Tuesday, May 3, 2016

Stinky Feet: Check out this video

https://youtu.be/pK8Sw3JRieM

Posterior Tibial Tendon Treatment Advice

I just updated the video taken on a trip to Maui on the treatment of posterior tibial tendinitis. I hope you enjoy and it helps you. Take this injury seriously, and get the right treatment quickly to get the symptoms down to 0-2 pain level. 


https://youtu.be/T47lVsjMEJg?list=PLuAexfdWrwEzPU7t9GErZEa0KabjoDPnY

Monday, May 2, 2016

Podiatrist's Biomechanics Corner: Email Advice

Hi Dr Blake,

I had a patient present today with some mild back pain, right foot pain, previous history of anterior right knee pain. No symptoms on the left side at all. He enjoys hiking and running.
Dr Blake's comment: As you begin to sort out the historical clues, you often see patterns of dominance to one side or the other. Since there are many reasons for this syndrome, all we can say now is that he has a more injury prone right side. 

No history of trauma and no medical conditions.
Dr Blake's comment: With no history of trauma, the biomechanical assessment of the patient will probably play a big part of his pain syndrome, likely related to overuse. When you overuse your body, the weakest links in the chain (called biomechanical faults) start to complain first. 

Based on these unilateral symptoms, I wanted to check if there was a limb length discrepancy. The iliac crests and greater trochanters were level, and the block test felt unstable on him for both the right and left foot at 3mm thickness.



On gait examination, there was slight right shoulder drop, left arm further away from body, both hips were slightly externally rotated, more tibial varum on the right compared to left, right foot supinated and left foot neutral. 
Dr Blake's comment: The right shoulder drop can be just the rounding of the shoulders. I like to look at the finger tips also to see if the lower shoulder is on the same side as the lower finger tips. A true shoulder drop can signify a short leg, a shoulder or neck injury (no history here), or a scoliosis. The whole trunk can be pulled to the side of the shoulder drop which is called limb dominance. The opposite arm can be further away from the body to equalize the fall to the limb dominant side. The external hip position is of unknown significance now, and the greater tibial varum generally leads to a greater supinated position (in this case on the right). 
 
RCSP was 4 degree inverted for right and neutral for left. Supination resistance was low for right and moderate force for left. Jack's test was low for right and moderate to hard force for left.
Dr Blake's comment: So, we have an inverted foot on the right and moderately pronated foot on the left. In classic biomechanics, you can assume that the short foot is the right and longer, more pronated foot, is the left. 

My diagnosis was possible sciatica, 3rd MPJ plantar plate sprain / capsulitis on right and non painful functional hallux limitus on left. Could not reproduce the symptoms of his right knee pain and there was no joint crepitus or limited knee ROM.
Dr Blake's comment:Excessive supination on the right side is a irriation to the low back causing tightness in the hamstrings as the knees straighten. The anterior knee pain may be medial meniscal compression syndrome due to the varus thrust at the knee from the rearfoot supination, or just a pinching of the anterior synovium from knee extension. The excessive inversion of the foot would place pushoff more lateral off the first/second rays and onto the weaker 3rd ray. 

Based on my assessment and diagnosis, I feel that the LLD is functional instead of structural and am thinking of using orthotic therapy instead of full length heel lifts.
Dr Blake's comment: With level Iliac Crests, and Greater Trochanters, negative block test, unless you get a Standing AP Pelvic Xray in Normal Stance, functional LLD makes sense. Functional LLD means the right side is functioning asymmetric to the left. And it sure is!! But the compensation for a structurally long left leg, with excessive supination on the right and excessive pronation on the left can present like this. Keep a Plan B!

For the orthotic design, I was thinking of reducing the supination on his right foot using a Root balanced orthotic, lateral Kirby skive, lateral arch fill and leaving the anterior edge of the orthotic to full thickness so that the force is transferred away from the forefoot and towards the midfoot / arch area.
Dr Blake's comment: So we are on the same page, when you want more lateral support, you tell the lab to have less lateral arch fill. I have not done the part of leaving the anterior edge thick (like a met bar), but makes sense. I would typically skive out more met arch in the plaster before pressing to get more met arch (maybe the same??). See the video below and make sure he can get to vertical on the right to know where to balance the heel to. 


For the left foot, I plan to reduce the pronation through a Root balanced orthotic and reduce the functional hallux limitus by adding a reverse Morton's extension.

