Accessory Navicular: Email Advice

I read your website and enjoyed your informative responses to others who have
an accessory navicular syndrome.

I have been suffering from this from 9/8/18 and would greatly appreciate any input. 

I am also happy to travel from NYC to see you if that would be better.

I’m also happy to contribute to your website to keep it going as it is 

so informative— just let me know how to do so.

I am a weekend jogger, a 43-year-old female, fairly active. I ran into a hole in the ground
and all my weight went

to my right foot on 9/8/18.  I saw a foot orthopedic surgeon in my hospital who said I have a

large accessory navicular (X-ray confirmed) and recommended 3 weeks immediately
in a CAM boot which I did religiously.

After 3 weeks I weaned off for about 3 weeks into an orthotic and was feeling better. 

As a mother of a toddler, I had to drive her to class for about an hour

on that 3rd week and my symptoms worsened.

I contacted my orthopedic colleague who told me that more boot time or physical
therapy probably won't help.  I saw another foot orthopedic surgeon who immediately
started talking re the Kidner procedure. I’m a surgeon myself and was taken aback
about taking off a bone I’ve had all my life and retracting a tendon.

Dr. Blake's comment: Thank you for common sense. This is very common in orthopedic

/podiatry where you immediately lean to surgery and forget conservative care. 

So I saw a podiatrist who is quite nice and told me to go back into the boot and

start physical therapy.  I am also taping my foot.
This has been helping but when I saw him again he said I needed more time in the boot

for another 3 weeks.  He did not recommend a MRI as he felt that the treatment

would be the same regardless of whatever MRI result I have.

Dr. Blake's comment: If one doctor is talking about surgery, and there are patients with 
accessory navicular that need surgery, you have to have all the information at hand to 
make the right decisions. I would vote for an MRI to see what is going on. 

I was able to convince my orthopedic surgeon to get a MRI.  It showed:

1. No tear in the PTT

2. Mild to moderate PTT tendonosis most prominent at the navicular insertion 

    next to the accessory navicular

3. Marrow edema along the synchondrosis of accessory.

Dr. Blake's comment: So, what does this mean? The tendinosis means the tendon has been
straining for a long while and maybe this area was becoming a weak spot to you. 
The chronic part that will take the most work from you is the tendinosis. 
I will attach the posterior tibial tendon strengthening program video I like andthe taping you
should do for a while. 
https://youtu.be/AcSSyBfFocE


https://youtu.be/w3FXx4OFqec


The bone edema is the acute part and that is going to take time since
that is very painful. You have to assume the worse that you broke the synchronosis
or synostosis bridge between the navicular and the accessory navicular. This is treated with 
3 months removable boot, 2 month minimum, to obtain the 0-2 pain level consistently.
Then you wean out of the boot into supportive shoes, good orthotics to support this area,
and use the taping. You ice for 10 minutes twice daily, and do contrasts baths in the
evening. You get an Exogen 5000 bone stim and treat this as a fracture, since it may. 
We will slowly wean into less supportive shoes, less supportive orthotics, less supportive
taping, but gradually as long as the 0-2 pain can be maintained. You gradually build up to 
2 sets of 25 level 6 theraband typically over the next 6 months. 

If I could ask your opinion on the following:

1. As of next week, I will be in the CAM boot for 10 weeks.  
    How long do I need to be in the boot?  It actually hurts now being in it.
    Dr. Blake's comment: It is hard to know if you have a delicate fracture across the
    synchondrosis needing more immobilization. What helps is the understanding that 
    if you can maintain a 0-2 pain level, you are pretty safe in whatever your 
    environment. Learn the taping, max the support from shoes and orthotics, and you
    should be able to wean out of the boot. Remember you need to wean out, typically
    2-6 weeks, based on maintaining the 0-2 pain level. 

2. Do I need surgery?

    Dr. Blake's comment: Typically it takes almost a year if the doctor is really trying to 
    avoid surgery by using rehabilitation to know if you need surgery. It is not wait and see
    but trying to figure out how to drive the pain to 0-2 but be completely active. First you
    want to figure out what it takes to keep pain down and walk 30 minutes daily and see 
    where to go from there. Did it take orthotics, shoes, taping, PT, AFOs, etc? Do you
    have to wear a boot occasionally due to flares?

