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Thursday, January 18, 2018

Removable Boots and Possible Cutting off the Circulation

Hi Dr. Blake,

I have been wearing the boot a few days now...I have been experiencing some pretty intense waves of pain in my heel (like a burning ache) when I'm just sitting with the boot on. It's pretty this a normal "adjustment" to the boot or is this a bad sign? Is this bursitis or a reaction to the boot? Can I take the boot off when I'm just sitting around? 

Sorry to have more questions!

Dr. Blake's comment: Yes, please take the boot off when sitting, it is cutting off your circulation at rest! You only need it for walking/standing. If the cramping continues even after you take the boot off, go to the ER for a doppler to see if you have a blood clot. Definitely, do not sleep in the boot. Rich

Plantar Fasciitis: Do Not Forget the Calf

My patient reminded me that after struggling for several years, and getting somewhat better with my orthotics and stretching and taping and icing program, that the final cure was the deep tissue massage she got in the calf and even front of her lower leg. This is a recurring pattern for my patients and PT or massage therapy can be very important for some patients to finally cure their plantar fasciitis by working out the tension in the calf and leg muscles and fascia.

Wednesday, January 17, 2018

Sesamoid Injury in a Rock Climber

First, thank you for the blog and book—both have been extremely helpful as I have been dealing with a frustrating sesamoid.  I am writing to get your opinion on returning to activity with this injury.

I’m a rock climber who sometimes loves to trail run.  I started having low-level foot pain in April. My pain gradually increased with time (had to quit running in June), but it never got to a point where I had to quit climbing.  One doctor told me I have AVN of my medial sesamoid.  The other two doctors I have seen said that the sesamoid is fractured but the bone hasn’t collapsed/isn’t sclerotic, so I should try to treat the fracture.   I found your blog around this time and started to follow some of your advice.  So for the past 4 months, I have been:
·      using the Exogen bone stimulator
·      taking Calcium and Vitamin D supplements
·      Wearing custom orthotics full time
·      Lots of icing and contrast baths
·      Activity modification (No climbing, lots of swimming and biking)

I have gotten to the point where I no longer have pain doing everyday activities, so I decided to start a walk/run program in December.  I can now jog for a total of 12 minutes with no pain.  (Yay!)  In January, I decided to see what climbing feels like.  After a little trial and error, I have found that with certain shoes, I will have no pain after 2 pitches.  But I definitely have pain if I do more climbing or if I wear shoes that are too soft.

Multi-pitch climbing. Multi-pitch climbing is the ascent of climbing routes with one or more stops at a belay station. Each section of a climb between stops at belay stations is called a pitch. The leader ascends the pitch, placing gear and stopping to anchor themselves to the belay station.

So based on my levels of pain, I was feeling like I was making progress.
Recently I got new X-rays and they showed no change/improvement.  My doctor doesn’t think I should be running or climbing at all for another 3 months if I want to give this thing a chance to heal.  And if it doesn’t heal after three months, then I need to think about whether I can manage/tolerate the pain or if I want to have surgery.
Dr. Blake's comment: I am so pleased what you are doing. You are doing everything right. Creating the 0-2 pain level is all you need for healing. And you need to stimulate the tissue for strength. A runner has to run and a rock climber has to climb. It is a basic part of sports rehab having the athlete do sports specific activities as long as they keep the pain level between 0-2 consistently. The xray will look bad for a while, even when internally it is healing. An MRI will show bone edema-indicating injury repair for long after the fracture has healed. How you feel is more important at this point because you are through the Immobilization Phase of Rehab, past the Restrengthening Phase, and into the Return to Activity Phase. Bone Stim for 9 months total. 

I have gotten so much value from your book and blog, so I am writing to get your opinion on a few things: 
Is it really necessary to give up the small amounts of climbing and running that I have recently added to my life?  No, unless there is more than just comparison x-rays, having another MRI 6 months after the first is great. Or, getting a CT scan to look for AVN signs now. If we have no other info, I say keep listening to your body and gradually build up what you are doing. 
Do you know anything about using shockwave therapy to treat sesamoid fractures (that was another suggestion recently made to me)? Sure, it is to cause microfractures in the bone to take a chronic healer and make it acute. You would then go back into a boot for 3 months and start the process all over. That does not make sense now. It also makes no sense to me that patients are getting this powerful treatment like a physical therapy session with no changes in activity, restrictions, etc. 
How and when do I go about making decisions about surgery vs. just dealing with it?  To me, surgery makes more sense than dealing with it. That can cause a breakdown in the joint, and compensatory pain. The surgery is typically very successful and then you have to protect the other sesamoid at high-risk activities with your orthotics. Not too big of a deal for most. But, in general, you want to save it if you can, common sense. If you were in my office tomorrow, and we had no cost restrictions, I would get a CT scan and repeat the MRI six months after the first. Then we would have a wonderful idea what the next year looks like. 
At this stage, climbing is really the only thing that gives me pain—but it is also my favorite thing to do.  I seem to keep meeting other climbers with sesamoid problems—do you have any experience working with climbers?  If so, any tips for returning to my favorite sport? 
Dr. Blake's comment: First of all, stay in rigid shoes that accommodate your orthotics and spend this year working on technique challenges that use mainly your upper body. Let your big toe have a break, so it is able to completely heal. Drills, like seen in this video with Daniel Woods, can be modified to avoid toe bending of the involved side. We are only talking about a short time in your long life. 

