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Monday, March 19, 2018

Abnormal Leg Sensations: Email Advice

Dear Dr. Blake: 

I wanted your opinion on an experience I have had off and on, day or night, for at least 20 years.  Recently it has increased and is worrying me.

I will have sensations that are hard to label, similar to very small contractions, twitching or pulsing in my legs. They are like phantom contractions because I have no pain and no actual movement of my legs.  I don’t feel an impulse to move the legs or walk.
Dr. Blake's comment: These may be dyskinesias or abnormal sensations caused by the sciatic or femoral nerves originating from a tension spot in the low back, cervical area, piriformis, hamstrings or calf. These are places that the sciatic nerve typically can be pushed on causing neural tension which presents in a third to half of these patients with these abnormal sensations. They can be from a slow clot or venous reflux formation and the irritation of the soft tissues. 

Doctors have dismissed the experience as unusual but not concerning.  Recently online I have learned it is not that unusual as others have the same experience.

I had a bad flu and over two months of very bad cough.  Perhaps unrelated but now I experience the sensation anytime I awake at night. It is primarily in my left calf and now in my left ankle and top of the left foot as well. The sensation is much stronger than before.
Dr. Blake's comment: Definitely get a doppler ultrasound to rule out a blood clot, and get a venous workup for reflux. Do you have any swelling? Have someone look at your spine with the possibility of a disc bulge could be causing peripheral nerve hypersensitivity. 

Additionally, my left calf is tight and I keep wanting to stretch it out.  I have been wearing hiking boots and that could give me some shin pain or tightness.
Dr. Blake's comment: A tightness in the calf that cannot be stretched out is sciatic nerve irritation or blood clot until ruled out. Then, you look for more minor problems.

I have wondered if these sensations are somehow related to mechanical issues that stimulate the body or brain in some way.  Perhaps related I have always had leg spasms that go away if I walk on the afflicted leg.
Dr. Blake's comments: I think leg spasms are always somewhat related to nerve irritability, perhaps coming off your back. What is your back history? Have you had surgery or sciatica in the past? 

Can you think of an explanation?  Should I get a Doppler? Yes I am going to Maui in April to boogie board in celebration of my 75th birthday so want to be safe flying!  By the way, I still try to jog and climb stairs but the flu and weather have prevented me from doing much.

Sunday, March 18, 2018

Oral Cortisone for Nerve Pain with Inflammation

Dear Dr. Blake
I wonder if you would be able to answer a quick question for me?  I'm here in the UK and have been suffering from neuromas in my feet (2 in each foot) for around 17-years.  The right foot was operated on in 2012 and now I have 2 stump neuromas (both >1cm).  The neuromas in the LT foot are also >1cm.

In an attempt to avoid further surgery I have had radiofrequency ablation, cryosurgery, alcohol injections, steroid injections etc.  None of which have really worked that well, though the steroids do help a bit.  The surgeon I have been seeing is reluctant to offer any more steroid injections because he is concerned about foot pad atrophy (he is not the surgeon who operated on the RT foot). 

My neuromas are causing me a lot of problems at the moment, though I can still cycle (which is a great passion of mine).  Later this year I plan to ride from Moscow to London, then at the end of the year, proceed with surgery.

My question is whether you think a course of oral prednisolone might be worth a try, just to get me through this exacerbation of symptoms/

Thanks so much for your help
Kind regards

Dr. Blake's comment: A 6 to 8-day course of oral cortisone to drive down inflammation is okay. Remember no strenuous activity for the duration of the meds and another equal time, including cycling! It can only be done once every 6 months! Rich

Two good articles:

This article above is great in cautioning it not to be used in skeletally immature athletes and limiting the total dose under 400 mg. But, there is no mention of not exercising while on it or for the next 6-8 days. This helps prevent bone problems like osteonecrosis, stress fractures, etc. From what I have read, these tips are anecdotal but an important precaution. One rheumatologist believes that any form of cortisone should be limited to once per month, with oral once per 6 months. The article below talks about the prednisone burst dosage and how wired people feel the first 4 of 8 days. Rich

This I wrote this article 8 years ago, I would add not to be used if you have Vit D deficiency or Low Bone Density, or any problems that cortisone may affect (slight Adrenal Insufficiency). 

Posterior Tibial Tendon Dysfunction with Accessory Navicular: Email Advice

Hi Dr. Blake,

I wanted your advice on my situation. I have been diagnosed with posterior tibial tendon dysfunction - stage II and accessory navicular syndrome. My doctor suggests the following surgical procedures: removal of accessory navicular, FDL tendon transfer and evans flatfoot. I had a recent MRI which showed some wearing of the tendon including a 1 cm tear. 
Dr. Blake's comment: As long as you are in Stage II, where there is no rigid deformity, you can undergo conservative treatment. So, if your arch looks close to normal non-weight bearing, you would be considered stage II, even in the presence of a tear. The tear needs to be treated with removable boot typically for 3 months, then ankle foot orthotics, then foot orthotics with posterior tibial taping or bracing. This should be done at the same time you are strengthening the posterior tibial, anterior tibial, achilles, arch, peroneus longus, and external hip rotators. This is a delicate matter and sometimes it is the inexperience of the health care provider in conservative management that leads to failure. You must find someone that can attempt to rehab this. 

