of Correct Toes - which are the difference that makes the difference for me being able to bear weight now. The way the "Correct Toes" brace my toes is holding the injured joints in a way that allows me to bear weight, without causing further damage (or so it seems)...
Dr Blake's comment: You so need to walk to build muscle and bone strength. I am so happy you stumbled onto a way to achieve Protected Weight Bearing with a pain level between 0-2. 

My injured toe is discolored - kind of reddish - for years now since I injured it. What does that indicate?
My whole foot is still slightly red, but much less red than it was even a few months ago. Could this indicate CRPS?
Dr Blake's comment: This is the vaso motor insufficiency associated with a sympathetic nervous system in stress. It does not mean CRPS, but it could be, and it typically points to a neuropathic pain syndrome.

SO - how do I proceed now to HEAL - and not injure myself further? How can a podiatrist help me now?
What questions should I be asking Podiatrist Dr Eric Fuller?

1. It has been a year since I had the last MRI, should I push for another MRI? What kind would you recommend I get? What size slices, is non contrast ok?
Would the results of the MRI possibly cause any change to the way I am treating this injury? On medi-cal it is VERY hard to get an MRI - and if I can tell Dr. Eric Fuller that it might change our treatment plan then he might be able to make an effective case for me getting an MRI. What do you think?
Dr Blake's comment: So far, MRIs have not helped you. A CT scan to just look at the bones would be great, but a referral to a pain management doc who deals with neuropathic pain is a must. Have Dr Fuller help you with various ways to have protected weight bearing, so you can rotate the stresses during the day. 

2. Do you find that is someone has partially torn their 4th toe plantar plate, that it may take years for that joint to get stronger, and that often with time people can eventually bear weight without bracing and without pain? Or? I am trying to figure out what to expect. You said in your Plantar Plate Tear post to the pregnant woman "You will be wearing the Budin splint while you strengthen the area for 2 years. Some of my patients run marathons in these splints."What exactly is strengthening in those 2 years? The actual plantar plate tissue and/or?
You also told her "As the pain calms down, and you get into more normal shoes, if the Budin splint is not enough protection, then you need to experiment with Hapad Longitudinal Medial Arch Pads." - again, how do I know if I need to add pads in addition to the Correct Toes? Which leads me to my next question.
Dr Blake's comment: Dr Fuller can help you with this part of protected weight bearing. Getting a splint or tape to stabilize the involved joint (I am still unclear which one) is great, and off weighting the area with Hapads, etc. is crucial. It is so important to walk to build strength, even if your injured area is 5 feet off the ground with padding. You are strengthening the long flexors to the toes and the foot intrinsics. You want the muscles that pull the toe down to be much stronger than the muscles that pull the toes up. Typically you start with metatarsal doming exercises three times daily. 

3. In order to walk with less pain I can only walk with the correct toes bracing the injured joints.
Are you familiar with Correct Toes and Dr Ray McClananhan's work? If not I think you will be greatly pleased with having that tool to add to your tool box. See link :)

I wonder if I should be adding any other bracing to the injured joint in addition to the Correct Toes, like a met pad? HOW do I discern if I should add padding to my weight bearing process - like metatarsal pads? The ONLY shoes I can wear are the Keen Whisper Lights -
and I can't really add padding to their foot bed - I could tape something to the bottom of my foot...
Dr Blake's comment: I will have to look at the links later. Thank you. Have Dr Fuller help you with padding issues to create the same relief that you get with the Correct toes. 

4. Would you recommend I do Metatarsal Doming Exercises based on what I have shared with you, or do you need more info to be able to give that feedback?
Dr Blake's comment: Definitely doing met doming is crucial for plantar plate problems if that is what you have, but it can not be painful to perform. Ask Dr Fuller if that is the correct exercise for you to do based on what he thinks you have. Any exercises can irritate a sore area, and when there is probably so neuropathic pain involved, it is even trickier to do. 

5. How do I choose my rehab help, so many people have led me astray. Is there criteria you would suggest I use to help me look for someone who can really help me rehab from this injury, without causing further harm to my body?    
Dr Blake's comment: Dr Fuller is fully versed in rehab of mechanical and inflammatory pain syndromes like most podiatrists and PTs, so that should be their role. A pain management specialist should help with the neuropathic part.          