3. Can I ever run if I do not have surgery?

    Dr. Blake's comment: Yes, that is why you have the surgery, so that there is no long term 
    disability. However, it is the same reason to avoid surgery, since a surgical complication, 
    less than 10%, could give you some long term disability. The surgery is very successful, 
    but the post operative course is a bell shaped curve for healing, and you could be in the
    slow group. This is surgery to the arch, arch supports will be a permanent addition to 
    your running accessories to rest this area. A surgical area in orthopedics tends to be a 
    weak spot to some degree going forward.  

4. Do custom orthotics matter?  I had some moldings done w an pedorthist in NYC. 

    Dr. Blake's comment: Depends on their knowledge with your injury, and what works.
    Based on your unique biomechanics, there is probably seven or eight orthotic cast
    corrections to choose from, not counting the modifications that are possible to the 
    device itself. It does not have to be perfect by any means, just thoughtful for you. 

5. What percentage of adults (not adolescents) who present to your practice 

    w accessory navicular syndrome need surgery?

    Dr. Blake's comment: Not common, and I am sure some are lost to followup, but I always 
    have a surgical opinion as we try to work this through. 10% that need surgery even 
    feels high to me. The surgery is normally because the tendon is more the problem I think. 
    Repairing a diseased posterior tibial tendon is part of the removal process of the 
    accessory bone. I think we know at 6 months if someone is going to avoid surgery. 
    And all the skills we learned trying to avoid the surgery in the first place: good shoes, 
    good orthotics, how to tape, how to get strong, how to get rid of inflammation, etc, will
    help in a post operative course. I know the last 10 patients I saw with this, none 
    needed surgery, but at some point in the ups and downs, they all would have had
    surgery if I had given up. 

6. How long does it take normally for symptoms to improve?  6 months?  1 year?

    Dr. Blake's comment: Phase I of Rehabilitation: Immobilization (where you are at). Here 
    the pain should be reduced to 0-2 by immobilization, fitting for orthotic devices, getting 
    stable shoes, avoiding barefoot, learning to tape, etc. In Phase II, Re-Strengthening, 
    you are progressiving through the stages of strengthening exercises, but still 
    maintaining 0-2 pain, so tape, orthotics, shoes, occasional boot are needed. Phase III
    Return to Activity you still maintain 0-2 while you start a Walk/Run Program, and
    other sport specific drills, continuing to tape, ice, bone stim, strengthen, etc. Therefore, 
    the symptoms should be low by the time the main immobilization is done, and 
    treatment is based on maintaining that as activity returns to normal. A poor 
    rehabilitation plan will not get you through, but I hope I have given you some idea of how
    to do it successfully. Sorry, but no guarantees in life. I would approach this as a rehab 
    program, not as "I hope I can avoid surgery program." The next time to think about
    surgery is 4 months from now to check how you are doing. Now your job is to begin
    to put the ducks in a row and maintain 0-2. 

Any help would be appreciated and again if you prefer to examine me

I am happy to travel to SF.  I was actually studying at the USF

in the early 2000s and

enjoyed living in the Sunset area.

Dr. Blake's comment: I grew up in the Sunset on 38th Avenue. Happy
to see you if it seems appropriate at some time this next year. Hope this has been 
helpful. Rich

Thank you very much.

Best regards,

Stim Router for Nerve Pain: Recent Patient with wonderful results

     Every now and again I am exposed to new technologies that may help many of my patients. This information on Stim Router came from a patient who was kicked in ultimate frisbee on the inside of his lower leg injuring the posterior tibial nerve. This gave him pain in the leg, ankle, and foot (especially the arch). He eventually had a complicated tarsal tunnel surgery at the ankle (although the injury to the nerve was 5 inches above the ankle. When that surgery did not work, he was referred for the stim router technology. They run a wire from one side of your leg under the skin so that it sits on top of the injured nerve. Then they attach a sensor on the outside of your skin that can be turned on and off to stimulate the injured nerve to stop the pain. Fascinating. The links to the technique and individual doctor my patient used at Stanford are below. 