I have been researching these conditions and come across studies which show that wearing an AFO with physical therapy can resolve PTTD. However, it is not clear to me if my accessory navicular or if my tendon tear would be an issue in the success of this protocol. 
Dr. Blake's comment: Definitely they are factors, but as long as your arch collapse is reducible when you are nonweight bearing, I would rehab. 

I would like to avoid surgery if possible but also do not want my PTTD to progress further.
Dr. Blake's comment: That is what is at stake. Surgery is very successful, but Stage II is fixable without surgery if it can be rehabbed. While it is being rehabbed, if the pain can not be controlled, and or the deformity of your arch gets worse, then you should sign up for surgery. I do not do this surgery, I have a wonderful podiatric surgeon as my partner, so I see the patients up to the point of surgery, and then 3 months after the surgery to finish the rehab. Whatever is done initially, if you eventually need surgery, then those same devices and skills can be used in the postoperative period. For example, the same AFO initially, can be used postoperatively until you get strong.  

Some more background: I am 41 years old and have been symptomatic for 4 years. Three years ago I wore a boot for 6 weeks and my symptoms seemed to resolve completely for one year. After that year I had some pain and limitations off and on but nothing that disrupted my life. I had not been wearing inserts until recently which I now realize was a mistake. Now I am in inserts and the air cast boot. 
Dr. Blake's comment: With or without surgery, orthotic devices can be vital, so I am glad you have a good pair. Begin strengthening, and stay in the air cast boot until you have your custom AFO made. Typically they start with a rigid model, and then as you improve, go to a hinged version for more mobility. Good luck!!

Thank you for your advice!

Useful review article: 

Saturday, March 17, 2018

Hallux Rigidus with Spurs: Role of Spica Taping

Dear Dr. Blake,

I am curious if you can see this Taping treatment as a way to restrict ROM for those with hallux rigidus + bone spurs in activities such as running (and other exercises that cause joint flexion)? I have been using a rigid foot plate for my hallux rigidus that was diagnosed about 6 months ago, but I believe it's throwing off my gait / causing further injury to my arch/heel/ankle. I am curious if you think taping could be an effective replacement treatment protocol for this condition... longterm! :) Thank you for this video, Dr. Blake! There isn't much info out there about using taping for hallux rigidus, so I would appreciate your thoughts!

Dr. Blake's comment: Yes, Spica taping is a very suitable alternative to carbon plates, without the dramatic effect on the whole body. That being said, there are many things you should do, and it is okay to rotate. I think using the flat carbon plates one out of workouts, maybe your easy workouts are great with or without the taping. You should develop with a local orthotic person an arch support that gets the weight centered on your foot with the arch part, and then uses a dancer's pad construction to take pressure off the big toe joint itself. Some shoes it will be good to skip the lace closest to the bone spur, and just design dancer's padding and use hapad longitudinal medial arch pads in shoes that cannot fit orthotics. If you have not tried the Hoka One One line, please do. The built-in rocker lessens the stress through the ball of the foot. Get some 1/4 inch adhesive felt from and apply on top of the foot just off the joint towards the arch. Usually, you use a one-inch square piece. For this problem, you can place another piece over the big toe itself (nothing over the spur) to help limit the bend of the joint.
But, I digress. Back to the taping. Once you are good with KT or RockTape, try to advance to 3M Nexcare Waterproof Tape and then Leukotape with Coverlet. These get stronger and stronger to do the job intended, but they are harder to work with so you better practice first with KT. The leukotape, the stronger tape I know, cannot actually touch the skin, thus you need the coverlet first placed on your skin. With 3M or Leuko start very loose to get used to it and the tension it gives. Good Luck. Rich
PS The key point, tape is good, but use other methods to take the pressure off the joint with it. If you are pronating, you must get a shoe that eliminates that problem, or the tape will not work in the long run.

Ankle Sprain: Email Advice

Hi Dr. Blake,

      I was googling Contrast Bathing for ankle sprains when I came across your website.  Thanks for the info!  I sprained my ankle on Jan 6 this year.  I knew it was really bad when it happened.  I've sprained this ankle now 4 times that I can remember and thought I could rehab with just home therapy after taking 2 days off work. 

     It's been up and down, aggravated by my overstretching and probably doing too much too soon.  Xray 5 weeks post-sprain was negative for anything acute and only showed an old avulsion injury.  Just had an MRI almost 10 weeks post-sprain which showed findings consistent with full-thickness ATFL tear.  I'm wondering if it's possible the complete tear can still heal this long post-injury.
Dr. Blake's comment: I have been around long enough to see the cycle go from surgery on these grade 3 sprains, to just rehabilitation, to some surgery. Truthfully, a lot of the success of rehabilitation has to do the expertise of the healthcare provider, or team, and the desire of the patient. I know too many patients who have had surgery, but probably could have rehabbed successfully, and I have rehabbed patients only having them need surgery down the line. It takes me a year of rehab on these sprains to decide on the few that need surgery, but of course, that is my bias from the start. 