6 How can I discern if my joint has been or is being altered such that it might lead to long term challenges like what I have read about on Dr Runcos website?
"...if progressive deformity occurs despite solid advised treatment it could certainly lead to permanent cartilage loss of the joint (arthritic joint). The instability of the joint causes subluxation (partial dislocation) and the repetitive mismatch of joint surfaces over time can lead to full thickness cartilage loss when high point one side meets high point on the other side. The metatarsal head can deform or the patient can develop a crossover toe deformity, starts mild and can end up severe..."
Dr Blake's comment: When I rehab patients like this, typically you can get them out of pain with splints, etc. But, if the deformity continues to worsen, surgery is recommended to fix the deformity. So, we do not wait for all the above to happen. The decision making is however slower than a snail's pace, since there is no pain, the patient waits a long time. Making a decision to have surgery, when you are in pain, is never completely rationale. Pain distorts the little objectivity we have on the situation. 

7. How do joints regenerate, and how can I support mine in regenerating? I have searched and searched for information on this topic, what I have found is confusing to say the least, there is joint immobilization, joint mobilization, etc etc. And what stage am I in, what do I need NOW? Do you have any guidance for me in this area? Anything I can read, etc?
Dr Blake's comment: I guess that is why you had the PRP and prozolone therapies. I really do not know if this is an issue for you. The CT scan made help if it shows joint displacement. But, would probably point to surgery if it did. 

8. How do we - your general Blog audience - receive the answers to the questions you posed in the information you shared from the core of your 2 lectures at the California School of Podiatric Medicine at Samuel Merritt Universitty in Oakland California October 2014?You pose this question in that post about sprains "Second Degree--ligaments partially torn (some ecchymosis) Why do 2nd degree sprains hurt more than 3rd degree sprains at times?"I REALLY want to understand why 2nd degree sprains can hurt more than 3rd degree sprains at times? I consulted with a doctor (Dr. Runco - I included a quote from his website in question #6) who completely tore his plantar plate and healed up very quickly compared to me, with far less pain. This seems like a perfect example of what you were referring to.
Dr Blake's comment: When you completely tear a structure, you get severe pain from tearing the nerves running through that structure, but then everything can calm down. When you partially tear a structure (Grade/Stage 2), the structure is very weak and the non torn part must try to function as whole. It can not, so the tissue strains and lets you know constantly that something is wrong. The torn part can scar in, which may be great, or may be very abnormal. So, between the weakness and the abnormal healing, a partial tear can be more painful in the long run than a complete tear. The complete tear does cause problems with instability, which can lead to chronic problems, so it is not better, just probably understood better by medicine. 

*******Is there ANYTHING I should be asking but have not?!!!!

I am including a picture I took of my feet right now. They used to basically look identical. You can see the redness in the injured foot and the injured toe deformity.

I am also including the MRI report from June 2013, and a pic of one slice from that MRI series.
Dr Blake's comment: The MRI slice is inconclusive. Sorry. If you want to send me your most current MRI CD I would review. Send to Dr Rich Blake 900 Hyde Street San Francisco, Ca, 94109

Please let me know if I can provide ANYTHING else that might help you, help me :)

Thank you, thank you, THANK YOU Dr. Blake!!!!!

I REALLY appreciate any feedback you can provide.

Very warmly and sincerely

Monday, November 10, 2014

Nerve Pain: Email about Calmare and MRI


This is an email that I received after letting one of my patients know that Calmare Pain Therapy for neuropathic pain was finally being offered in the San Francisco Bay Area by an MD Dr Susan Gutierrez in Danville and San Ramon areas. 

Hey Dr Blake, thank you for thinking of me.  Have you had patients experience success with calmare pain therapy? (the success of one patient's treatment with Calmare has a link below)

Here is the post from my one patient so far.