The video below is one version of the technique. 

https://youtu.be/FadXF_CwVGM

http://stimrouter.com/

https://profiles.stanford.edu/einar-ottestad

Discussion from a patient who just had the procedure.

https://youtu.be/TFYO-C2KPfM

Problems post Big Toe Joint Fusion: Email Advice

Dear Dr. Blake,

I was referred to you by Stephen Pribut (podiatrist in the Washington, DC. area).  He said you may be able to respond to my questions by email and offer suggestions for a course of action.

I am writing to request your opinion on the problems I am having with the fusion of my left big toe.  I know this is not an examination but I believe you can address a couple of specific questions I have described below.

In May 2017 I had my left big toe fused due to hallux rigidus.  Once I started trying to walk, I felt significant pain underneath the last joint of the big toe.  There is no pain at the MTP joint.  For the last 18 months, I have been trying to determine the cause of the pain with no success.  The surgeon says the fusion is okay. 

In June 2018, I got 2nd opinions.  I was told either the angle of the toe was fused too low or the hardware was to blame.  I didn't want to redo the fusion so I had the hardware removed.  This did not solve the problem.
Dr. Blake's comment: This is not uncommon, but a pesty complication where the big toe is not fused high enough so the end of the toe becomes the low point when pushing off and takes all your body weight. You can rebreak and refuse or design orthotics to off weight the point to distribute the force. Most choose the orthotic or padding option. 

I came across the chapter attached discussing complications of the fusion.  My symptoms mirror exactly the situation where the toe was fused too plantarflexed or too low.  If you look at the upper of the HOKA rocker shoe I've been wearing, it is evident that my midfoot to the 5th toe is bending over to the outside.  Then, as I walk, I pronate and roll over the foot to the inside trying to avoid the end of the toe.  I have a large callous on the side of the toe as a result.  I have tried but now realize I can not really feel the ball of my foot/MTP joint touch the ground.  So, when I toe off, all the force is on the end of the toe.  It looks like the xray shown in the chapter - Figure 2A and 2B, p117.

I would appreciate your comments on 2 items:

1. I had a gait analysis on November 19, 2018.  The graph is in the attachment while other data is copied below.  I believe the graph/image supports an over plantarflexion of the left big toe.  I know this is not a formal examination but please can you tell me what you see from the graph/image? Dr. Blake's comment: Yes, that is how it looks.  

I would note my right foot looks more normal to me even though I had some scar tissue excised on the 2nd and 3rd toes just 2 weeks ago.  It is little stiff but no pain like I experience with every step with my left foot.

2.  Noting the pronation of my left ankle, the physical therapist believes that might be a cause.  I have always had some pronation but I have never had pain under my toe until this fusion.  I believe the pronation is now exaggerated because the midfoot is rolling to the outside which it never did before.  So the ankle has to roll farther to the inside to get me over the toes.

The pt suggests a medial wedge.  I think this may make the midfoot problem worse.  What do you think?
Dr. Blake's comment: Yes, a medial wedge will just throw you out and mess everything up from more constant supination. Typically it is a balancing act of some lateral support so not to supinate at all, and some off weight-bearing padding on a full-length orthotic device to take pressure away from the point of pressure in the gait image. 

He taped the inside of my calf/heel as a test and that caused pain just below the knee on the inside.

All the modifications to shoes, orthotics, etc. to avoid the big toe only make foot mechanics worse, not better, in my opinion.
Dr. Blake's comment: You are on the right track. You need stability with weight spread out on the big toe, just not on the sore spot. After a fusion, the benefit is to have this stable big toe joint that is not painful and can accept all this weight. At least by theory. So, you want a stable orthotic that loads 90% of the big toe, not off weights the big toe. 

I would be most grateful for your opinion on these 2 matters.  It is looking like I will need to get the fusion redone.  I want to make that decision with the benefit of all the information I can obtain.  It is difficult when there will be opposing views.  My goal is to return to downhill skiing and hiking if I can.  Three years ago I was playing tennis too.  Now, I can't go for a walk because of the pain in the foot and related hip and lower back issues.

Thanking you in advance for your help, Good Luck!!