Since his left foot and leg is asymptomatic, I AM not sure if I should I add a medial Kirby skive, increase the width of the orthosis and reduce the medial arch fill to minimum? I do not want to cause any new symptoms for his left foot.
Dr Blake's comment: I think your approach is fine on the left, although the moderate Jack's test may need alittle more inversion. I love to place in the heel this inversion force, so a medial Kirby or 15 degree inverted pour would work subtly. 

 Thanks for reading and your thoughts on this are greatly appreciated.

Regards,

Sunday, May 1, 2016

Plantar Fasciitis and Arch Taping from Support The Foot.com

My wife Pat and I had fun putting together this video for you on taping for plantar fasciitis and other forms of arch pain. The tape is called quick tape and the company website www.supportthefoot.com. It is quickly becoming my favorite way to tape for these problems due to the patient's ability to self tape and the consistency of the support given. Good luck with your own experiment. 




Saturday, April 30, 2016

Posterior Tibial Taping: Ask The Podiatrist Segment #1

I am very proud of this video, and another part of my career, taking more questions from you. This will be different then my normal emails. I am asking for a more personal relationship. The questions to be answered each week need to be mailed to: Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. I am beginning today on April 30th, 2016, now 6 years after starting my journey with my readers and followers. Please make sure you subscribe to my YouTube channel and Blog. Thank you so very much. Rich Blake



Tuesday, April 26, 2016

Dr Lance Silverman's blog: Good Reading

http://www.anklefootmd.com/running-can-improve-bone-density/

I have signed up to follow Dr Lance Silverman's blog. He brings up good topics that affect the foot and ankle and I thought my readers may find very useful information there. Dr Rich Blake

Monday, April 25, 2016

Plantar Fascial Tear: Email Followup

Hello Doctor Blake,

I hope you are doing well and enjoying the spring so far.

I am way overdue giving you an update on the recovery of my right foot from the torn plantar fascia. 

I've been out of the boot since mid-March (just over a month).  For the most part, I'm pain free when walking just around the house and the office.  My stride is becoming more normal as I try to remember how to walk.  

I'm still wearing the tape, except for the last few days when I simply didn't put it back on yet.
Dr Blake's comment: Support the Foot tape www.supportthefoot.com

Right now, I can walk about 3/4 of a mile to a cafe, sit for a while, and walk back with relatively little discomfort.  I have no discomfort when I walk, but when I'm home, I feel a little bit of tightness and soreness in the arch right where it meets the heel bone.
Dr Blake's comment: At this stage of weaning out of the boot, I have not let him begin plantar fascial stretches, so this tension is normal. Also, not sure how much icing he is doing. 

Last Sunday, I put my foot to the test: I walked about 1.5 miles to a local cafe, then took the long way home (~2miles).  I felt little discomfort while walking (and I felt elated to be able to do this), but when I got home, I had some intense soreness in that exact same spot (where arch meeting heel bone) that reminded me of the pain I felt walking around Europe in October, before the MRI and the boot.  Icing and massage didn't make it go away much, but the next morning I felt no discomfort and took it easy on Monday - Wednesday.  Thursday was my follow test: walked 3/4 mile to a local cafe and back.  I felt no discomfort while walking and only a tinge of tightness after I got home for the rest of the day.  That seems to be about the right amount of distance for now.
Dr Blake's comment: This is also normal, and not considered a flareup, if the pain resolves in several days. We have to have patients test it and work through good pain, and try to avoid bad pain. 


The Emeryville PT folks have been great.  They feel that I need to work on two things: [1] ankle flexibility and rotation and [b] gluteus muscles.  They say I have a dipping hip on the right side when I walk, so they've got me working with a band to do all kinds of gluteus strengthening exercises.  They also have me doing calf and hamstring stretching and finally have me doing calf lifts to strengthen those muscles.  I'm getting stronger on these muscles, but it's a slow process.

What do you think?  Are these the right exercises to be working on?  Should I be doing other things?
Dr Blake's comment: Avoid negative stretching, but begin doing plantar fascial stretches gently 3 times a day. the upper and lower hamstrings are also important. See the below videos. 

https://youtu.be/JZpcapqBnZg

https://youtu.be/KEFpJaMwEtQ


Any advice about walking too so I don't feel that soreness at my arch/heel bone connection?
Dr Blake's comment: Make sure you work on distance covered, not speed or hills just yet. Walk 3 days per week with the longest walk on one of the two weekends. If you bring the removable boot in a backpack, you can continue to weekly push the envelop and stop if the pain begins during the walk. Whether you hurt or not, ice for 15 minutes after each exercise walk. Besides the exercises above, you should be strengthening with the following exercises each evening to get your feet and ankles strong:

  1. met doming
  2. single leg balancing
  3. posterior tibial theraband
  4. peroneal longus theraband
The PTs can show you if you do not understand them on the videos below. Give me another email in one month. Rich


Thanks and I hope you're doing great.