I am also sending all my nerve patients to Dr Lee Wolfer now if I can get approval/insurance coverage to see her. My other favorite docs are Dr Michael Moskowitz and Dr Michael Savella in Marin County. Thanks to your recommendation. 

  i'm asking because overall the CRPS pain is doing much better, thanks to dr. wolfer's dextrose nerve blocks since feb of this year..  these are done with ultrasound guidance.  i've had blocks on my femoral nerve, sciatic nerve,  sapenous nerve, and the most stubborn, oldest pain site - the tibial nerve. lee actually would love if you called her.  she believes she can help some CRPS patients if you are open to talking with her, that is.
Dr Blake's comment: Dr Lee Wolfer is an amazing pain specialist. Here are several links referring to her.

i had a classic prolo injection into my big toe joint about two weeks ago. it helped quite a bit.  i will most likely need a few more as well as a repeat tibial nerve block.  man, this condition is stubborn.  as i wait for an appt with lee, i continue to do everything else:

homeopathic remedies with accupuncturist who does muscle response testing (this is fascinating stuff!)
PT exercises to the point i can bear the pain
supplements - more than i can bear at times; pill fatigue is real
bike or swim 
anti-inflammatory diet and moderate paleo
contrast baths

In regards to my left big toe joint, i do the spica taping and cluffy wedge daily.  and i walk in my orthotics all the time except when going to client meetings. i continue to scan the web for womens shoes with removable footbeds.  my foot doesn't fit well into a lot of the brands.  so i continue to search, order, and return shoes.

anyway, this is a long update to say i'll hold off on seeing dr. gutierrez.  but i will post her name on the facebook CRPS support group.  should i get to a point where i was pre-february 2014 then i will definitely make a consultation.  i'm spending so much money (~ $1,200/month easily cash) as it is.  the thought of adding another cash consult/procedure overwhelms and stresses me even more.  not to mention the added coordination and travel.  i've tried four PTs, several MDs, three accupuncutirsts before landing on the multi-disciplinary team i have now.

thanks again so much for thinking of me.  i need to make an appt with you after i get my hands on my some shoes that fit my feet. did my MRI show anything besides big toe joint OA and inflammation?

hope all is well with you,

Here is the image of the left big toe joint on MRI. The sensor is along the second toe side. The fluid in the medial side of the first metatarsal signifies substantial bunion joint arthritis. No wonder the nerves around the big toe joint get upset and painful.

This MRI of the left foot focuses on the inflammation in the 3rd intermetatarsal space where a Morton's neuroma may reside. Definitely a cortisone shot can calm that down and prevent the nerve triggering.

Another image of the big toe first metatarsal head. The white within the bone is not healthy. The sensor overlies swelling in the space between the first and second toe which irritates the deep peroneal nerve in that area. This is the second trigger of left foot nerve pain.

Here the image highlights the first metatarsal bone swelling on the bunion side of the joint. The swelling is plantar (bottom of the foot), making weight bearing hard, and making the spica taping, dancer's padding,  Cluffy Wedge, and Hannaford orthotic devices crucial.

This last image also highlights all the intense swelling right where the intermetatarsal nerve runs. This can produce Morton's neuroma symptoms without actually being a neuroma. Cortisone injections are considered for this.

And here my patient's response: 
very thoughtful response, as always, dr. blake.  i especially love how you educated me (and all the other readers of your blog) on what my MRI means.  

a few quick names i want to pass along.  srinika is my acupuncturist and nutrition/supplement advisor.  she did a nutrition response testing on me and i was fascinated by the results:

  1. my body needs to detox itself before it can absorb any supplements
  2. the toxins in my system are due to a category called air pollution.  see her blog entry -->
  3. my body responds to the homeopathic remedies!  my skin started itching as a result of the toxins trying to escape my system.  
  4. the homeopathic detoxification remedies along with weekly acupuncture are extremely helpful in improving pain
this is her site:

interestingly enough, lee used to work in the same office as lee years ago!

i also like my PT, rachel feinberg, in palo alto.  she has 13 years experience in CRPS and tailors a functional restoration program for each patient.  link is below, which also has her CV.

still shoe searching!

Sunday, November 9, 2014

Sesamoid Fracture Email Advice

Dr. Blake, I am so happy to discover your blog!