  I've been off the foot as much as possible a good week now while waiting for the MRI auth and results during which the most stubborn area of the swelling has improved some.  But now that a peroneal tendon tear and OCD have been ruled out, I'm doing some weight-bearing and limited activity again. Any thoughts or advice you have would be greatly appreciated!
Dr. Blake's comment: A bad ankle sprain has on average 3.5 months of swelling which causes instability. You are right to do your contrast bathing daily, and twice on weekends. If you have functional instability, a feeling that you may sprain your ankle, you should wear an ankle brace during these stressful activities. Physical therapy is wonderful to progress you in terms of strengthening, especially the fast twitch muscles and proprioceptive nerve endings, and then return to activity. If you keep the 0-2 pain level healing environment as you decide what you can do now, each month for the next 3 months, you should be able to do more and more. One the best things if it is at all swollen is to wear a compressive wrap or sleeve when you sleep. Definitely start Single Leg Balancing now and progress each month making it harder and harder. If you have more specific questions, I will try to answer. 

Thank you so much,

PS: Here are some other videos that may help.

Friday, March 16, 2018

Short Leg Treatment: Email Advice

Dear Dr. Blake,

     I came across your blog online and am hoping that you will have a moment to read and respond to my question- I would REALLY appreciate it.  I am a 38-year-old woman.  When I was born apparently there was a glitch with the movement of my right leg that the doctor noticed and said might just go away on its own.  My parents never pursued it any further so I have no idea what was noticed when I was born or whether it is at all related to the current issue I'm trying to address.

     For many years I've noticed that my right hip and shoulder sit slightly higher than my left side.  I would typically walk with my right foot toes pointing out about 40 degrees.  My right knee has always turned in toward my left leg when I'm in a standing position.  A couple years ago I started wearing some Powerstep insoles on both sides, which helped turn my right knee out a bit straighter.  Growing up I was told I had slight scoliosis.
Dr. Blake's comment: You are describing a long right leg with more pronation or internal rotation on that side. When you stand is your right knee in and right foot out as mentioned above, or is it only in walking. You can turn your right foot due to the long leg and excessive pronation that collapses the arch and drives the right knee in with it in attempt to shorten that leg. 

     So, I've been to a couple chiropractors for adjustments and they said that my left leg was about 1/2" shorter and that my right hip was tilted forward, which they adjusted.  They didn't seem to really look at my legs or hips much but said that the leg length difference was because I needed regular adjustments. 
Dr. Blake's comment: The chiropractic world is to adjust out these imbalances that can start as leg length differences when you finish growing, and end up with pelvic tilts and scoliotic curves in the spine. Podiatrists, not skilled in these adjustments, tend to want to lift and support the short leg. It is an art though since there are many variables to consider and many ways patients adjust to lift therapy. 

     I felt that perhaps they didn't have much experience addressing these issues.  I think maybe I do have a structural leg length difference that has contributed to these other issues.  I tried a small heel lift on the left side but that seemed to make me feel more imbalanced on the right side.  Now I'm wondering if I should try a full length (as opposed to just heel lift) maybe 1/8" lift on the left side (in addition to the Powerstep insoles on both sides) and gradually work my way up to 1/2"?  If you think that's a good idea can you recommend a brand of full-length insole and over what period of time could I work up to 1/2"?
Dr. Blake's comment: I prefer full length lifts to balance the foot out throughout the gait from heel contact to push off. You can cut out the toes to give yourself room. You can go with simple Spenco Insoles without any arch, just flat. You can use the left as the first lever, if it feels okay in two weeks, try the right turned upside down as the second layer on the left side. The second layer you may or may not need to cut out the toe area, but keep the lift under the metatarsals or ball of the foot. For the third layer and possibly fourth layer, you will have to get another pair. You should feel better and more stable with lifts. If not, you should consider getting an AP Standing Pelvic Xray in normal stance barefoot to document the true structural leg length. 

Thank you very much!

Dr. Blake’s comment: Yes that sounds right. I tell my patients to get Spenco flat 1/8th inch insoles, you just flip the right one over to make a second left. If you are crowding the toes too much, you can stand on the insert, and mark between each toe. Cut out the area of the insert in the area of the toes. Typically you go 1/8th inch every 2 weeks.

My remaining questions after spending additional time on your blog-

Should I try switching from Powerstep to Sole insoles since those are what you recommend?  I have not tried the Sole brand before.
Dr. Blake's comment: Yes, you should try both to see what is more stable and fits you better. From my standpoint, they are both easy to adjust and customize for the patient. 

Just to make sure- would the full length lifts be placed under the Powerstep/Sole insole in the shoe?
Dr. Blake's comment: Yes, they go under the arch support. Hope this helps Rich

Thanks a million!

Here are some of my videos on short leg syndrome.

Wednesday, March 14, 2018

Scar Tissue Breakdown: Update from Patient

Hi Dr. Blake,

I've been trying to break down the scar tissue in my heel fat pad and so far the best success I've had is actually from an enzyme, Serrapeptase. The large bump I have has shrunk half in size so far. 