Quad Sets: Simple but Effective for Runner's Knee

https://youtu.be/K4O3RQKlAxQ

    The top 10 initial treatments of Patella problems are:
  1. Create a pain free environment.
  2. Ice 30 minutes 3 times daily
  3. Start Quadriceps strengthening painlessly on day one
  4. Stretch the quadriceps and hamstrings 3 times daily, although avoid knee flexion over 45 degrees (Too much knee flexion for kneecap pain)
  5. Knee Brace for Patellar stabilization like Bauerfiend Genutrain Knee Brace
  6. McConnell knee taping with Leukotape and underwrap or KT taping.
  7. Core Strengthening for external hip rotators, including gluts, iliopsoas and piriformis muscles.
  8. OTC or Custom inserts to stabilize any overpronation tendencies, or just varus cant. Goal is to get the knee to function in the center and not internally rotated.
  9. Use activity modification to get cardio without irritating the knee. Consider raising the seat in cycling to prevent too much flexion (over 45 degrees the patella starts pushing hard on the femur). 
  10.  If it is a running injury, shoes are crucial for stability. Have a good running shoe store help you pick out a great stability or motion control shoe for you.

Your shoe selection should help avoid the heel valgus where the heel rotates outward driving the knee inward too far. 

Sunday, April 24, 2016

Massage Balls for Chronic Foot Pain and Tension/Tightness

More and more of my patients with a variety of foot problems have turned to these spiky massage balls to help with their conditions. And, I have noticed some help to many patients. I love ice for inflammation in the form of a frozen sports bottle, or heat for tissue loosening with warm water in a metal bottle, but there is a place with chronic conditions just to massage. The author of this video describes four arches in the foot and the gentle massage to each. 


https://youtu.be/qPg8JJVbsp4

Short Leg Syndrome: Advice for Treatment

video
Short look at the fish from Hawaii I tried to take home to San Francisco with me.



Subject: Re: Leg Length Discrepancy - Please help!

 Dear Dr. Blake,

 I am not sure if you do provide your advice through email correspondence
but I am taking a last plunge to try to contact someone who may at last
 have the requisite knowledge and experience to help me with my problem as I
 have just about exhausted every other avenue! I have just read your 2007
 Podiatry Today article on LLD and for the first time have read an article
 that so accurately describes many of my own conditions.

 I have lived and worked in Hong Kong since 1992 although I am originally
 from Liverpool, England. I am now 40 years old and I have been a  passionate
 runner for the last 15 years. I stepped up to marathons about 6 years ago
 and am now training for an ironman and have entered the 2016 marathon des
sables race across the Sahara.

As a child I broke my left femur aged two and my right femur aged three.
When I first started to get running injuries, a chiropractor diagnosed that
I had LLD and taught me several stretches to alleviate tightness that was
resulting. He informed me that I had naturally tilted my pelvis forward to
 compensate, had slight scoliosis in the back but that this wouldn't worsen
and that as long as I stretched I would keep the injuries at bay.

At this time I wasn't running too many miles per week and so the stretching
 worked. Then, I stepped up to marathons and the real problems began. I
 sought advice from physios and chiros again and was constantly told I
needed custom made orthotics which I duly bought but hardly wore as they
 were far too restricting for my running.

I would go though periods of being injury free as long as I continued to
stretch and strengthen BUT I really struggled to put two consecutive
quality training days back to back, always having to hobble the day after a
 good session.

 On hitting 40 I decided to go for a PB in the London marathon - training
135Km per week and succeeded in running 2hrs 32 mins. To achieve this I  had
 my lower limbs x-rayed to find out the exact LLD which was 2cm in my right
leg. I therefore experimented with different insoles and ended up putting
 an 8mm insole in the right shoe. This just about got me through the
 training but I was never really pain free and it nearly put me off running
 altogether.

 I do severely overpronate in my left foot - no doubt to also compensate
for the shorter right limb and so I would like your opinion on whether or
not the insole solution is all that should be required or if I should
combine it with orthotics somehow?