Thanks again for all the information--I really can't express how much it has at helped at a time when I have really struggled finding a medical team who understands my goals. Welcome

Nice Article on Finding the Right Diabetic Shoe

Barefoot Dancing: Help for your Sore Metatarsals

This patient of mine was having a lot of pain, in the 6-7 range, with barefoot dancing, even some Morton's neuroma symptoms, until she discovered these from Bloch (to me only known for their Ballet Shoes). There is room in the slip on to add more padding, like Dr. Scholl's forefoot pad if you need it. Rich

Hi Dr. Blake,

This place was slightly cheaper per pair than the SF Dancewear on Mission St.  No tax (to CA) and yesterday, free shipping on orders over $40, not $65!

The San Francisco Dancewear, 659 Mission St. let me try them on.  I bought 2 pairs from them.

Amazon price was $19.95, plus tax.

They have many other kinds of footwear/supports that might work for other needs, too.  You can get a catalog from this website.

Thank you so much for your help!

Tuesday, January 16, 2018

Why do partial tears hurt more than complete tears?

Hi Dr. Blake,

Thank you so much. It is so frustrating to have doctor after doctor call this "plantar fasciitis"...the podiatrist yesterday told me that "if there is a tear, I don't think that's what's bothering you because the surgery to fix plantar fasciitis is actually cutting the plantar fascia." While that may be true, there's also a pretty extensive recovery period for that! May I ask what your opinion is on EPAT and if that would speed the healing process? Also what type of exercise would be considered "safe"? Swimming? Biking?

Thank you!!!

Dr. Blake's comment: This patient is struggling with a partial tear of the plantar fascia. I have only found them to heal with 4-6 months of no stretching and no tension allowed on the plantar fascia (with a removable boot or hike and bike shoe to not allow bending of the big toe joint). The doctor's comment revealed a lack of understanding (sorry!!) of why partial tears hurt more than complete tears. This is so true, and better explained, with the Achilles tendon. When someone completely tears the Achilles, or an ankle ligament, the immediate pain is severe, but then they have relatively no pain. They only have the instability caused by the injured structure not doing its job because it is torn. With a partial tear, the ligament, or tendon, is trying to work when stressed, but the weakest link in the chain is the tear, and that will hurt when stressed. A 10% tear of the Achilles can hurt much more than a complete tear of the Achilles. I have seen patients who have torn their plantar fascia completely, completely recover. But I have seen patients who have their plantar fascia cut in surgery for chronic plantar fascia, who are left with a flat foot or other foot issues. My recommendation is to rest it the next 4-6 using the plantar fascia tear protocol in this blog and be done with this injury. 
     I am sure that there is a role of EPAT, PRP, stem cells, etc for these injuries. I think you must immobilize them anyway to take the tension off the structure. Will they speed up the 4-6 months? I am not sure. Swimming for a plantar fascial tear can be okay, definitely no fins or pushing off the wall. Cycling seems to be fine, initially, I do not have my patients get off their seats. Rich

Monday, January 15, 2018

Advice for Plantar Fascial Tearing and Intense Inflammation

This is a patient I have been helping, along with her imaging. The plantar fascia has a partial tear and the inflammation since she is not addressing this properly is intense. I had her email me a full story, plus she gave me other feedback from her doc's visit today. 

Here are the images of the partial tear and intense inflammation.

Hi Dr. Blake,

That is very interesting, I am so appreciative of you taking the time to review these soon as I got the report from the MRI I felt it was just didn't add up that everything I tried had failed if it was "just" plantar fasciitis. The story is rather long but here goes:

I am a distance runner, and around March of last winter (2017) I began to experience pain in my left heel. Unlike typical plantar fasciitis which usually presents almost out of thin air as pain in the morning one day, this came on during a run. As symptoms gradually worsened, I decided to take time off. I knew the body's inflammatory response usually lasts a few weeks, so I refrained from running for about 2 1/2 weeks. The pain didn't get worse, and it didn't get better. It was always the worst after getting up in the morning, stepping out of my car, and getting up from my desk. I figured, if the pain wasn't going to improve with rest, I might as well run! I am also a huge believer in Mind-Body Syndrome (TMS), and I was 95% convinced this was the cause of my heel pain, and that I could continue to run and eventually the symptoms would dissipate. Running actually wasn't painful, but afterward (especially following long runs), the pain was pretty intense. It took a few months, but as crazy as it sounds, the pain did go away. I considered myself completely healed and didn't even remotely fathom the pain could or would return.
Dr. Blake's comment: This could have the initial tearing of the plantar fascia, so small a tear, that it would heal and re-tear no matter what you did. I had a runner in several years ago that this syndrome went on to some degree for 10 years. We finally placed him in a removable boot for 3 months, with no achilles or plantar fascial stretching, and the other 3 months of keeping the pain level between 0-2, and he allowed the plantar fascia to get stronger intrinsically, and he has not had problems for 2 years. Knock on wood!!!