Dr. Blake's comment: I have seen the MRI showing this patient's scar tissue in the heel area. This enzyme is taken orally and can thin the blood, so if you take meds already for blood thinning, or that can thin the blood, you may have problems. Best to review with a pharmacist. I found it at Walgreens and they have pharmacists normally at all their stores to ask. 

Walgreen's carries it. Serrapeptase

Saturday, February 24, 2018

Hallux Limitus: Email Advice

Hi Dr. Blake,

I am a 34-year-old runner with Hallux Limitus and am hoping that you could help me. I have seen two podiatrists in my area (Lynchburg, VA) and they both have told me to just stop running. I run 20-25 miles per week (I did do a couple of 50k trail races last year but found that the steep up and down trails in the mountains irritated my toe). I am okay with not running these long races if it means that it will make my condition worse but I would love to be able to continue to run for many years.
Dr. Blake's comment: Hallux Limitus is either functional (which can be totally reversed with some arch support and dancer's padding to off weight), structural (meaning some degenerative process which will get worse and you still try to keep your pain between 0-2 and experiment with off-weighting and arch support), and structural and functional combined. If your big toe joints have some structural damage (typically diagnosed by x-ray or MRI), I would still run as long as you can in that 0-2 pain level. If long races increase pain, then you must avoid, but if 5-10 miles is fine, it is actually better for joints to have a pain-free high-level loading for cartilage nourishment.  

I do not want to ignore this and make it worse but rather run responsibly.
I have been running in Hoka Bondi's but I'm finding with the orthotics inserts a PT suggested I use (she has said I can continue to run), that the toe box is too small. I did try on Brooks Glycerin and Altra Paradigms and both shoes felt great but I'm not sure if they're great for this condition.
Dr. Blake's comment: There are some many factors that jam up the big toe joint, so it is experiment time for you. Definitely, find the wider Hoka One One shoes, they are out there. Hoka should be a great shoe for some of your running. Also, get a medium gel toe separator to see how holding the big toe in the center of its joint makes you feel while running. I love Brooks Addiction or Beast for the varus cant off the big toe, but of course, we do not want you to roll your ankle. Definitely, you want to see if those shoes, along with a 1/8th-inch dancer's pad to keep the weight in the center of your foot at push off. The zero drop shoes are good for metatarsal pain, but not good usually for hallux limitus. They put you back on your heels more, for pain reduction, but in most make it harder to push off. Some of my patients push off hard, and others hardly at all. 

Do you have any suggestions that will keep me running without irritating my toe or cause this condition to progress? Above If I take care of it and am cautious, does this condition always get worse? I would rather be proactive now than later.
Dr. Blake's comment: Have some weight bearing xrays taken of your feet, take photos of each frame, and send. Again, if it is primarily structural, you will have more work to do keeping in the 0-2 pain range. You would want to re-x-ray in 2 years and see what is happening. Arthritis is made worse faster by not using it, then if you can use in a pain-free environment. Look up the nutritional theory of cartilage development. Yes, if you have arthritis, and you push through pain, you will speed up the need to have joint replacement surgery. 

Also, do you know of anyone in the Central Virginia area that is up to date on this condition? 
Dr. Blake's comment: Call Richie and Company, an orthotic lab in Charlottesville, and ask who are the good biomechanics people in your area. They would know. Use my name. The owner is Brett Richey. 

Thanks so much. This whole thing has been frustrating and disheartening, to say the least. Also, I attached a picture of my most recent xray.
Dr. Blake's comment: The x-rays were poor quality and not sure if weight bearing. Have AP, Oblique, Lateral, and Plantar Axial xrays taken of both feet at some time and send me 8 individual photos. Please make sure they are weight bearing. Good Luck, Rich
Thanks again,

Monday, February 5, 2018

Considering Tackle Football for Your Youth: Please Read

This is a foot and ankle blog, but CTE, or Chronic Traumatic Encephalopathy, is bad and preventable. It is important as parents to at least discuss the subject when placing your child in a sport where CTE is a possibility. Is it Time to Ban Youth Football? When the Last Super Bowl be within the next 20 years? As a society, immune to change, unlikely. But, as an individual with a child you love, worth a few minutes of your time to ponder. Hate mail begin!!

Sunday, February 4, 2018

When Is 0-2 Pain to be Ignored?

This patient is recovering from a serious injury, and at some point had to ignore my advice to create that 0-2 Pain Level for healing, and Push Through The Pain. When do we Honor, and when do we push through pain? Email discussion

Dr. Blake

Reading that advice to maintain 0-2 pain level concerns me a bit.  If I hadn’t pushed through the 7-9 pain I’m not sure I ever would have come back from my problems.  I think the first period I had to try to offload it to heal but once that time had passed I kept trying to keep the pain low and that I think attributed to the rest of my body breaking down.  The one thing that changed for me was the area of the pain changed over time. At one point or another, I had serious pain in about every part of my foot as I got my strength back.