What I don't understand is that when I have been measured for orthotics,
 my LLD has never been taken into consideration and surely I only
overpronate to compensate for LLD? So what good are orthotics for me?
Surely if I correct the LLD I wouldn't overpronate as the left foot
wouldn't need to? In addition, as the first Chiro told me, over the last
 thirty plus years my body has adjusted itself to deal with the LLD and so
exactly how much insole should I be using? surely not the whole 2cm as
there has probably been too much ligament/tendon change to be able to
simply measure the LLD and substitute it with an insole (although 2cm is
too much to put in one shoe anyway)

 I would love to be able to run pain free and be able to near the end of
 long runs without feeling the tightness in the hamstrings and glutes which
 I inevitably get nowadays and that really slows me down. I am still a
 competitive runner but lose so much training time because I cant run pain
 free on consecutive days. I am just looking for qualified advice instead  of
 from non-sportsmen who have little understanding of the punishing training
 regimes i undertake to achieve my goals.

Any help/advice would be greatly appreciated!

 Kind regards


Dr Blake's comment:
Thank you for your email. I will try to analyze this for you and set some direction. This will definitely have to be multiple correspondences. As I ask you various points, please respond back in the comment section or by my new email address in the headings section, and I will put in the comment section.

     First of all, one assumption is always made in this scenario that the leg length discrepancy is responsible for most of the symptoms. Correction of the severe over pronation of the long left leg may be the answer to the remaining soreness. The orthotics designed must have much more correction on the left side to fully correct the pronation, compensatory or not. One approach is to stay with the 8 mm lifts on the right for now and work with someone who can fully correct the left and right foot pronation. Pronation causes anterior tilt of the pelvis leading to its own set of hip, pelvic, and low back pains. Golden Rule of Foot: Do not under treat the asymptomatic side. There are so many types of orthotic designs out there that you should be able to have one made that is not too rigid.

     Secondly, when dealing with the leg length difference, you need to correct the limb dominance. When watching someone walk, run, or cycle, you can note which side that they place more pressure on. If you watch the head, it will normally sway side to side, but when there is limb dominance, the head tends to stay to one side. This tells us what the spine is doing. Patients can normally feel when there limb dominance is corrected, under corrected or over corrected. I would recommend not worrying if you have 8 mm, 9mm, or 20mm lifts, but with each sport or activity analyze what amount of lift corrects for this limb dominance. With various patterns of scoliosis and hip/pelvic tightness, which affect different activities differently, you may have a range of what corrects this out. But be stubborn at analyzing this. Another Golden Rule of Foot: It is better for stability to use full length lifts than heel lifts when treating leg length differences.

     I am assuming that you are limb dominant to the right, but are you? If you are, greater pronation correction on the left will pull you to the left, and you will need less support. See how this works in general. What happens on the right affects the left and vice verse. You could have someone film you from the back on a treadmill running at 7 min/mile pace, no incline, first focused on the heels of your shoes, and then your whole body, and email me with it to look at.

     Thirdly, if you can get great orthotics that equalize out your pronation, stand in them when you take another standing AP Pelvic xray. I have my patients wear their orthotics, shoes and lifts when taking this xray to know the exact difference the patient is still off (even though the radiologists can never say what the difference is with all this in their shoes). Sometimes this information is very helpful to get motivated to put more lift in the shoe itself. The mid sole of shoes can have some or all of the lift with care to allow the metatarsal area to bend. Many shoe repair shops do this well, or pedorthists in the US.

     Fourthly, consider Sole or Your Sole inserts (www.yoursole.com) as one possible orthotic correction device. Get the soft athletic version, and heat them to custom fit. The lifts on the right side go underneath, and should be full length, at least to the metatarsals. The left arch can be built up by adding material. If someone in your area understands varus wedging for pronation control, then the left side can be varus wedged more than the right. Running shoes can also be varus wedged up to 3/8 inch in the mid sole fairly easily, and along with power lacing, can take some or most of the responsibility away from the orthotic devices to control the pronation. This usually makes the orthotics more comfortable.



Golden Rule of Foot: You are never far off  base if you strive to make the bio mechanics more stable.

     Fifthly, as a maturing athlete (hope you take no offense!!), quality workouts four days a week in the main sport (running), mixed with cross training 2 other days , and a full rest day off per week, makes the body stronger, more  resistant to injuries, and perform at a higher level. When an athlete comes from a 80+ mile/week background, it is hard to find happiness when not working out at full speed daily. This area may need some work. There are many great coaches, like my buddy Marc Evans, world renowned triathlon coach. See his website at www.evanscoaching.com.