Dr. Blake's comment: 

I am just back from Hong Kong, visiting my son and his family so my response will be influenced by jet lag to some degree. First of all, thank you and Stephen for contacting me. The graph looks like the pressure from standing only with you having a high arch. Is it true,  and are there other graphs? Typically these problems do not need another surgery, so I am so sorry the hardware was removed. If the big toe was placed too far plantarflexed, and you can not bend the joint, you have to get orthotics that stabilize both sides of your foot and get Hoka shoes that roll. Typically you can build up the orthotic device under the big toe joint and the base of the hallux to even the pressure through that area. Most podiatrists can accomplish that. You can test that theory by getting 1/8th-inch adhesive felt from www.mooremedical.com and place something like a cluffy wedge on your foot (explained in my blog). The area on the toe that is hot should not have any covering. Please take this info and ask me other questions. Rich

Fractured Sesamoid with long first metatarsal: 2 Year Need Minimum of Dancer's Padding

Dr. Blake,

Thank you for your very informative blog. It has more information about sesamoid fractures than most other sources combined. 

I'm 56 years old and have always been very active outdoors hiking and biking, although I've never been a runner. 12 months ago I felt a pop while squatting during some home repairs. The immediate discomfort was not great and I quickly forgot about it and learned to favor that foot slightly and not squat, thinking it would work itself out. As the weeks and months progressed, so did the discomfort. I never had any discoloration, obvious swelling or point tenderness. The range of motion is good.
Dr. Blake's comment: That is the history of the big toe joint sprain, not fracture. The sprain is the ligaments in that area and can be the ligaments around the sesamoids or between a bipartite sesamoid. 

6 months after the injury I finally got an x-ray with a diagnosis of the fractured lateral sesamoid. The podiatrist said the pieces had moved too far apart to knit back together and gave me a steroid injection to help calm down the tendon. We also put a cut-out dancer's pad under my insoles to relieve pressure around the sesamoids. I started an ice massage 3-5 times/day. The plan has been to let things calm down, then make custom orthotics to replace the dancer's pad. Surgical removal was mentioned as a possibility if things didn't improve.
Dr. Blake's comment: Remember, steroid injections give some relief up to 9 months, but they also mask pain which may not be good. 

By 9 months it was feeling much better and I was able to routinely hike 4-8 miles again, with pain levels in the 0-2 range. I stopped icing. Then I got a new pair of cycling shoes and did ONE RIDE without the relief pad. The next day I noticed slight discomfort had come back and it continued to get worse over the next two weeks. I resumed icing. A new x-ray at 10 months showed the sesamoid remains non-union and I got another steroid injection. As the first injection, it took about 2 weeks before I sensed improvement. 

It's now been 12 months since the injury and I'm again feeling like there's hope of a good long-term outcome. But information here has me wondering. My questions are:

1) Is the steroid injection simply masking symptoms? Dr. Blake' comment: Yes, stop doing those, you can hurt other things by masking the pain. These long-acting cortisone shots, I am assuming this is what you got, work for 9 months. With 2 in your system, you have 7 more months of the shots doing something so it will be May 2019 before they are out of your system. If your symptoms are still good in May, then you will probably be fine. 

2) At this point, is there any hope that the sesamoid pieces will heal back together? If not, can I have an active lifestyle (backpacking, mountain biking) with a fractured sesamoid? Dr. Blake's comment: The last 2 xray views show very round edges to the junction which means it was probably a bipartite sesamoid that broke. This means it will never go back, you just want the injury to stabilize and stop hurting. Your injury made sense for a bipartite sesamoid sprain where the two pieces separated more than a fracture. 

3) How concerned should I be about the degradation of cartilage on the metatarsal head caused by the rough, fractured edges of the sesamoid? Dr. Blake's comment: I am not sure. We don't remove the sesamoid for fear of this being a problem. When sesamoids are removed, it is due to the disability the whole problem produces. It can be hard to know exactly what is the trigger of pain in some patients. Sesamoid removals are in so few patients who break their sesamoids, and some heal with a lot of irregularity. Yearly checks on the condition by the treating doc is advised if only to refurbish orthotics and occasionally take x-rays. 