Dr. Blake's comment: 

Hey, Yes, you are right. The 0-2 applies to typical orthopedic musculoskeletal pain, not the nerve pain you had. With nerve pain, there is a time to Honor the Pain and a time to push through the pain. You had to learn when to do both. It is very hard to tell someone to push through pain because you are not sure if they are hurting themselves. Physios with nerve training, and docs also, can help people but it takes awhile to get a sense from each person. You have to then test the experiment, push the envelope of pain, and see how you respond. Thank you for this very honest discussion. I truly appreciate this. Rich

And the Patient Responses: 

Sounds like the guy needs to find a different doctor.  It really sounded like he's about to go down the path I did.  I went to 3 different Podiatrist and none of them knew what to do.  They all wanted to try to solve it with cortisone and I really think that is where my tears came from.  They didn't have those in the first MRI.   They would talk about surgery but I knew to go away at that point.   All Orthopedic surgeons I visited including Mayo, UAB, Andrews Sports Medicine and Birmingham Orthopedics said surgery was not a good idea for the situation I had.  The problem was they just didn't have a solution either!  

The more I think about it the more I think that shoes played a large role in my issues.  A Pedorthist told me that the New Balance shoes of all widths are now on the same footbed.  I believe that because I just can't wear them at all anymore.  If I put on shoes that put any pressure on the area I can immediately tell now that I need to stop wearing them.  Before I just thought it was "support".  Now I think it caused pressure on the area and caused at least part of the problem.  When the PT told me to get ASICS and I went with a larger size I could feel immediately there was not any pressure on the area.    I'm now getting into other shoes, boots etc and it takes quite a bit of time to find them wide enough but I know it when I find them. 

Wednesday, January 31, 2018

Insertional Achilles Tendinitis: Email Advice

Dr. Blake,

I have been diagnosed with insertional Achilles calcification in my left ankle. X-rays showed a pretty large buildup, which was actually the cause of a very visible bump on my ankle. I stopped all activity for 30 days and wore an elevated shoe, to avoid the boot. It helped but the pain is definitely less frequent but still there. I can’t get back to all of my regular activities I had enjoyed, like running or just horsing around with my son. Any period of activity of more than a couple minutes results in pain a couple hours later.

My ortho has suggested a boot for 30 days and if that doesn’t work, surgery. I read one of your earlier responses that icing down the area immediately after a workout is a good thing. Could I create more of an issue trying this and reincorporating activity or should I keep chasing a fix? My trainer saw the x-ray and agrees that it’s large enough to where it’s not going to go away.


Dr. Blake's Response: I have always taken the approach that pain from a bone spur is suspect since the bone spur has been there for a long time, so why is it just now hurting. I know that there is more to your story so I will add it on if you reply. When the "S" word is used, my deep-seated gut is looking for ways out.  You have to take out the bone spurs, and really just think of Achilles tendinitis at its insertion. How do we treat general tendinitis? The mnemonic is BRISS: Biomechanics, Rest, Ice, Stretch and Strengthen. The Achilles is now your weak spot that you have to make stronger. Maybe that will ultimately require surgery, but maybe not.
     The Biomechanics that help is a plantarflexed or pointed foot. This is why an elevated heel helped. Women have the advantage here by hanging out longer in wedges and heels and avoid flat foot. You must also take that rule and apply to stretching--only stretch to the ankle at a right angle, not negative heel, where the heel drops below the front of your foot. Strengthening you want to work the range first of your heel on a 1-inch lift and go up and down from there, not lower.
     The Rest is for Activity Modification. It normally takes 9 months to completely rehab an Achilles tendon. You are in month 2. The first few months are the Immobilization/Anti-Inflammatory to create a 0-2 pain level. The next Phase is Restrengthening. The final Phase is Return to Activity. You can not jump to Return to Activity now, that is reasonable. What we need in the good Physio approach to the restrengthening and gradual increase in activities.
     The Ice is anything that helps us reduce the inflammatory. Ice pack 2-3 times a day for 10 minutes is good. If there is a lot of swelling, then contrast bathing. You can use oral meds for 5-10 day bursts of the full dose, and then 2-4 days off to rest your system. Physical therapy and acupuncture are wonderful at reducing the inflammation, increasing blood flow, and PTs can give you exercise advise.
     The First "S" is Stretch. For any Achilles problem way down at the heel, the best stretch is the plantar fascial wall stretch. The second best is the soleus bent knee Achilles stretch. PTs have some heel. But, since stretching the Achilles in some cases is painful, you must consider only during deep calf massage to loosen its force on the heel. 
     The Second "S" is Strengthen. This is crucial for the achilles. Even relatively strong athletes can improve their strength 30-50% where it can help symptoms. Here is where range of motion comes in. You only want to strengthen the tendon from an ankle neutral to ankle plantar flexed position. Try to stay away from an ankle dorsiflexed position to start the strength work, like starting a heel raise from a deep squat or where the heel is dropped off the step. 
      These are some points I hope help. The more information you can share the better. Thanks and good luck. Rich

The Patient's Response:

I appreciate the response. This started early 2017, which had coincided with me picking up running after taking a break for several years. I was able to start doing 4-5 runs a week, typically on a treadmill, for 3-4 miles each time. I started noticing that my ankles would get very stiff several hours after running. I then started waking up with soreness but once I was moving around or running, the pain would wear off eventually, usually after pushing through. 