    Sixthly, you really need a good hamstring, quadriceps, hip muscles, low back/core strength review. Sounds like you know what muscles to stretch, and this predictably helps you. If you have a scoliosis, this evaluation can go higher. Even asymmetrical shoulder strength can put an abnormal torque on your pelvis (remember right hip functions with the left shoulder). I have found so many athletes, even world class runners, with poor hamstring strength for example. And I think it is even worse when it is asymmetrical.

     So, I hope this helps you in some way. I am happy to help you further by having recontact me. Good Luck!!

    

   

    

Saturday, April 23, 2016

Hapads: Good OTC Foot Support

Hi Doctor quick question.  Can you double up on hapads when I place them in the shoe? In other words can I put one on top of another? I have a bad case of metatarsalgia on one metatarsal for close to a year.  Thanks 

Dr Blake's response: For sure. Hapads are nice since you can add and then peel some or trim some of the thickness back as needed. Rich


https://www.hapad.com/

Tuesday, April 19, 2016

Possible Nerve Injury Post Sesamoid Removal: Email Advice

Dear Dr. Blake!

I found your website when i was looking for some answers for my questions about my problem. I found so many useful things still im clueless a lil bit. 10 years ago i had a fractured sesamoid bone what was removed by operation. Since than i have constant pain in my foot,My doctor told me as in thefoot there are so many nerves its possible that some of them got hurt and thats why im having the discomfort feeling.I learned to live with it but lately i cant even step on it. Soon after the operation I left my country (Im from Hungary) and moved to Spain. Its been a while ive been working in catering, restaurants so im always walking or running. the skin of my big toe and the one next to it feels weird like numb. when my boyfriend massages it feels so much better though i dunno he does good with that. sometimes  when i walk i cant step on it cos it feels like im stepping on needles thats why im putting my weight on the other side of the foot but now my ankle and knee started hurting because of that. I am really sick and tired of having that pain all the time. im only 5 feet tall and cant  bare high heels! im about to see a doctor cos i need to do something about it but if you have anything in mind any advice i would appreciate it.
Thank you forward!

Dr Blake's response:
     Thank you so very much for your email and I am very sorry for your dilemma. I will be walking the Camino de Santiago in Spain in September. Your symptoms sound very much like nerve entrapment. You want the doctor to try to find out if the nerve is hung up in the scar or in the joint itself. This can takes many injections into the scar to see if he can deaden the nerve for 5 hours or so with long acting local anesthetic. If that can be identified, then injections with cortisone or enzymes can help. If not, then a second surgery to find the damaged nerve and possibly remove it like they do with Morton' neuroma. Nerves at this level are just sensory, so you are only left with some numbness.
     If you read through my blog you can see other treatments to try for nerve pain (like NeuroEze) or sesamoid pain (like icing, dancer's pads, and spica taping). I hope some of this helps. Please keep me in the loop. Rich

Saturday, April 16, 2016

Possible Sesamoid AVN: Email Advice

Dear Dr. Blake,

First of all, thanks so much for the invaluable website. Your knowledge - and the experiences shared on the website - have provided me with so much support and education whilst I've battled through the
sesamoid minefield!

Here are my details:
  • Active 27 year old;
  • Pain in the area of my right lateral sesamoid for about 5 weeks;
  • Before the pain started I ran about 5 miles 3 times a week;
  • I think a spin class, in which I had to wear tight fitting cycle shoes and pedal right over the sesamoid area, triggered my pain, but from MRI images my doctor thinks it has been fractured for years.
For the first week or so the pain was intense. So intense I could walk only on the outer edge of my foot.  So intense it kept me awake at night and even the pressure of the bed sheet hurt!

After the first week the pain got much better - I started wearing a gel dancer's pad and think that helped to take off the pressure from the area.

Since then, the pain is always there, but it's minor. I can walk "normally" and the pain is a 2 or 3. It's just really annoying. Occasionally it gets worse and is more like a 4 or 5; doesn't seem to be any rhyme or reason to this - it can get worse even when I've been lazing around all day and haven't been on my feet much.

I'm too scared to run - it feels like I'm living my life on a tight-rope right now and that one bad move will put the pain right back up and undo any healing I've helped promote. Does that make any sense? I'd give anything to put back on my running shoes and go for a run - I don't think it would cause pain during the run but I'm terrified of making it worse.

My doctor thinks my lateral sesamoid is AVN and said the MRI shows "signs of degenerative change" around the area. 

His view is that I should try custom orthotics (they'll cost me nearly $1000) and then if it's still causing me pain in 3 months, surgery is the only option and is "risky" with "potential side effects". I get the impression he thinks I should just "live with this". Apparently I should avoid getting a shot because it could make it worse?