 Fast forward to October, I was happily plugging away training for the Philly Marathon. I had just gotten word that my qualifying time from 2016 got me in to Boston 2018. I was super excited. During a 15 mile training run at an extremely hilly course in Valley Forge Park, the heel pain returned quite unexpectedly. I was absolutely convinced it was in my head. I had run through this "plantar fasciitis" before successfully, and I was about 3/4 of the way through my training plan, and I really did NOT want to shut it down and I continued to train. Only the pain did not get better, it continued to get worse, to the point where every single step of running was painful. I must have started to compensate in some way in anticipation of the pain, because I ended up with a calf injury. 
Dr. Blake's comment: First of all, my son Chris went to Cabrini in Wayne, PA, and I love Valley Forge Park. Secondly, this time you increased the tearing, which had never gotten perfect in the first go around in March. I am linking to my blog post on Good vs Bad Pain that should be your bible from now on.

My calf bothered me running, but I could power through...afterward, however, I could barely walk. At this point I decided the situation had gotten dire enough that it warranted a visit to my PCP. He ended up recommending x-rays and referring me to a podiatrist. X-rays revealed a heel spur (not a surprise), but not a stress fracture. At this point in time, my main (and most painful) concern was my calf (I had pretty much gotten used to the heel pain which was admittedly pretty bad). The podiatrist advised the standard protocol for plantar fasciitis (rolling with an iced water bottle, stretching, prescription anti-inflammatories). I wasn't keen on the idea of an injection, so he said we could follow up in a week and do the injection then if necessary. I asked if I could continue to run, and he said yes. That plan failed miserably. Despite stretching, rolling, icing, heating and doing everything imaginable to baby my calf, after a 17 mile long run I couldn't walk for two days. The podiatrist then recommended a venous duplex to rule out a blood clot. He was also suspicious of exercise-induced compartment syndrome. The venous duplex (was expensive) and negative. At this juncture, I knew there was nothing left to do but shut it down and rest so that I would be healthy in time to start training for Boston (which would begin at the end of December). I rested for about a month and a half. My pain subsided. 
Dr. Blake's comment: I must say that there is a lot more to healing than having the pain go away. The pain is inflammatory usually and can improve, but the tissue may not be close to healing. You can not be seeing a sports doc since your advice is questionable. What that diplomatic?? Pain like this in your heal is from either 3 things: pinched nerve (which can give you the calf pain also), tearing of the plantar fascia (which your later MRI showed), and stress fracture of the heel bone (which your MRI ruled out).

When I started running again, I did so by gradually building up mileage. I tried to play it smart, but while my calf pain seemed 100% cured (I'm going to assume it was a strain), it didn't take long for the heel pain to return. I wore a night splint, I visited my chiropractor for ART, I went to physical therapy where they did a variation of Graston, heat and ultrasound therapy, and stretching...and while the pain generally improved, it still persisted. I discovered that rolling my foot on a little wooden roller for plantar fasciitis was the one thing that actually provided relief, but rolling over my heel the pain was so intense that it would shoot up my entire body. And while stretching was universally recommended to me by every doctor across the board, it always seemed to make things worse. 
Dr. Blake's comment: This is one of the reasons why it is important to get an MRI. Plantar fasciitis improves with stretching, ART, Graston, night splints, whereas plantar fascial tearing is only made worse by these treatments. Historically, you told the world that this was not plantar fasciitis since it came on suddenly in a run, not gradually over time. 

And, the pain started to have different patterns than it did before; suddenly it was worse in the evenings, some days the pain would ebb and flow during runs, and some days it would dissipate after a few miles then come back toward the end, sometimes it wouldn't bother me after a 5 miler and other times it would. I have discovered that while there are time that it may not bother me walking, my entire heel is consistently extremely sore to the touch.
Dr. Blake's comment: These are complex. You have the orthopedic injury that needs a solid treatment plan to heal. You can have the up and down of inflammatory pain which you are experiencing which is influenced by what you ate, how hydrated you are, what you did 1-2 days ago, how much alcohol you consumed, etc etc. And then there is neuropathic pain based on whether you are limping or the injury is next to a nerve etc. 

 I finally decided it was time for answers, and went to a new podiatrist to get a referral for an MRI. The report stated that the findings were "consistent with plantar fasciitis. No plantar fascia tear. Minimal bone marrow edema in the calcaneus about the plantar fascia attachment may reflect reactive marrow edema, stress reaction, or a combination thereof." I was disappointed only because I was hoping to learn something from the MRI other than "it's plantar fasciitis." Since I had tried everything in the book to treat it already (rest, ice, heat, NSAIDs, stretching, night splint, chiro, physical therapy, etc.). Since Boston very well may be a once-in-a-lifetime opportunity (and it was extra special to make it in this year since I qualified for but was cut from the 2017 race), I am hoping against hope there is something I can do now to make it there in April. 
Dr. Blake's comment: I am sorry about Boston. You need to once and for all heal the tear that was seen on the imaging. Sorry the MRI report did not report the tear, but it is there. You need to go into the plantar fascial tear protocol. These things heal, but we need them to get strong also so that it won't tear again. The entire process is typically 6 months. So, you need a goal of running for 2019. We need to get this healed, then 3 months of base running (no goals). Then, you will be ready to start training for something special!!