4) What symptoms should I be alert for that would indicate avascular necrosis? Is AVN still a risk 1 year after injury? Dr. Blake's comment: Not much of a risk here. Full examination with MRI and CT scan would be required. Bone stimulation for 9 months if any signs.  I sure hope this information helps you. 

I'm emailing x-rays, in case they help if you have a chance to answer. 

Irregularities noted on the bottom of both sesamoids, especially lateral

Smooth borders of separated sesamoid fragments appearing to show bi-partite condition

The lateral or fibular sesamoid has definitely been remodeling. The irregularities within the bone show this process. I love the Exogen 5000 bone stim if insurance covers. I also love contrast bathes each evening as a deep flush to the bone to remove swelling that can slow bone healing. I also want you in sesamoid protection nonstop until you are back doing everything for several months. 

Samuel Merritt University research for the California School of Podiatric Medicine

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Nerve pain in Ankle Area: Email Advice

Dear Dr. Richard,

I live in London, U.K. My job is in I.T. - so desk based all day.

I came across your blog today, looks very informative. I actually saw the video where you talked about pain around the heel possibly due to back issues.

https://youtu.be/E0E60NpOSHg

Please, could you provide some advice to me? 

I have had foot pain since last 4.5 years that started one morning after some leg exercises in the gym (possibly causing back issue?). I felt heaviness in the left footbed when I sat cross-legged in the office after gym. Now the issue is with both feet - which are very flat, but show arch if I am dangling my feet in the air, rather than standing on them. 

Dr. Blake's comment: This is called a flexible flatfoot. The heaviness is a symptom of nerve dyskinesias, also called abnormal sensations like buzzing, burning, things crawling on your skin, or a rolled up towel under your arch or toes. 

Pain first thing in the morning has always been 3/10 level, never to the level of having to scream. The pain is worse if I walk a lot or stand at one place for more than a couple of minutes. 

Dr. Blake's comment: Yes, standing can be the worst time, since nerves like motion most of the time (like neural flossing exercises). 

The pain is around the heel area and travels up on the calves. Areas of soleus, behind the knee are always sore be it first thing in the morning or last thing in the day. The metatarsals and Achilles also have random tenderness.

Dr. Blake's comment: I always think nerve pain if there is tenderness but not swelling in the tissues. Do you have any swelling when it hurts?

Different types of insoles haven't helped. Recently I got expensive custom-made orthotics done, but I doubt them. Funny enough, I feel more comfortable wearing "Teva jetter lux slide sandals" than ASICS Kayano 25 that I am wearing with insoles. 

Dr. Blake's comment: Nerve Pain around the ankles, called tarsal tunnel syndrome or some version of it, can make patients wear the least supportive shoe or sandal so the sides of the shoe do not press against a sore spot. 

Recently I got MRI of feet done, which showed some bursa, inflammation liquid, little spur under left foot - which doctor said could be present in a healthy person's feet too.

The doctor also said that the plantar F hasn't got enough thickening to say that is an issue. He thinks I might have fat pad syndrome or something coming down from my back. I am currently waiting for my back MRI results.

Dr. Blake's comment: Yes, sounds typically double crush syndrome where the nerve is being irritated from above (even at the neck) and at the foot. The back MRI is a static exam, so will not pick up some back problems, but is a good place to start. You want to find a conservative peripheral nerve specialist, in the states they tend to be osteopaths, who will look at all the possible causes of sciatic nerve involvement. 

I have recently got some tape which my partner wound around my heels and that felt good after walking in that. I will try that for a few days.

Any guidance from you will be greatly received and I will make a donation too at some point as gratitude. 

Regards and many thanks in advance.

Dr. Blake's comment: I think you are going in the right direction. Make sure you are massaging the area three times a day with a gel or lotion for nerve pain, not anti-inflammatory (I have my patients buy Neuro-Eze online). Learn how to neural floss from a physio (my one video is below, but there are various techniques). 

https://youtu.be/g94F8g_jzGg

See if Lidoderm patches can be prescribed for a month trial. Begin 3 weeks experiments of the supplements that help nerve pain. 