I'd be so grateful for your thoughts: does this look like AVN to you (MRI pic attached)? Apparently he thinks it is AVN because the lateral sesamoid is "black"? If it is AVN, can the sesamoid recover from this? If not, when it "dies" completely could it become symptomless?

An article I read by you online suggests a CT could help to diagnose AVN and that an Exogen bone stimulator could help; what is your thought on this? Your article actually resonated with me so much because it sounds like my exact situation, I couldn't believe what I was reading because I feel exactly the same as this patient: http://www.podiatrytoday.com/blogged/treating-possible-case-avascular-necrosis-sesamoid-bone

Best wishes and thanks again for the great website,
Dr Blake's response: Thanks for your kind words and patience with my response. I am sorry I could not put the image on my blog, but it had your name in the corner. However, it looks like a normal healing fracture of the sesamoid, the black on that view is the bone swelling. On the images that show normal bone black, the sesamoid will look white. The initial healing of a fractured sesamoid is 3 months, and I do not like my patients to push off during that time. They typically wear an Anklizer type removable boot, with a insert with a dancer's pad. You can go out and buy OTC inserts that provide cushion at the front of your foot and some arch support. You can buy 1/8th adhesive felt from www.mooremedical.com to use for your dancer's padding. You can use the 


powerstep insole above to attach the dancers pad and even apply more arch. If the area under the sesamoid is still too hard, you can sand down the buld in half. Work on the swelling in the tissue with twice daily 10 minute ice packs, and evening contrast bathing. Before you get out of the boot, get your CT scan and look for the sign of AVN called fragmentation. I have had patients become asymptomatic with AVN, but it takes a year to know where it is heading. You typically qualify for an Exogen bone stimulator at 3 months post initial MRI or xray if the ordering physician repeats the test and documents delayed healing. The 4th and 5th months are the months that you begin to wean out of the boot into normal shoes. You have to be maintaining 0-2 pain levels and this rule dictates what you need (what does it take to keep the 0-2 pain level): carbon insoles, custom orthotics, rocker shoes, spica taping, etc etc. Hope this all helps and makes sense. Rich



Sesamoid Fracture: Email Advice

Dear Dr. Blake

Thank you for all your efforts that you put into this blog - tremendously helpful for people like me that are suffering from a sesamoid fracture.
Here a side view using CT scanning showing the broken tibial sesamoid with different bone densities acoss the fracture


This bottom view of the tibial sesamoid using CT Scanning shows that it was bipartite before the injury due to the rounded nature of the fragments across the fracture site. 

My sesamoid fracture happened around 4 months ago (stepping too hard on that bone on a hard surface) and I broke it twice again since (after week 5 then after week 12 due to too much pressure). Before the latest trauma I was walking almost normally again (therapy was no sports, little weight on the sesamoid, carbon sole, taping big toe, gradually increasing weight, no crutches or cast).
Now, the fracture seems not to be healing again and is terribly sensitive. I use crutches since the last trauma (due to awful tenderness on palpation on the fracture; four weeks now) and an orthoic similar to the one you describe (insole with soft pad under the broken bone with weigh support on the arch and 2-4 metatarsal; stiff sole with rocker bottom). However, the third trauma resultied in a new stinging pain that goes up to the knee on a light touch on the sesamoid and I cannot take benefit of the orthoic so far.

You can see the tremendous reaction of the body to this injury which looks like gout, and gout could be layered on top of the sesamoid injury. This could also suggest RSD which is an over-reaction of the nervous system leading to vaso constriction and vaso dilatation episodes (vaso motor insufficiency). 

Received diagnosis so far (X-ray week 3: bipartite sesamoid, bone bruise; MRI week 7: fracture or stress fracture of medial sesamoid; CT week 12: sesamoid fracture, with bone bridge after some healing). I enclose a few CT and of course would be happy for any specific advice you have to get the healing process started again (I read most for the relevant entries in the blog). As I have a family I am completely stuck and I am desperately looking for a way forward!

My specific questons:
- Where I am not sure on your advice on the blog is, if during the initial period following the trauma you recomment total immobilisation with NWB for some time or if is advisable to put some weight on the foot (e.g. with using crutches) also at an early stage to the extent pain remains 0-2?
Dr Blake's comment: I would definitely see if you get great pain reduction with an Anklizer type removable boot with your orthotics inside to off weight. We always want as much weight as possible as long as you can keep the pain within 0-2. I would discuss with your doc about the redness and the possibility of gout flare or RSD flare. Both would influence what is done next. 