It early in 2017 though, it got to the point where the pain was constant and would last for days at a time. I am in Texas and a fan of cowboy boots and I noticed that wearing them seemed to help. After consulting with an orthopedic surgeon, it was determined that I had calcification at the Achilles. That is essentially where I currently am at. I will say that at this point, when I do have pain I can sometimes manipulate my ankle by twisting it around until it feels like it pops and that provides instant relief. I have avoided running but have replaced it with long walks and about 50% of the time I will have pain while other times it is totally fine. Basketball, tennis, anything with sudden side to side movement is out mainly due to the fear of pain from a couple of times I have tried it.

Dr. Blake's comment: This is extremely interesting, and it is good the pain is not constant. The fact that you can release pressure, means that the ankle joint is more involved. That sign of popping and feeling better is a joint symptom. I am hopeful you do not rush into surgery and give this proper time. Hopefully, some imaging can be sent here. See the blog post on WeTransfer. I would love to see a good MRI to look at the Achilles, spurs, and ankle joint. Good luck!


Saturday, January 27, 2018

Effect of Sequential Leg Compression Pumps

Dr. Blake attached are a set of photos showing my legs before and after using the pneumatic sleeve. The after is pretty much the way my legs after every use. However, there are times when my legs are quite a bit more swollen than is portrayed by this photo. If you would like additional photos. 
Dr. Blake's comment: I think this is hard to show, but the reduction of swelling is dramatic for this patient with the use of one hour a day Spectrum Sequential Compression Pump.

Thursday, January 25, 2018

Metatarsal Pain: Email Advice

Dr. Blake,

I hope this message finds you well. Thanks for the blog--it’s a great resource, I've been learning a lot from it, and I appreciate your therapeutic approach.

The short version: pain in the area of the right foot MTP joints on the underside of the foot, associated with activity, pretty well under control for now but worried about increasing activity levels in general and hills in particular.

The long version: healthy, active, 25yo male, lifted regularly, walked lots, went for backpacking trips with a heavy pack with no trouble for years, worked part-time in a commercial kitchen, etc. Tried to take up boxing in the summer of 2016, got some small but stubborn tibial stress fractures from skipping rope on concrete, took a lot of time off but gradually resumed activity (lifting, walking, dancing) with no trouble. Incurred some very small fractures in the left metatarsals in a motorcycle accident in March 2017, healed fully, resumed activity. A little pain in the left foot from time to time, but nothing that worried me.

After a couple of brisk hikes in late June/early July, I noticed some unusual pain in about the 3rd-5th MTP joints of the right foot, on the underside of the foot. Not tender to the touch, but a kind of dull throbbing on and off throughout the day. I thought it might be just part of the adaptation process--it had been a while since I had done any serious walking, what with coming back from the broken foot. And I had a short-term job that required a fair bit of loaded hiking (forestry), so I pretty much plowed ahead. The foot didn’t get any better, but it didn’t get dramatically worse, either; I was in stout, supportive boots (albeit possibly too narrow and with too high a heel, see below) during the day, and I noticed some pain when I took them off at night, but nothing crippling.

Still, I figured some time off would do me good, so after the job wrapped up in September I stayed away from running and hiking for a couple of months. The foot calmed down but wasn’t quite back to normal after six weeks off. Pain during everyday life was essentially zero, but eccentric calf raises with the forefoot on a block caused a lot more pain in the right forefoot than I would normally expect, so I saw a primary care doctor who ordered x-rays (attached--let me know if the attachment doesn't work) and referred me to a podiatrist.

The podiatrist diagnosed hallux limitus in the right foot--there was a lot of talk about “degenerative,” “never gets better”, “have you tried swimming, it’s great cardio,” etc. I didn’t care for the sound of this, not wanting to go back to working at a desk, and the podiatrist didn’t strike me as the most competent. So I sought a second opinion from a local AAPSM/ACFAS guy who had a fair bit of running experience (former D1 distance runner). I also began a walking/jogging progression, very conservatively, while avoiding anything I knew aggravated the foot. In particular, I noticed that time on the stairmill and on a steeply inclined treadmill seemed to cause pain out of proportion to impact, and forefoot striking when I ran also made things noticeably worse.

The second podiatrist said that hallux ROM was fine, he didn’t see any swelling, no tenderness to the touch, and encouraged me to experiment with shoes and over-the-counter orthotics and running surfaces and to stop walking around the house barefoot. He didn’t see anything unusual or alarming about my gait, and noted that my feet were a bit flat but not necessarily in need of an orthotic. His diagnosis was “metatarsalgia, like a bruise--not a stress fracture”. This was in about the first week of December.
Dr Blake's comment: This is why I love the AAPSM. Right or wrong, good overall approach. Sounds like nerve to me, and I am glad you had no Hallux limitus. Did he check your achilles for tightness? This is a big reason why patients get metatarsalgia. You work on the 3 causes of pain: mechanical, inflammatory and neuropathic. Mechanical is dropping the heel height, stretch the Achilles tendon, and Hapad longitudinal Metatarsal Arch Pad Small just behind the soreness. Inflammatory with icing or warm water soaks (have to see what feels better). Neuropathic with pain-free massage, Neuro-Eze gel, Neural Flossing three times a day. These at least for what we know now. 