Thank you, Dr. Blake! Sorry the long-winded story, it's been quite the (unfortunate) ordeal...

Since I hadn't yet answered the above email, this one also came. 

Hi Dr. Blake,

I apologize for bugging you again. I had an appointment with a new podiatrist today and I'm a little upset. She only very quickly looked at my MRI images (even though I showed her your site as well) is recommending 2 weeks in a boot + physical therapy (I have already done physical therapy, but it was focused mostly on the foot whereas she wants to send me somewhere that would address the "glute weakness" that she thinks is the root of the problem). She is not at all concerned about the tear and is calling it "plantar fasciitis." I just really find it hard to believe this chronic issue I've had for a year now will get fixed in 2 weeks with physical therapy. I asked about an injection for the bursitis and she said she is not a fan of them (generally speaking I am not either, but I was under the impression an injection for bursitis would be in a different location from an injection for general plantar fasciitis?) I'm just wondering what your recommendation, in this case, might be?
Dr. Blake's comment: Yes, stay away from the injections, as they can weaken the tissue more. The boot is fine for the next 3 months, and you can get some Hike and Bike shoes to walk around with more and more as the months go on. Even if you only wear the boot for 3 months, you will need to transition out of the boot over a 2 to 6 week period, and that is usually with Hike and Bike shoes or Hoka One Ones. We need to create a 0-2 pain level ASAP, and then keep it there for 6 months. No stretching at all, you can massage the calf. The PT would be for the inflammation, and for the gait, and core strength right now. Get an EvenUp for the opposite side if you can not get things level, and float the heel if it still hurts in the boot (see the post below). Good luck my friend. Rich

Thank you!

Sunday, January 14, 2018

Awesome Toes vs. Correct Toes: Let the Battle Begin to see which One is Better!!

If you are trying to prevent, or at least slow down, the development of bunions and hammertoes, these are 2 good products to use on some regular basis. I have attached my original post on conservative management of bunions and these should now be included.

Saturday, January 13, 2018

Managing Peripheral Neuropathy Post Chemotherapy

Excitable Neurons!!

Several days ago I saw a young man who developed peripheral neuropathy in his feet with level 7 pain secondary to chemotherapy for colon cancer. This is technically called CIPN or Chemo Induced Peripheral Neuropathy. His podiatrist made some great orthotics that helped some, and I added Neural flossing and Lidoderm Patch Rx on my first visit. The article below has a nice discussion of the problem and treatments. I have many other treatments, like Calmare, Neural Flossing, Quell, previously discussed on this blog.

Friday, January 12, 2018

MRI Transfer to Dr Blake via WeTransfer: Worked Beautifully

This protocol was sent from a nice lady that could send me her MRI images clearly. Thank you for sharing the steps with us. 

Hi Dr. Blake,

Here are the steps to send MRI Images from a CD through WeTransfer:

  1. Load the disk into your computer and open it.
  2. Select ALL the files on the disk, then right click and select "Copy".
  3. Create a new folder on your Desktop titled "MRI Disk".
  4. Open the folder. Inside the folder window, right-click, and select "Paste". All the files should now be inside the folder.
  5. Close the folder. Right-click on the folder on your desktop then point to "Send to" and select "Compressed (zipped) folder". (On a Mac, right-click and choose "Compress".) This will create a compressed .zip file.
  6. Go to and click the "Take me to Free" button.
  7. Click the blue plus sign inside the window on the left to add your .zip file. 
  8. You can choose to e-mail the .zip file to a recipient or create a link to the file. To e-mail, simply enter the recipient's e-mail and your e-mail in the corresponding fields. To create a link to the file, click the blue ellipses inside the circle at the bottom of the window and select the button next to "link".
  9. Click "Transfer" and you're done! 

Hope this is helpful! :) 

Thursday, January 11, 2018

Plantar Fascial Tearing with Intense Inflammation MRI Images

The Plantar Fascia on the bottom of the foot should be as dark as the Achilles Tendon shown here.

The Plantar Fascia should be uniform thickness and density. Here it is seen rising up and with gray holes. 

The slice through the bottom of the foot under the heel bone showing a bursae sac of intense inflammation. 

This is the section that is at a right angle to the raised part of the plantar fascia seen above. The fascia above my arrow should be a solid dark fiber like the Achilles. In this image, it is showing 90% torn with the gray signifying fluid and scar tissue. 

The image just in front of the last view looking more solid, although some irregularity and less density.

This is the initial image again in our series showing a section of plantar fascia separated from the bone. 

A defect in the plantar fascia more to the outside of the foot. The arrow denotes the defect and is surrounded by intense inflammation probably a bursal sac. 

Only slight irregularity noted in the plantar at this section, but see the inflammation is so intense it distorts the normal fat pad below the arrow. 