- Would you also recommend some very light physiotherapy at an early stage to increase blood circulation (e.g. moving the big toe lightly, soft massage on the inflammated area) or to leave it completely?
Dr Blake's comment: You are going to need to find a good PT that understand this, so starting now is great and being proactive. Just to avoid the development of nerve hypersensitivity you want to massage the area 3 times a day with NeuroEze, Biofreeze, or another cream/gel recommended by your doc. Nonpainful massage is wonderful and desensitizing and moving swelling. 

- Is it in your experience now rather likely, that after two repeated traumas it is much less likely to heal (pseudoarthrosis) and therefore it would make sense to look into surgery rather sooner than later?
Dr Blake's comment: Yes, and no. Repeated traumas can cause worsening of the fracture, but it is probably just making it longer to heal. Since you have passed the 3 month level, you should really get an Exogen bone stimulator for a 6 month rental. It will reduce the chance of non healing for sure. 

- Any idea how to bring the inflammation down?
Dr Blake's comment: Massage, not continuing to irritate, see if contrast bathes help, but start with one minute of warm water (100 degrees) moving your toe up and down, then 4 minutes of cold tap water (no ice), alternating for 15 minutes total. If that helps you can slowly add more time to the warm, and less time to the cold. Hope all this helps you some. Rich

Best regards

Possible Sural Neuritis: Email Advice

Hello:

I saw you blog and figured I'd give it a go.  I also want to walk to Camino in Spain - I need to conquer this sural neuritis first.

Anyhow - I'm male and 44 - basically healthy. It started about 7 months ago ( about a month after I'd taken cipro) with ankle pain - the podiatrist said it was plantar fasciitis - then Achilles tendinitis - then I got an MRI and there was a small tear in a minor tendon than goes to my ankle - in which I was referred to another podiatrist/orthopedist who diagnosed the sural neuritis and gave a nerve block which did nothing - I have pain in my heal, outside ankle and Achilles - it's barely noticeable in the early morning and gets worse throughout the day as I'm on my feet quite a bit.   I many times find that sitting later in the day is the most painful and walking is better.  I used to run and could easily stay on my feet all day with no pain.  My current Dr. Says it's just a waiting game now to see if it heals - he says I can do any athletic activity I'd like but I might pay for it in the following days (and I do).  While my ankle is completely stable - it goes numb (ish) after 2 miles walking and my toes get painful and feel cold - but aren't physically cold...  I just say when a doctor "suspects" a cause, I feel like a bit more investigation would be in order - or does my description sound like sural neuritis and it's just that hard to accurately diagnose...

Anyhow - thanks for your time.

Dr Blake's response:
     Thank you so very much for your email. Sural neuritis is diagnosed two ways: you tap on the nerve and you get a tingling or other nerve symptoms in the area of your pain, and you inject the nerve and the pain goes away for 5 plus hours. If this is not the case, then something else is going on, and that could be many things. You can treat sural neuritis with nerve flossing and NeuroEze gel application (both done 3 times a day), and see if another injection of long acting local anesthetic would help. You can also shot gun the approach to wellness with 2 months in a removable cam walker (midcalf in height) and 8 visits of physical therapy. The physical therapist would see you twice a week and probably get a good handle on what is wrong. If the only thing wrong on the MRI is a small tear in one of the peroneals (which sometimes is only an artifact of the technique), then the removable boot would help that. Have the physical therapist really test the strength of both peroneal tendons and see if one is painful and weak signifying a tear. Hope this helps some. Rich

Sesamoidectomy: Email Advice

Long back story but as of today I'm about 8 months removed from a tibial sesamoidectomy. Surgery was successful but I'm still dealing with post op discomfort. I think it is shoes and I'm guessing I still have a bit of swelling down there.

I wear.Clark's with new balance pressure reducing insoles to work. I still have a feeling of fullness on the sole of my forefoot behind my big and second toe. Just got a new pair of ascics sneakers and they feel pretty good. Just looking on some advice for dress/ work shoes. Appreciate your time.

Dr Blake's response:
     Thanks for the email. So you want a stable shoe with some good cushion in the sole. You want one with a removable insole so you can and padding and dancer's pads. The adhesive felt to make a dancer's pad can be purchased atwww.mooremedical.com and get the 1/8th inch adhesive felt. This way you have room in the shoe to customize to your foot. Try to ice for 10 minutes once a day and do contrast bathing once every third night to continue to push out some of the chronic soft tissue inflammation. The scar tissue naturally heals from 9-12 months and that will also make you feel better. Make sure you are walking normally through your foot and not cheating by hanging out on the outside for your foot. In the long run, that will hurt you. Rich

If God is Not Done with You, then He is not Done with YOU!!