I ended up in the Altra Olympus, very happy with them for walking and running, and somewhat happy with Altra’s desert boots for casual wear. (I tried Hokas, but even their wide sizes were a touch narrow in the forefoot for me.). A felt metatarsal pad on the stock insole (for both feet) also helped a good deal. I found that easy running on grass with a heel strike and a high cadence didn’t seem to make things any worse, and got a pair of cushioned flip-flops for walking around the house.
Dr. Blake's comment: You are doing everything right. For those that do not know Altra shoes, they are all zero drop, meaning no heel lift to put pressure on the front of your foot. I love the big Hapads to spread the force. You may have to thin out. The small size is usually perfect. 

Hapads on top of Orthotic Device with various pads under forefoot to accommodate or cushion

Since then, I’ve been titrating up the jogging, taking it easy and staying on grass, adding 5 minutes here and an extra session there, and I still seem to tolerate it pretty well, so that’s all to the good. I’m down about 5 pounds from 200 in December to 195 now and plan to drop another 5-10 in the coming months, which should also help. I’ve been supplementing D3 and K2 for years and have continued to do so, along with milk, yogurt, and a calcium/magnesium supplement. I've also been lifting and it doesn't seem to cause any pain. Two things have given me cause for concern.

The first was a hike I took on December 26 or 27. About 11 miles round trip with ~3000 feet of elevation gain, a big day out but the sort of thing I would have done without a thought before the motorcycle accident. I was in Asolo TPS 535 boots with Sole orthotics, a combination that had never given me any trouble on backpacking trips and big hikes before forefoot problems started. (Different pair of boots from the ones I had worn over the summer--I hadn’t really worn these for any major hiking since the forefoot problems had started.). By the time we got back to the car, my feet were in quite a lot of pain--both feet, dull throbbing pain pretty much all across the MTP joints, and also some “spiky” pain in the area of the right sesamoids. Outside of the 0-2 range, definitely not the normal soreness I would have expected after an unusually big hike. The pain was probably 90% back to normal and back to normal within a week, where “normal” means “maybe a little sensitive in the right 3rd-5th MTP joints with occasional fleeting mild soreness here and there, but essentially no pain and no discernable pain with everyday activity.”
Dr. Blake's comment: The problem was the new unbroken-into shoe, and a more then what you were used to hiking. It sounds reasonable it should have flared up with the shoe was not flexible enough at that moment allowing more stress to the tissue. Glad it calmed down. 

The second was a few days ago when I tried to stretch my calves by standing on a block with my heel hanging off and letting the heel drop. Felt fine at the time, but about three hours later, I noticed a dull throbbing pain from the right 3rd-5th MTP joints, which came and went periodically for the next 24 hours or so. I’ve been icing for 10 minutes 1-2x/day for the last few days as per your blog--too soon to tell whether it makes a long-term difference, but it sure seems to help acutely. I'm also going to start contrast therapy. Again, the pain was pretty much back to normal (so, a little “sensitive” or “tender” but essentially zero real, consistent pain with everyday activity and jogging on grass) within about three days.
Dr. Blake's comment: This is called placing your foot in a negative heel position and all the weight on the forefoot. Another unusual stress that irritated things. These are benchmarks for what you can and can not do this month. Typically they are not permanent in any way, but you are not ready for that for the next 3 months. Then you can test it again. Were you doing it single leg or double? Less stress with double. 

Anyway, what these two incidents (together with my earlier experiences with the stairmill and inclined treadmill) suggest to me is that even though I can run a bit on the flat, hills may be a problem. But I’d like to work in forestry again this summer, and walking up hills is a pretty central job requirement. And it’s been six months now, including two months more or less completely off--seems like a long time for this not to heal, given the circumstances.
Dr. Blake's comment: Please experiment when you are doing at risk things only either the double loop Budin splint (loops on the 2nd and 4th toes) and a carbon graphite plate under the insert you are wearing. These are only for the times you feel you should have the extra protection. 

So: any recommendations for reintroducing hills? Any suggestions for thinking about how much heel my work boots should have, other than trying various different things and seeing what’s comfortable? (For reference: high heel like what I wore last season, lower heel.). Anything I should be thinking about that I’m not? Anything I shouldn’t be thinking about that I am? Should I worry more, less, or exactly as much as I am that this is the first inkling of a degenerative condition that will lock me into a desk job forever, or at least for next season?
Dr. Blake's comment: Your thought process is wonderful, and we are dealing with some many variables: heel height, stiffness or lack of flexibility more like, tightness of shoe. The tissue is stressed by holding the stretch for a long time, like the negative heel stretch, making it too hard to bend through (like with the new shoe), explosive actions, high impact. Try several shoes and pick the one with some flexibility but some cushion (not weighted heavily on either side). Try to be mindful to reduce stress in your actions, whether that is slower, or gentler, or using your arms more to push you up. Do not favor or something else will go wrong. Ice daily whether you think you need to. Experiment with the plates and Budin splints or hapads, but try to change the environment. Work through times that get sore even if you thought you were getting it right. Healing should occur, even with these ups and downs. Good luck Rich

I think that’s about everything I wanted to ask, together with all the relevant information. If there’s anything else that would help you give an informed answer, feel free to ask. Thanks for reading, and thank you for your time.