     My daughter is 14-years-old, and being recruited for a college athletic scholarship. Comparing x-rays, MRI, and CT scan, the orthopedic has diagnosed a non-union medial sesamoid fracture. The break is horizontally across the middle, so the appearance is similar to a bipartite sesamoid. This was an acute injury, which occurred 11 months ago. Initially, she wore an orthotic shoe for 3 weeks, started to feel better, and was cleared to return to strenuous activity after 3 weeks. Well, here we are 10 months later and she plays in constant pain. Orthotics and taping have not worked at all. The doctor now suggests a non-weight bearing plaster cast for 6 weeks. I am happy to try any non-surgical option!   I have several questions for you. 

#1 Is there a chance cast will work to heal a non-union fracture. 
Dr Blake's comment: Totally, she should be in the Immobilization Phase of Rehabilitation for a 3 month period with a Exogen bone stimulator to use daily. During that time, you want to do contrast bathing once daily, and icing twice per day. She needs to substitute biking and swimming, with strengthening and flexibility workouts, for her main sport. The next 3 months are even harder, as you wean out of the cast, continue anti-inflammatory, keep the pain level 0-2, gradually increase the activities, continue cross training, and feeling loss a lot of the time (important to have a great PT or sports doc to help her through this time). Need to have a good protected weight bearing orthotic at that time. 

#2 If the cast does not work what is her best option to heal this trying to screw the bone or remove it? 
Dr Blake's comment: Most remove all, some partial. When removed, you have to wear protected orthotics forever for sports, and toe separators between the first and second toes in all enclosed shoes to help slow bunion development. 

#3 Are we risking all her years of hard work to get to this point athletically being ruined? 
Dr Blake's comment: If you go conservative, you have to be committed to 6 months of keeping that pain level between 0-2, and another 6 months to have surgery and healing, if the conservative treatment does not work. If you have surgery tomorrow, you will have to give 6 months to healing before she is back to her pre-surgical level of activity. As a physician, if I feel that there is a reasonable chance to heal conservatively, I will always recommend the conservative route, even in the face of loss of college scholarships, etc, because surgical complications can occur. Part is your comfort level with the potential surgeon. This does not mean we do not do surgery in the situation your daughter finds herself in, but at her age, much more caution and opinions are used. 

#4 Should she just play through the pain? 
Dr Blake's comment: No!! Playing through pain does so much damage to the joint potentially, and the rest of the body due to compensations. You also are risking nerve hypersensitivity which can disappear slowly even with surgery. 

Heel Bursitis Injection near the Achilles Tendon: Email Advice

Hi, thanks for the great post (regarding the thought process around cortisone shots) and all the responses to comments which I've read with great interest. I had a cortisone shot yesterday into heel bursitis (also known as retro-calcaneal bursitis when it is near the achilles tendon). Doc went through the achilles at one stage (I was led to believe) but I was very clear prior in requesting he be cautious in relation to the tendon given a history of prob's and utter paranoia about the possible consequences. Wasn't told whether short or long but since it had the anaesthetic (which took good effect), I'm guessing long. The ultrasound showed a pretty gnarly achilles tendon and lots of old scar tissue on calf including a probable tear of the plantaris tendon(???). I have always dealt with a degree of pain which makes me even more nervous about resuming high impact as I may not have a great sense of any pain beyond the norm. Anyway, my sport is squash at a high level, which is obviously pretty ballistic. I conclude from this post and others I must endure 2 weeks of no weight bearing or ballistic cardio, (maybe cycling without raising from seat) , then building from slow to faster running. Any views on sprints and bursts of fast stop start? When and how do you recommend that be started? Am for once willing to be conservative and would welcome any thoughts. Thanks in advance! 

Dr Blake's response:

     First of all, you have a 95% chance that if you are smart over the next several weeks, and then give yourself 4 more weeks to gradually return to activity, you will be fine in regards to any potential damage from the shot. With your history however of a pretty gnarly achilles, with lots of scar tissue (which is always causing some inflammation), etc, and some inflammation in the area that devitalizes the achilles (any tendon), you are at risk of someday hurting it. Hard to know the odds/never really been studied. 