LOOK CLOSELY AT PHOTO 1
(Don't go  to photo# 2 until you look at #1 closely..)
This is an interesting, even  breathtaking couple of photos. 
Be sure to  read the 1st caption below picture before going to the 2nd photo. 
Look  closely at the first photo take your time, then  scroll down very slowly



Look at the picture above and you can  see where this driver 
broke through the  guardrail, on the right side of the culvert,  
where the people are standing on the road,  pointing.... 

The pick-up was traveling  about 75 mph from right to left 
when it  crashed through the guardrail. 

It  flipped end-over-end bounced off and across the  culvert outlet, 
and landed right side up on  the left side of the culvert, 
facing the  opposite direction from which the driver was traveling.

The 22-year-old driver and  his 18-year-old passenger 
were unhurt except  for minor cuts and bruises.

Just outside   Flagstaff , AZ , on U.S. Hwy 100.   


Now look at the second picture  below...
 



 



 




If God isn't done with you, Then God isn't done with you !! 

Generalized Heel Pain: Email Advice

Hi Dr. Blake!
I noticed that one of your hobbies is hiking. I feel like you might have some good advice to get me through a field season. I was recently diagnosed with PF and Haglunds Heel and my heel is on crooked.  I hike 10ish off trail miles a day for work. Several of those miles are in streams on river rock, jumping off of log jams, etc. And all of these miles are done in waders and wading boots.
I have insoles, my right foot is taped (I haven't had my left foot examined yet), cortizone injection 3 weeks ago and I am a frequent user of Ibuprofen. I'm not completely weight bearing yet. 
Do you have any stretches that I can perform out in nature? I watched your stretching video, but I don't have any walls around me. I've been doing the stretch you say is a no no. But, I do it one leg at a time. I hang my heel off the river bank or a log. I do try to find a good boulder to try to stretch on, but it's difficult to get a balanced stretch.
I usually, but not always will have time in the work truck between sites where I use a tennis ball over my foot~ is there any stretches I can do in the truck?
OH, and is backpacking possible?  
Thanks so much for this service you do with your blog,

Dr Blake's response: Shannon, first of all, tell me what hurts (ie bottom of heel, arch, back of heel, achilles, calf), and when it hurts (getting out of bed in morning, putting boots on, walking at work, evening hours, sleeping), and what makes what better or worse. Rich
Thanks for your speedy response!
Since having the cortisone shot in my heel, that spot is pain free. The shot is in the heel (center left (my left)).   But, everything around it feels pain.  The back of the heel gets painful. My Achilles is often sore. I don't feel the morning pain since the shot, and I do stretches before getting on my feet. I do get stiff after I get home and sit a while. When I'm working I have been feeling pain about one mile in. No pain at night since the cortizone shot.  I had to stand on my feet in one spot for 5-6 hours the other day...pretty painful by about the 2nd hour. I notice that I walk on my toes more often and that can't be good for my back.
Ice and heat help.
I'd love to soak it in Epsom salts but my foot is taped.
Ibuprophen ( We call it I-be-broken in our household) helps. I recently took a 4 day break from it and my heel and ankle were sore.
I've been massaging my calf muscle and foot and that helps keep my calf from tensing up.
I hope this is helpful.
Thank you!

Dr Blake's response:
Hey Shannon, switch to support the foot taping so you can get it wet and do Epsom salts, may make a difference. Go to www.supportthefoot.com. Get the regular size. Just seems like the inflammation is out of control. Could you wear an Anklizer boot on in the field 4 hours a day to rest it better? I would love an MRI to see if you have a bone bruise/stress fracture!! At least, making the right diagnosis can help with PT recommendations on what to safely do. Hope this helps some. Rich

Thank you!! I just ordered the Support the Foot tape. I've actually had a big change this week with my foot. I tried the hard plastic insoles and they've helped dramatically! I was dreading hard plastic, but it really did the trick. I did about 9-10 miles each day last week and I'm able to bare weight. I'm so excited! I think I will be able to go backpacking and hiking (outside of work) this Summer. 
thanks for your advice and thanks for doing your blog~ I've learned a lot.

Have a great weekend!

Dr Blake's Response: Great News. Glad getting the right support helped. The support the foot tape will be good for flareups or long hiking for added protection. Rich