This is really the best image of the problem. The patient's image shows the split partial horizontal tear of the plantar fascia seen as is there was a layer of Oreo cookie in the fascia. How do we know it is injured, the intense inflammation under the tear where the swelling is pulled downward by gravity. I would not want to walk on that heal. 

This is the same image of the plantar fascia 1/8th inch further under the heel bone. It looks totally fine, so the tear is the 1/2 inch in front of its attachement into the heel. The swelling from infracalcaneal bursitis will travel all under the heel and the reason patients can not walk well. The plantar fascial tear protocol should be started. Plantar bursitis will take some work off-weighting the heel to transfer the weight into the arch. 

Wednesday, January 10, 2018

Taking Pressure off the Sesamoids with Hapads

Hi Dr. Blake,

I’m a dancer (mainly jazz/tap but also ballet) and I have been having pain in the ball of my foot. I first experienced it this fall (October-ish) when I was dancing a lot in my character shoes. 

Then, it felt like stretching on the ball of my foot. After no longer using the character shoes, it got better. About two months later, it came back much worse and turned into more of an intense soreness underneath the big toe and second and third toe. This got worse on releve.

Ballet Releve on the weight bearing foot

 I rested it for three weeks. This week, I have returned to dance while being mindful of it, and as I have gotten back into dance it has gotten bad again. BUT I have VERY important college auditions this week and next week!!! šŸ˜±šŸ˜°

I initially had thought it was Metatarsalgia from my own research, but my dance teacher thinks it may be Sesamoiditis, and now I think it may be that? I’m not even sure if I can even see a doctor before my auditions, and would need to power through anyway unless there is a fracture. The only thing I’ve seen online to do with these injuries is rest and ice. If I had to dance on it, what are things I could do to help with pain and limit the risk of further injury? I definitely struggle on releve and it feels like a big bruise on the ball of the foot, but at least right now, I could mostly get through a dance call. Any advice would be very helpful!
Dr Blake's comment: Get hapads, both small longitudinal medial arch and small met pads and try to protect the best you can!!

Image that is the sesamoid being floated and that should take 80% of the pressure off. Ice also. 
Many patients also will go into a removable boot for all non-dancing activities to rest it as much as possible. I linked to the Anklizer which is great unless you have a really thin ankle, and then you need a taller one to grab your ankle.

Boot with homemade float for the sesamoid (the area cut out of any insert).


Cartiva Joint Implant vs Arthrosurface: Present Thoughts

     As you all know there are 2 givens in this post: I am not a surgeon, and it is hard to recommend anything you have no experience dealing with. So, that is the basis of our office recommending Arthrosurface for joint implantation if surgery is decided on to help the pain created by Hallux Rigidus. As of January 2018, I have not seen one patient present with the Cartiva implant, so please be free to comment below. Cartiva seems to be doing a great PR campaign, but the only comparison I could find between Cartiva and Arthrosurface was very heavily supportive of Arthrosurface. I am sure that the jury is out. I think all of these procedures do work when done on the right person. It is finding the right person. Doctors must rely on what they are trained in doing unless the doctor is dissatisfied with the results. Or, unless they are seeing patients from other doctors (our patients are so mobile so I follow patients from literally all around the world) that are getting fabulous results from another procedure. This is presently not happening with Cartiva. I would not believe a representative of the company, but patients who have used the Cartiva or the Arthrosurface are free to weigh in. I am hopeful this blog can inform people intelligently, but in some way, you have to trust what your doctor wants to do. At least now, you can pre-operatively ask if Arthosurface or Cartiva is right for you. Maybe your doctor has experience in both and prefers one over the other. That is what I am actually looking for. A doctor who has experience in both, and knows when to use either one (what are the implications to use one versus another). Wouldn't that even be a better post on my blog?

Arthrosurface Implant Left Big Toe Joint in one of my patients

Side View Arthrosurface Implant

Tuesday, January 9, 2018

Cortisone Shot #1: Patient Feedback

After I give a cortisone shot, in this case for a left foot third intermetatarsal space Morton's Neuroma, I tell the patients that they may need 3 in total. We have to wait 2-4 weeks to get a strong sense of what each shot does, and then make our decision. The Golden Rule of Foot: Cortisone shots if attempted to bring down pain and inflammation should be done until 80% improvement is noted. This means you have accomplished the 0-2 pain level. You should not give more than what achieves that 80% relief. If the first shot gives you 20-75% pain relief, a second shot should be considered. If 0-20% relief is attained, you probably should not give any more, as it only works on pain produced by inflammation. 
     If you give a second shot, you can use the same rationale for determining if you need a third shot. Rarely, if ever, will you need a 4th shot, and I think 4-6 months should be the delay in deciding on that 4th shot. Typically, you get to 80%, and rest of the inflammation is helped with PT, daily ice or contrasts, NSAIDS, or topicals like arnica, etc. I am only talking about long-acting Kenalog 10 or Celestone Acetate. Never use Kenalog 40 in the foot. 

Hi Dr. Blake,
I think it's been almost two weeks since the cortisone shot. I will say that I think it's helped but not nearly as much as I had hoped. If I had to put a number on it, I'd say it feels around 60% better.  It's hard to say because one day it'll feel quite good, but it takes so little for it to start hurting again. One small misstep sets me back quite a bit. What I have noticed is that the little lump I can feel in the neuroma area seems smaller but is still there and causes nerve pain upon pressure.  In addition, I often sense a general tingling throughout that area and in my third and fourth toes.