    I would look at this return to full activity as a 6 week journey. The next 2 weeks should be walking, biking without getting off the seat, swimming without pushing off the wall, elliptical without lifting your heel off the plate. Of course, review the BRISS protocol for tendinitis for any other recommendations regarding anti-inflammatory, stretching, biomechanics. Especially please avoid negative heel stretches.

   The second 2 week period is your return to running. Try running every other day, with no hills or sprints. Run 2-3 miles each time just to test how the tendon feels post shot. On the days off running, continue your other cross training. 

   The third 2 week period is your return to squash. Continue every other day, ice after, and start easy with several days of simply hitting. A 3rd and 4th squash workout could be with a partner designed not to be competitive, but gently putting more stress on the tendon. I wish you luck and remember "handball is the real man's game."  

Saturday, November 8, 2014

TuTu Project: Are You There for Your Spouse when Illness or Injury Strike??

This was sent by a patient with severe foot pain, very chronic and disabling, and with the #1 Spouse. He is always there for her. When your loved ones need your love and support, give it unconditionally and whole-heartedly. It can be the touch that allows complete healing. 

Sunday, November 2, 2014

Toenail Pain: Where does it come from??

Dear Dr Blake...I have excruciating pain in my toe nails (left foot 3rd and 4th toes) when I feels like someone is pulling my toenails off upwards (not fwds)....or maybe like having your barefoot toes rolled over by an office chair....there is no toe trauma at fact when I reach down and massage the toes the pain is strangely gone and even I am almost sure it is a nerve damage situation....I thought I had Morton's Neuroma because the 4th toe is slightly curved in...however, there is no pain when I do the metatarsal squeeze test...also the pain is exclusively in the toe nails, not the ball of the foot. Additionally, a week ago I had an injection into my foot but that did no good whatsoever. Can you give me your thoughts ??? Thx !!

Dr Blake's comment: You are most likely correct that is it nerve pain. The 3rd and 4th toes are in the L5 nerve root distribution. You can have a Morton's neuroma developing between the 3rd and 4th metatarsals, you can just have a bulging disc at L4/5 or L5/S1, or both called "double crush". To evaluate you have to go up the leg from the foot and look for hot spots or "triggers" which would produce neural tension. See a podiatrist or neurologist/physiatrist to evaluate as your starting point. Try Neuro-Eze OTC nerve med (online) and start doing neural flossing (but it could aggravate things also---at least a clue to what is going on).

Saturday, November 1, 2014

Shin Splints: Basic Treatment Tips


    Injuries to the lower leg are quite common with compartment syndrome being the hardest to diagnosis, and one of the only non-traumatic injuries in the leg that may require surgery. Many cases of Shin Splints are actually tibial or fibular stress fractures which may be quite self limiting (time is a great cure for these). Severe calf cramping (with the meaning of “severe” different from patient to patient and doctor to doctor can be a warning sign of a venous blood clot (not to be ignored). I will focus here on the common injuries/pain syndromes that a podiatrist will treat in the leg on a daily basis called shin splints, but could be stress fractures, muscular strains, acute tears of the muscles ( “Tennis Leg”), and the less common DVTs and compartment syndromes that one needs to be on the lookout for.

Shin Splints

Shin Splints: What are they? What is the basic treatment?

Shin Splints literally means pain somewhere between below the knee joint and above the ankle joint. There are a lot of structures that can produce pain in that area, so the treatments range from simple to complex. Mostly, shin splints is an overuse of one group of muscles/tendons that start (originate) in the leg, and end up (insert) into part of the foot. Each one of these muscle/tendon has various functions around various joints. It can be one of these muscle functions that has been forced to work in an overuse fashion that produces pain. Podiatrists, physical therapists, orthopedists, chiropractors, and physiatrists (rehab specialists) tend to be the most qualified to recognize the exact muscle/tendon involved when treatment is stalling.