Wednesday, January 24, 2018

Sesamoid Injury: Email Advice

I have been corresponding with this patient over injury to the sesamoids. Here are some of our recent conversations. 

     I reviewed the MRI which shows you have bone edema in both the tibial and fibular sesamoids, and also the joint, and also the soft tissue. It is one unhappy joint. For mineralization of the bones we need protected weight bearing with orthotics and dancer's pads. You need to be doing icing twice a day and contrasts once a day. You need to see if you can get the Exogen 4000 bone stim, like Harry Potter's broom!! You need some PT to de-inflame the joint, and help with the off-weighting. No surgery since more than one thing wrong and you can not be sure if it is the sesamoid and which one that is bothering you. A new MRI in 6 months to check progress is important. No NSAIDS or cortisone shots since they are bad for bone healing. No surgery should be needed, but it may take awhile for impact sports again. No guarantees, however. Have your overall bone health checked. Questions? Rich

The patient's response:  Wow, that is a lot of problems with my foot. Not good at all. Thank you so much for taking the time to review my MRI. As I suspected, my local doctor told me today that after reviewing my MRI, he wants to put me in a cast 4-6 weeks, preferably go on disability, he fears a possibility of Avascular Necrosis in the sesamoid bones. He even mentioned a steroid shot! Aggh. After the 6 weeks of casting, I should heal then begin retraining my foot to walk. If all fails he wants to remove the sesamoid bones. Aggh. What a way to start the new year. I wish you had a local office nearby. Lol. I asked if PT could help, he said it would just make inflammation worse. 

Dr. Blake's response:    Good luck my friend. See if you can push for a CT scan in 6 weeks to see the true shape of the bones. The MRI is vague sometimes when there is some much inflammation. The CT scan only shows the bones and many times shows things better then they seem. A CT scan is always good when the phrase "avascular necrosis" is being waved around. Please push also for Exogen bone stim. It is a commitment to 9 months of conservative care. Rich

     Hi Dr. Richard Blake, just an update. So today I got my cast put on. I took 2 months off work, and I'm doing my best to stay off my foot 100%. I'm using a knee scooter to get around the house and using crutches to move outside the house. I've been offloading all the weight of my right foot that now my left foot is aching near the same spot in the ball of the foot of my left foot what😥 a bummer. So I still want to get the device you recommend, Exogen 4000. But my doctor says it's to expensive and that it cost thousands of dollars and that my insurance won't cover it. He's right, my insurance won't cover it, so I'm still looking around. I found one on eBay used, does this look like the device? If it is I'm willing to buy it out of pocket. But my question is, could I use this with a cast on? Is this the one you recommend? 

     Doctor, from your personal and professional opinion, do you believe the 6 weeks of cast should fix my issues? I'm really scared of not being able to do any sport activities again like running and hiking. I just had my first daughter 6 months ago and I really want to be able to do sport activities with her. I'm afraid of the 50/50 possibilities my current doctor is giving me. He says there is a 50/50 chance the cast does not work and we need to do surgery. I asked him if he believes if this should work and he says according to all the literature, it's the best approach. I'm afraid he has no actual experience with this sesamoid issue. It's so hard to find a doctor that knows how to treat this. I feel like a guinea pig with my doctor. 

Sorry for my rant and for bothering you, but I'm at a lost right now. I truly do appreciate you taking your time to even read my emails.

Thank you,

Best regards,

Dr Blake's response: Any of the Exogen 4000 units should work. You are getting it to start a one year process of healing, with the 6 weeks of casting just the start. You should be at a 0-2 pain level and you then advance to a removable cast weight bearing for 2-4 more months still keeping the 0-2 levels. The bone stim should lay on the top of the big toe joint twice daily for 20 minutes so the cast would have to be opened up by the doc or you wait until the cast comes off. See all the advice in this blog on the treatment post-boot. Rich Good luck!!

OTC vs Custom Orthotic Devices: Dr Blake's Powerpoint Presentation

Monday, January 22, 2018

Several Modifications to Classic Plantar Fascial Stretches

I hope I am never too old to keep learning. This wonderful video on plantar fascia presents 4 stretches for plantar fasciitis sufferers. The first two for the gastrocnemius and soleus are common, but he discusses a variant of my plantar wall stretch and introduces the importance of stretching the anterior tibial tendon. I have included my video below James Dunn's video for your comparison. Thank you, James. I can not wait to try these versions and get my patients feedback. It is how we learn.