Also, there is something weird on my right foot I'd also like to talk to you about. I feel a similar little lump under the second space and have felt zinging a couple of times.

In any case, should we try another cortisone shot or move onto the next step?

Thanks much,

Dr. Blake's comment: Please schedule to see me for a second shot. See you soon. I will also look at the right foot. 

Monday, January 8, 2018

FRAX: Fracture Risk Assessment Tool

This is an area of great interest to doctors and patients with osteopenia and osteoporosis. It is an epidemic to make our bones stronger, and prevent falls. It can help doctors discuss your fracture risk as you age, which presently affects 40% of postmenopausal women. My active patients want to stay active for as long as they can. The post I do tomorrow will discuss Vit D and calcium intake.

So, FRAX Algorithms (just love that word for some reason) will give you and your doctor your 10-year probability of having a fracture. Hip Fractures have complications and actually have a 20% death rate in the next 5 years. So, it can be huge to lower your risk and become more healthy. And, for some, they get to eat a lot more (when they have low body weight).

Most of the links below get too scientific, but it is good to make you aware. You can challenge your doc or your parent's doc to see what FRAX says. The common risk factors include:

  • having a fracture as an adult
  • having a parent, sibling or child with a fracture due to some bone weakness
  • having low body weight
  • current smoking
  • taking oral corticosteroids
  • having poor health
  • having a low bone density
  • having rheumatoid arthritis
  • having previous hyperthyroidism
  • having poor depth perception
  • having tachycardia
  • taking alcohol 3 units/day
  • and also there are age, sex, race, and height factors
I hope the articles below are somewhat helpful if you are trying to get a grip on where you are going and how to make your fall risk less. Good Luck. Rich

Sunday, January 7, 2018

Accessory Navicular post Ankle Sprain: Email Advice

I'm a female 37 y/o. I have a question about treatment for a recurrent problem with left accessory navicular after a sprain to ankle in April '17. 
Dr. Blake's comment: When you have a typical inversion sprain where your foot rolls to the outside, you should have all your pain on the outside. When someone has an inversion sprain and has some inside pain (medial side of the foot of the arch side or big toe side), you have to investigate. This is a Golden Rule: There should never be inside pain after rolling your foot to the outside. If there is inside pain, you must consider that something else has been injured in the sprain. That you possibly have more than one injury at the same time. 

 Seen two orthos and they want to keep in brace/orthotics, off feet if in pain and if worsens back to boot then consider cortisone injections, last resort surgery.   Podiatrist made orthotics. 
Dr. Blake's comment: This is a bad area to have cortisone shots since it can weaken the tendon attachment causing further problems. Stick with PT, icing, contrast bathing, diclofenac gel, etc to reduce the inflammation at the attachment site. 

Last time hurt was 12 yrs ago playing soccer was put in a hard cast then air stirrup, crutches. and PT, no break. No surgery. Was back to activities faster but took a year to get back to playing soccer. 
Dr. Blake's comment: This is definitely a weak spot if it took more than a couple of days to recover. One year tells me it is vulnerable, but you got better. Hooray!!

 This time April 6th, 2017! tripped walking and inverse ankle roll but made my body fall on left (opposite side as I was initially falling)due to injury in right wrist and wanting to protect. No fracture on MRI/X-ray just soft tissue rupture w/some edema. Was put in camper boot for 8 wks and out of work couldn't walk w/o pain. 
Dr. Blake's comment: It is a significant injury if you can not walk on it. If the edema was in the bone, we have a long injury ahead of us. 

Started PT and got out of the boot in a week and learned to walk again w/o brace. PT focus on being able to walk again, balance on board, desensitizing foot due to being in the boot so long w/setbacks. PT did physical manipulation work which was the only thing helping me but PT stopped after 10 visits due to insur.
Dr. Blake's comment: So, the typically 8 weeks of boot/cam walker is fine. You know you are doing okay, if the transition from boot to no boot is done with maintaining your 0-2 pain level. I assume it was. But, an injury to the posterior tibial attachment with or without the accessory navicular should be progressed from boot to custom orthotic and posterior tibial taping ideally. Slowly wean off the taping. I have attached my video to this taping.

 Now it's 2 mths w/no PT and almost 7 mths later since the injury. Orthopedic surgeons want to do surgery now and remove the bone. I’ve been wearing custom orthotics since sometime in July w/ASICS cumulus. Tried to return to work Sept 15  (on feet as hospital social worker log up to 3-4 miles a day on feet) but it was too painful, had pain getting up from a chair, ended up limping barely able to walk, swelled up, back out of work.
Dr. Blake's comment: Always need to know how to get you to that 0-2 pain level. When you went back to work, were you at 0-2. Were you walking fine without a brace, but with orthotics? Can you go back to work with a removable boot and EvenUp (on the other side)? At least you could wear the boot the 2nd half of the day. Do your orthotic devices need improvement? Can the above tape help you? Can you get an AFO for work to be able to rest the pull of the posterior tibial tendon, but still wear a shoe? The surgeon could be right of course, but you need to have all these things before you try to recover some accessory navicular surgery. You have a lot to do before surgery is to be done or considered. 