1.      Lipoic Acid 300mg 2x/day

2.      Acetyl-L-Carnitine 2000 mg/day

3.      Inositol 500-1000mg/day

4.      Vit B6 50mg/day

5.      Vit B12 1000mcg/day

6.      Vit E (up to 1,600units/day)

7.      Thyroid Natural Supplements

Diet for Nerve Pain

http://www.rsdrx.com/four_f's_diet.htm

Here was the advice I gave to another patient:

 Nerve Pain is helped by some combination of the following (many of these topics are in the blog already):

• Neural Flossing three times daily (find out if sitting or laying techniques more productive)
• Nerve Pain supplements like B12, Vit C, (gradually you add one per month to check effectiveness so you would wait on this right now) etc 
• Some topical nerve cream applied 4 times daily (NeuroEze or Rx)
• Heat over ice
• No sciatic nerve/calf stretching (find out everything postural wise that is tasking your sciatic nerve from beds, sitting chairs, standing habits, workout techniques). 
• Oral meds (start with evening doses only of Lyrica, Neurontin, or Cymbalta). 
• Epidural injections into the L5 nerve root
• Soft based orthotic devices like Hannafords
• See if there is a Calmare Pain Therapy center near you 
• Sometimes TENS and Capsaicin is helpful (but you have to go through 14-20 days of more pain first)

Hope this points you in the right direction. Rich

Toenail Fungus is Among us!!!

Hello,

We have been faithfully 100% following your protocol you sent me back in FEB!!!!! Vinegar soaks 3x per week, sanding once a week and nightly application of TT oil on the toenails. The first pic is what they look like today and the other is back in Feb. when I first contacted you! They are looking better, but still not GREAT! I am curious to know what I should do next?? Do I continue or switch it up at this point? OR LEAVE THEM ALONE?! It has been quite a process

Thank you for your kindness in helping me!

Before Treatment

After 8 months, a lot of Vinegar (70% better to my eye)

Dr. Blake's comment: My comment to the mom was to keep going. She is doing this for her son. I told her for her reward of doing so well, 6 more months of the same thing. The nails seem to be clearing, the part at the end of the toenails is the last to go. 

Maximalist vs. Minimalistic Shoes: Dr. Blake debates Dr. McClanahan

https://www.podiatrytoday.com/point-counterpoint-are-maximalist-running-shoes-better-minimalist-running-shoes

And yes, another picture from my son's wedding in Maui last Saturday 10-20-18!!

Meet Mr. and Mrs. Chris and Courtney Blake!!

Does B12 Injections help with Nerve Pain like Mortons Neuroma? Some feel it does and should be Considered.

A question was just asked my blog about the use of B12 injections for nerve pain like Morton's neuromas. This seems to be a technique not commonly in use, but why? I found many articles discussing its use and I would use the guidelines from the first article for the 2 injections. I do not see why it could not be added to cortisone or alcohol injections (although you would have to calculate the alcohol percentage with this in mind). The B12 comes 1000 micrograms per ml, so you would use 1/2 ml. See the interactions discussed in the last article below from the Mayo Clinic.

https://www.sciencedirect.com/science/article/pii/S0929644115000053

This article proposes 500 mcg (micrograms) of methylcobalamin injected around the nerve twice (after the first one wait 2 weeks for the second shot).

https://www.webmd.com/drugs/2/drug-6550/vitamin-b-12-injection/details

http://www.vitality101.com/health-a-z/Neuropathy-b12_shots_for_nerve_pain

https://www.mayoclinic.org/drugs-supplements-vitamin-b12/art-20363663

Cheilectomy: Exercise Program Post Surgery

My wife Patty's Wish came true: Sunset, Champagne, and Santorini on 60th Birthday!!! 

(4 Years Ago)

Hello Dr. Blake,

I am writing to you from Santorini,… Eventually, I have not avoided the operation and I had cheilectomy in my right big toe. Stitches were taken out 2 weeks ago and it seems everything is fine. I have started wearing mainly my training shoes and also I walk every day, for about half an hour.

My doctor said I do not need any physiotherapy, he only told me to do one simple exercise 2-3 times a day, for 3-4 minutes, it would be sufficient. I am attaching a photo of my foot doing the prescribed exercise.