Shin splints is so common, and normally responds so well to basic treatment, that most clinicians do not get too involved in its complexities. The basic treatment of shin splints involves:

  1. Reduce activity to pain free levels for at least one week.
  2. Ice the involved area for 30 minutes 3x/day.
  3. Change your athletic shoes if they may be worn down.
  4. Minimize your speed workouts and hill workouts.
  5. Consider if levels of Calcium and Vitamin D may be low.
  6. Attempt 3 to 4 days/week alternative exercises as long as it is pain free (i.e. cycling, elliptical, walking, swimming, court sports, etc.)
  7. Stretch the achilles tendon 2 positional (knee straight and knee bent) for 1 minute each 3x/day.
  8. Experiment with an ankle brace or ankle taping if it is painful to walk.
  9. Wear tie-on supportive athletic shoes full time while the shin is healing (although you may experiment with clogs as an alternative).
  10. Attempt pain free muscle strengthening of the muscle group involved.

As your symptoms get better, gradually increase your activity back to normal levels (normally 15% increase per week if you were still able to exercise, and 10% per week if you had to shut it all down). A walk/run program may be an appropriate starting point.

Now, let us review the anatomy of Shin Splints. The 4 basic types of shin splints are Medial (most common), Anterior (2nd), Lateral (3rd), and Posterior (4th).

Medial shin splints involve a group of muscles (with most commonly associated muscle function) including the posterior tibial (controls over pronation), flexor hallucis longus (stabilizes the big toe), and the flexor digitorum longus (stabilizes toes 2 to 5). Photo below shows where medial shin splints occur. Since over pronation, bunions (unstable big toes), and hammertoes (unstable lesser toes) are all common problems, this type of shin splint is the most common. More specific treatments of these problems include various methods in controlling pronation, stablizing the big toe area or stablizing the lesser toes.These include toe separators/spreaders, shoe inserts with Morton’s extensions, big toe spica taping to stabilize the big toe area, and toe crests, toe taping, reverse Morton’s extensions all to stabilize the lesser 4 toes.

Many patients purchase shoes too wide in the toe box leading to marked instability, especially when they have bunions. Too much room with resultant sliding around is just as bad on bunions and hammertoes as having too little room with resultant crowding. To help stabilize, the patient will grip with the toes, possibly producing medial shin splints. Even good fitting shoes initially can begin to loosen up as it breaks down. Try power lacing to help gain stability. Runners can also get medial shin pain commonly from tibial stress fractures. The 2 most common places for tibial stress fractures are distal medial (just above the ankle) and posterior (presently as calf pain or medial shin splints).

The 2nd most common form of shin splints is anterior shin splints (see photo above). The muscles (functions) involved all help to control foot slap after heel strike, and then to help lift the foot off of the ground at toe off. Overuse situations can easily occur with hill running and increases in the speed of workouts. It is the most commonest form of shin splints in the first month of cross country season, so common that most coaches ignore since the muscles due tend to get strong. The muscle/tendons involved are the anterior tibial (controls over pronation and stabilizes the first metatarsal), extensor hallucis longus (stabilizes big toe and lifts toe up at toe off), extensor digitorum longus (stabilizes lesser toes and lifts these toes up at toe off), and the peroneus tertius (stabilizes the outside of the foot including the cuboid , 4th metatarsal and 5th metatarsal). When the peroneus tertius is involved there can be a problem with over supination just like lateral shin splints.

This muscle group is normally the weakest of the 4 groups and has to constantly pull against the more powerful Achilles tendon. As the calf/Achilles gets too tight/too strong with vigorous exercise, it is hard for the anterior group to keep up. These muscles will strain under the added stress of working against the tight Achilles. Hopefully, when someone has anterior tibial shin splints, treatment should be directed towards:

• Stretching of the calf

• Decreasing hills/speed for awhile

• Stabilizing pronation (medial support) or stabilizing supination (lateral/cuboid area support)

• Stabilizing any digit appearing unstable (with toe separators, taping, toe crests, etc.)

The 3rd most common form of shin splints is lateral shin splints (see photo above). The muscle/tendons (functions) involved are the peroneus longus (stabilizes the lateral ankle against excessive supination and stabilizes the cuboid and the first metatarsal), and the peroneus brevis (stabilizes the lateral ankle against supination and stabilizes the cuboid and fifth metatarsal). So together they stabilize the lateral ankle, and both sides of the midfoot area. Ankle braces, ankle proprioceptive exercises (see post below on flat footed balancing), power lacing, and stable shoes if you pronate or supinate too much can all be part of the treatment.