 Finally saw 6 mths wait-to-see sports medicine doctor at HSS Sept 21 and he prescribed me anti-inflammatory, PT, stationary bike, and rest for 6 wks, didn’t think ready for surgery that pathology does not merit the pain I’m reporting.Rested and iced swelling stopped and pain decreased so for back to walking with sitting breaks up to 2.5 miles. 

Went back to same PT for re-evaluation last wk finally once insur allowed and referred to acupuncturist says extra accessory navicular bone is jammed and other stuff around is locked and would help to consider trauma related to few times I hurt it and address either on my own or with a Therapist.  Wtg to find out if insur. Will approve more PT or not. Saw acupuncturist today first time at the same facility and did cold laser since I was scared to start with needles. She thinks I need both and to address trauma. My goal is to resume all normal activities (job on feet all day) and get back to being able to do recreational sports/activities (hiking, soccer, tennis). I want to avoid surgery. I’ve been reading your blog so thanks for the info. and support when it can seem so isolating. I greatly appreciate any feedback. Thx

Dr. Blake's comment:
Since I had not answered the original email for 2 months, I asked her for any additional information. 

Hi Dr. Blake,

Thanks for your reply. Happy New Year.
The update is I did receive 5 more PT sessions after insurance reversal of denial with the last PT session on 12/12/17 and the insurance denied any further PT treatment. I had a total of about 20 sessions of PT. 
Dr. Blake's comment: Did you make some progress? Are they working on the overall strength of the area? I have attached my video on posterior tibial strengthening which must be done or you will still break down. This is you probably do on your own, but definitely, lay an ice pack for 10 minutes 3 times a day, and learn to tape for sure.

My sports MD prescribed me Diclofenac on 11/15/17 due to what my PT told the sports MD; 1. Lateral cuboid does not plantar flex, 2) lateral cuneiform does not plantar flex, 3) distal fibula does not translate. 
Dr. Blake's comment: These can be all left over from the inversion sprain that the PT should be able to rectify. 
The doctor's notes from this session 11/15/17 are attached for your review. 
Dr. Blake's comment: His comments were pretty unremarkable. If one side of your foot is not working, the other side will work abnormally. It seems normal after and sprain and boot and rest that you need some PT to mobilize the lateral column. I am worried that I see no mention of re-strengthening the posterior tibial tendon, or any other part of the foot and ankle, and no mention of how supportive the orthotics are, and whether taping would be helpful. It is all a bit superficial. 

My last appointment with sports MD was 12/13/17 and the plan was to return to work on 12/18/17 light duty at x 4 hours per day but my employer (being a hospital) does not offer light duty and referred me to the Office of Reasonable Accommodations. I am waiting for the paperwork to be submitted by my sports MD to my employer to see if I get approved for an accommodation although I'm not sure how they can accommodate me when the issue is being on my feet for extended period of time. Otherwise, I'm going to have to resign for medical reasons. 
Dr. Blake's comment: Can you work with a boot on? I do not see why not? Or perhaps an AFO that stabilizes you, but can fit in a shoe, or just the tape the video shows may be all you need or a combination of things. Many of my patients, so they can get back to work, have them all: boot, AFO, custom orthotic devices, taping, and posterior tibial dysfunction Ankle Brace called Aircast Airlift PTTD Brace. Some days or hours you need more restriction, and some days less. 

My next appt. with sports MD is scheduled on 1/30/18. He seemed to think I should try for a full year of PT and alternative treatments before I consider surgery.
Dr. Blake's comment: Sounds about right, since you have all the above mentioned stuff to perhaps try.  

It will be one year on April 6, 2018 from the date of injury and mid-June 2018 since PT started. 
Dr. Blake's comment: Like many patients, for many reasons, it is just hard to find the right things that work sometimes. I am assuming you did not know the joints are still jammed up, any info on AFOs, PTTD Braces, taping, and how to make your orthotics better.

I continue to use orthotics, go on the bike 20-30 min on level 3 (Keiser M3), to do alphabet with left foot, calf raises each foot, stand on each foot for 30 sec while holding other foot up., while seated stepping down with ball of left foot on piece of foam without moving legs. I attend weekly acupuncture but will likely cut back to biweekly due to insurance/OOP fees. 

I have difficulty doing the calf raises more on my right foot. 
Dr. Blake's comment: After doing the posterior tibial exercises for a week, you should know where you are on the right foot and where you are on the left foot. That can be really revealing. You start from the beginning with each side, making sure you can easily progress through an active range of motion, then with gravity, then isometrics, then level I theraband, and so on. The therapists will have the theraband, or else you can buy them. 

I had stopped doing the towel, marble, side lunges, heel cord stretch, and ball roll underfoot, amongst other exercises.  
Dr. Blake's comment: Why? Were they sore? Were they easy? Did you not know which were important? 

My PTs said I could come back once a month out of pocket for a mechanization session and just do the exercises at home the rest of the time. 