Please, would you be kind enough to propose me any kind of additional exercises you deem necessary so that to perfect my toe mobilization, apart from the one I am sending you?
Best Regards,

PS I was glad, that you had attended the conference in Santiago de Compostela, which is one of our favorite places in Northwest Spain. Think about revisiting Greece, so that you visit the island of Santorini.

Dr. Blake's comment: The image below shows good motion, but it is only a stretch on the bottom structures of the foot and you need to get the weight on the lower part of the toe (you are bending the joint closest to the toenail more than the one you need to be stretching. 

And yes, if we get back to Greece, for sure we want to go the Crete and Rhodes, we will want to spend several days again on Santorini!! Unbelievable place!! You can not take your eyes away from the vistas!! We stayed at Canavas Suites in Oia Village. 

We definitely want to do self-mobilization as shown in this video. No exercise should evoke pain, however. 

https://youtu.be/GY-mJjXmeIc

You should also strengthen both the Extensor Hallucis Longus and Flexor Hallucis Longus.

https://youtu.be/tNrh1yV8ZEA

If you want to learn how to do theraband progression, see my video on posterior tibial exercises. It will be the same principle for any muscle. 

https://youtu.be/w3FXx4OFqec

For the extensor, put your back against the wall and assume a sitting position with the knees at a 45-degree angle. Then do 2 sets of 10 of pulling your big toes up into the air slowly, leaving the rest of the foot on the ground. When 2 sets of 10 get easy, try 2 sets of 15, gradually getting to 2 sets of 25.

I also think building up to 2 minutes of single leg balancing helps tremendously. And gradually increase the height of 2 sided heel raises to get the achilles working well. Like with sesamoid injuries, you sometimes have to protect the big toe joint by building a well to offload. Good luck Rich

Maui Wedding for My son Chris and his new Bride Courtney!!

Rich, Courtney, Chris, Pat (my wife), Henry (grandson), Steve (other son), Clare (daughter in law)

Hallux Rigidus Post Toe Fusion Running!!! Amazing!!

And here is John Trautmann running a 4:14 mile in his mid-40s with a fused left toe:

https://www.youtube.com/watch?v=ZXku7EyqOVg

He wins the race beating a bunch of college kids.  Look at his form in the very last straight away, he is sprinting with a fused toe.  I've tried very hard to detect an obvious bio-mechanical abnormality that would indicate a toe fusion but I can't see anything.  Amazing.

Snapping Peroneal Tendons and Nerve Hypersensitivity: Email Advice

Hi Dr. Blake,

I am not sure if you remember my previous emails, but I started experiencing bilateral sesamoid pain after an ankle sprain and I wanted to update you on my condition and ask a few questions if you have time.

I did physical therapy for a month - my hips are strong now, but I still have the same pain level. I decided to get a second opinion from an osteopathic doctor/foot and ankle surgeon. He found that the outer sesamoid bone is tender on my right foot, and both are tender on my left foot. My peroneal tendons are snapping over the bone slightly on the left side (this began at the end of August when I tried Hokas and the previous doctor said not to worry) and while the intensity of the snapping motion has decreased slightly over time, I am having a lot of pain in the area of the tendons and all the way up through the muscles of the leg. He decided to put me in a CAM boot on the left side for a month. He did say that often this can't be fixed without surgery. He also talked about surgery for the sesamoids. That was scary!
Dr. Blake's comment: Nothing points to surgery for these unless MRIs show a permanent condition. Patients who irritate the peroneal tendons somehow, sometimes abnormally supinating away from their sore sesamoids, begin to feel snapping as the tendons get tight from overuse and the motion of two abnormally tight tendons causes snapping sound. You have to make sure you are not abnormally supinating, and make sure you are icing the area twice daily do remove some of the inflammation.

I asked about using sesamoid protection in the boot, but he said it wasn't necessary. However, I think I will follow your advice and make a pad out of felt.
Dr. Blake's comment: Thanks for the common sense.


I'm also having custom orthotics made (finally) that will be able to be adjusted as many times as needed.