The 4th common form of shin splints is posterior shin splints (see photo above). The upper 2/3 of the calf is considered a shin splint if the pain is deep. This can be a stress fracture on the posterior aspect of the tibia (very common in runners) and often misdiagnosed as calf muscle strain. It may also be a strain of the soleus muscle (deep part of the calf) where it originates on the tibia. The gastrocnemius (or gastroc) is the bigger, more superficial, muscle of the calf. The soleus muscle starts deep to the gastroc and becomes the other ½ of the Achilles tendon below. Therefore, the soleus functions to lift the heel. It also attempts to slow down pronation at heel contact, so over pronators may strain the muscle. It is harder to strengthen the soleus then the gastroc, so weaknesses may develop and muscle strains can occur with relatively minor overuse situations.

In general, soleus strengthening is done with the knee bent 45 to 90 degrees and the ankle is then plantarflexed with resistance (pointed downward like a ballerina on her pointe shoes). Treatment of this type of shin splints must initially rule out a tibial stress fracture which requires other treatments and concerns. Once tibial stress fractures are ruled out by x ray or bone scan typically, functional changes include decreasing ankle plantarflexion (extension) and stabilizing pronation. Also, avoiding activities that produce a negative heel effect where your heel is unsupported and drops below the plane of the forefoot, like getting off your seat in cycling. A slight biomechanical change in activities to minimize heel lift (ie. walking more flatfooted even when going up hills, or lowering the seat on your bike) can greatly speed up treatment.

 This time of the year (September and October especially) is made for Shin Splints. Cross Country season is starting and all high school and some college coaches are drowning in Shin Pain. Most of the time the athlete's pain is related to the bone and muscles not being used to the activity and overuse occurs. A shin splint technically is when the muscle pulls so hard on the bone that the lining of the bone (called the periosteum) is pulled away from the bone causing bleeding between the bone and bone covering. This normally is improved with time, icing, some stretching, and activity modifications.

However, when the bone is weaker (poor base of running, low Vit D or Calcium, low estrogen, abnormal bone structure) than the muscle, the bone may actually be the weakest link in the chain and break. This break in the bone normally remains a stress hairline fracture not detectable by normal xrays. Only in rare cases does the bone break all the way through into a complete fracture. The complete fractures are easy to diagnosis, due to the intense pain. A hairline stress fracture, also called a fatigue fracture of the bone, can at times be run on for weeks and even months. Top athletes, with apparently high pain thresholds, have presented to our office with 3 to 5 stress fractures and still running with so-called "shin splint pain". More reading below on the Weakest Link in the Chain concept.

So, when shin splints are not improving with the simple measures of relative rest, ice, shin sleeves, cross training, shoe changes, stretching and strengthening, etc, I advocate the use of a bone scan. It is positive within several days of a stress fracture, and is less expensive than an MRI. In our hospital, for the same price you get both legs for comparison, where MRIs are now being charged for only one side at a time and small areas at a time.

Christina, a freshman X-Country runner in high school presented with significant pain right greater than left tibias. Definitely she could not run through this pain. Bone Scans below documented a stress fracture only on the left side. The right tibia had generalized increase uptake of the dye which we call pre-tibial stress fracture or tibial stress reaction. Stress reactions can hurt just as much as a stress fracture, although heal quicker.

On this front view of the tibias, see the intense dye uptake in the middle of the left tibia. Since Christina is fourteen, she is still growing so her growth plates near the knees and ankles are still very active.

Here is a side view of both tibias with the left again showing the spot where the tibia broke.
This is also a good example of why MRIs probably would have mislead us in Christina's case. Christina had more pain on her right side. Due to the expense of MRIs, and the fact that each side has a separate cost, I probably would have only done the right side. I would not have found the fracture, and probably allowed her to run sooner. We never will know. So consider getting a limited bone scan instead of an MRI when shin splints are not improving. Thank you Christina for being a good model, but sorry your shins hurt.

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