The PTs said the issue is my foot keeps reverting to an unnatural resting position after the mechanization as if my foot was still in the boot. She suggested physiological calming and to pay less attention to my foot as  I'm no longer panicking worried I'm causing further damage when I have pain after being on my feet for a while but the pain still happens. 
Dr. Blake's comment: I guess that means you stiffen up your foot. It probably fatigues out. That is why in the middle of the day if you feel this, and can throw in a brace, boot, AFO, you can essentially rest it for a couple of hours. Then you can remove the brace, etc. 

Although the mechanization can be quite painful at times she has been able to get my foot to release or whatever the word is and was even able to set up an obstacle course and I dribbled a soccer ball after in the same session without pain but a week or so later the foot reverts.
Dr. Blake's comment: That can be only a strength issue since you are definitely improving, but your orthotic devices and the amount of strength you have cannot maintain supporting you. But, that is definitely the best news you have told me and makes the possibility of surgery less and less. Get really strong, better orthotic devices if possible, and you may lick this. 

My balance has improved and ability to pivot and step up and step down. At close to 2 miles I get pain from walking. Riding the subway is difficult and painful when holding onto the bar when the movement of the train is pushing against my body and I'm trying to maintain my balance. The cold weather has been very painful for my foot so I double layer my socks. 
Dr. Blake's comment: The 2 miles is the fatigue of the tissue setting in. Taping alone, even before you are stronger, should raise that bar. It is sort of fun playing with different taping, different braces, different orthotic modifications, and have the patient report back how that helped or did not help.  

I'm hopeful I will be able to return to full activities including day hiking and hopefully pick up soccer. My acupuncturist thinks I'm making some progress with acupuncture, cold laser, and tens. She suggested to ice for 10 min when in acute pain after being on feet a lot then follow with heat. 
Dr. Blake's comment: At least, if the pain is located at the navicular, ice pack for 10 minutes 3 times a day, whether you hurt or not at the time, should reduce some inflammation significantly after 75 to 100 times, so get started. 

Any input would be helpful at this point as I'm unsure if this is even a reasonable time frame to heal and I need to just trust my body to heal and do the exercises. 

I really do not want to do surgery as it is unclear to me how this would resolve the problem at this point and appears might create other complications and challenges I would rather avoid.
Dr. Blake's comment: I can find nothing that seems like it needs an operation at this point, so follow the advice above, and from the sports doc, and PTs. Ask them to perform a good foot, ankle, and leg strength test on both sides and see what it shows. Tell them I want particularly the differences in the anterior tibial, posterior tibial, peroneus longus, and peroneus brevis. Thanks and Good Luck. Rich

Thank you for your time.

More info from the patient:
Hi Rich,

My apologies for not using or inaccurately using proper terminology and omitting info. you asked for.

Just to clarify, I rolled my left ankle inward but stopped my body from falling that way and made myself fall outside due to avoid the risk of falling on right wrist.

 Also, I did the transition from boot to ASO brace, to taping to just orthotics as per Ortho in about 3wks. At first, I was wearing an old NB shoe that was too over stabilizing + the ASO due to it being able to fit the brace and was closer in height to cam walker boot. When I got my orthotics I also got the ASICS cumulus sometime in June or July. I preface this to say I could not use crutches due to the wrist and had to use a cane on the left side which I got a week after injury. BTW I’ve both ASO and aircast braces got after was put in a boot (initially using a flimsy store wrap right after injury referred by the pharmacist) but haven’t used ASO or air cast since the Summer. 

I’m beginning to think didn’t get clear enough instructions from providers as no one has mentioned returning to brace or taping and only suggestion was gradually increasing time on feet.

One Ortho said might’ve to go back to boot but that was in August but I didn’t go back to him or other Ortho who seem to just want me to go for surgery. Podiatrist made me orthotics but haven’t been back I didn’t get a good impression he could do anything else.

 From what I’ve been informed by providers all along is that the range of motion has not been an issue. 

I’ve been doing some of the strengthening exercises for posterior tibial tendon as you suggested in video and walking backward on a treadmill then w/o treadmill, and toe raises on a weight machine at PT.  

Ar home I continue to do the exercises instructed by PT; alphabet, heel raises, stand one leg, the ankle dorsi/plantar, eversiĆ³n and inversiĆ³n exercises. 

I stopped standing calf stretch, resistance bands, side lunges, marble, towel, ice baths bc I wasn’t told to continue last time I asked but will check again this week to get a full list of what should do now.

Perhaps, I wasn’t clear but PT had been working on to get the left foot to mirror right foot at rest and not have my foot overextend to the outside when doing the eversiĆ³n exercise. 

As far as a timetable, I had my PT cut off again but in Dec. last they thought that I would be ready by June. My acupuncturist thinks I’ll be ready by April-most optimistic of all.

I’ll update you when I get rest of info you asked for about strength tests hopefully at next appt.

BTW do you have any NYC recommendations for doctors who treat this issue?
Dr. Blake's comment: You can see Dr. Joseph D'Amico at the New York College of Podiatry. 

Thanks so much for your help. The videos are great for reference.