My first question is, what can I do to maintain strength while in the boot? I'm allowed to take it off while at rest on the couch and for sleeping. Obviously, I will avoid any motions that cause the tendons to snap, but I'm worried. I will continue to do my hip exercises from PT.
Dr. Blake's comment: You are trying to relax the tendons, not strengthen them at this point. Standing flat for balance should be okay for 2-3 minutes twice daily. The tendons are irritated in different ways when the ankle is pointed or flexed too much. The most important is cross training with stationary bike riding if available. You usually can lower the seat enough to feel the less strain on the tendons.

Next, I'm still having constant tingling in both of my feet and legs (worse on the left side). My spinal MRIs are clean (very slight bulge at L4-L5 but the neurologist said it was so small they weren't sure it was there). I also had a nerve conduction test and an EEG and both were normal. The neurologist decided to start me on Effexor/venfaxaline as we both think my nervous system is just on overdrive due to anxiety. I've been on it for five days. Last night, I awoke in the middle of the night and there was no tingling for the first time in months! It did come back, but I think that is progress.
Dr. Blake's comment: I think this is a good approach. Unfortunately, those tests only show big issues, so fortunately, you have some nerve hypersensitivity but it should resolve. The medication helps the nervous system relax. You keep whatever dose needed to achieve pain/symptom relief for 2 months straight, and then you try to wean with less dose per week not per day.

So, I guess my biggest question is what can I do to keep myself comfortable while dealing with the boot? I am worried about the stress on the nerves. Should I continue contrast baths/neuro-Eze/gentle massage?
Dr. Blake's comment: Yes, please continue the gentle help from neuro-eze, gentle massage, contrast bathing, and neuro-flossing. These will help the nerves. Take the boot on and off as much as possible, since you only want the boot on when you walk. If you are wearing a boot, you have to get an Even Up on the other side, so balance the hip height with adequate shoe height. That will protect your spine.
 Do you think these approaches sound adequate (boot for peroneals, orthotics for sesamoids)? See above, and good luck. Rich

Thank you so much for taking the time to read this.

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Hi - I’d like to thank you for the advice you gave me last year for a sesamoid stress fracture. It’s been a very slow recovery process, however, I was just able to run the Chicago marathon! I’m still trying to get back into racing shape and am dealing with overcompensation injuries, but it feels great to be running again and building confidence in my foot. I really appreciate your help with understanding the injury and recovery!

Conference in Santiago de Compostela Spain

I just spent a wonderful week in Spain at the 49th Congress of Podiatry in Santiago de Compostela. It was through this blog that I was invited and had a wonderful time. Thank you Eladio Martinez Garzon for arranging such an incredible adventure for my wife and I. I gave three presentations: 1) Runner Treatment Philosophies, 2) 35 Years with the Inverted Orthotic Technique, and 3) Treatment of Adult Acquired Flat Feet. I hope to get back to my normal schedule, although jet lag is a wonderful time at tiring you out. Rich

Orthotic Cast Correction on Cast Fill: Email Question

Good morning, Rich.  A quick question – regarding “cast fill” – do you generally prescribe the “normal” cast fill on the Root Lab form and find that leads to good patient outcomes?  My experience with other labs has been that their standard cast fill, seeking to make the device more “tolerable,” is so much that it significantly compromises the effectiveness of the device for people with excessive pronation issues.  That is far and away the most common problem I see with my PT patients who are referred to me because of other injuries, but for which excessive pronation is really the root cause -- e.g., runner’s knee.  I often prescribed “minimal” cast fill with other labs and I just wonder what your experience has been with Root lab with whom our practice is now working. 
Dr. Blake's comment: Yes, that is a big problem. Root Lab is truer to the arch than some labs for sure. You do want to have a grinder since some plantar fascial bowstringing requires a groove when the arch is true. If you are using vertical cast correction, how much change (transition modification at the first metatarsal head) will you ask them to do to a 5 degree vs 10-degree forefoot varus? I have found you have to go to a 25 degree inverted cast correction if the forefoot varus is over 5 degrees and you want great support (or at least modified forefoot correction for comfort but ask them to use a 2-3 mm Kirby skive and some extra medial column support (minimal fill proximally in the arch not distally). I will send this to Jeff Root to see if he responds. I hope this helps. Rich 

Any experience you can impart would be very much appreciated.

Thank you.