Plantar Fasciitis:General Principles of Treatment

 Plantar Fasciitis is one of the most common problems facing podiatrists. 

Several Golden Rules of Foot are common.

Golden Rule of Foot: Plantar Fasciitis begins gradually over weeks and months before effecting athletic performance. It does not come on suddenly.

Golden Rule of Foot: Even bad cases of plantar fasciitis have no swelling. Heel swelling typically is a sign of something worse like an actual tear in the fascia or a stress fracture in the heel bone. 

This can be such a stubborn problem that it is easy to get very frustrated. Very few people need surgery for this since there are so many options for treatment. 30 years ago 1 in 10 patients required surgery, now surgery is less than 1%. The treatment options are so numerous that we are normally limited only by our time and imaginations to develop a successful treatment plan. Each week there should be improvement once active treatment begins. If improvement plateaus, a change in treatment options should be made, but not the basic conservative treatment protocol. Analyzing what is working and what is not working should be part of that process.

The patient and health care provider deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanics (one being the transference of pressure from the painful areas to non-painful areas). Most cases of plantar fasciitis need simple solutions like daily icing (anti-inflammatory), plantar fascial and achilles stretching 3 times daily (flexibility), and arch support (either custom orthotics or store-bought arch supports). Some of the more stubborn cases of plantar fasciitis need all of the above along with physical therapy to improve flexibility and anti-inflammatory measures, custom-made orthotics if not already manufactured, night splints to gentle stretch out the plantar fascia, cortisone shots if a bursitis under the heel bone is found, and many other options.

In resistant cases, 3 months in a removable cast can help calm down the inflammation. I presently would not recommend this unless I got an MRI. The MRI typically will show you why a case of stubborn plantar fasciitis is not improving. The moral of the story with plantar fasciitis is to never give up. Keep trying to find the right combination of anti-inflammatory, flexibility, and mechanical changes. Good luck. Also remember that 25 to 30% of all cases I see for plantar fasciitis for a second opinion, have something else. Neuritis, bursitis, stress fractures, and plantar fascial tears all head the list in the differential diagnosis. I hope this helps and gives you encouragement. Dr Rich Blake

Here is a video on the stretches to do and not do when you have plantar fasciitis.



When I talk about mechanical changes that effect plantar fasciitis, there are many Golden Rules of Foot and come into play.

Golden Rule of Foot: When designing an orthotic device, or using an OTC arch support, the patient must feel that the weight is being transferred into the arch (even borderline obnoxiously) and the heel is feeling protected. The patient should never feel that the majority of the pressure is in the heel. 



Golden Rule of Foot: The most stress on the plantar fascia and achilles is when the heel just comes off the ground. Treatment of plantar fasciitis therefore typically involves staying in elevated shoes, orthotic devices, clogs, and remaining flat footed in some exercises like the elliptical, and sometimes not getting off the seat in cycling. 

Golden Rule of Foot: A negative heel stretch (where the heel drops below the ball of the foot) can irritate the plantar fascia with all of the body weight suspended at its attachment. This is in stark contrast with the same position of the Downward Dog in Yoga which never seems to bother the plantar fascia as the body weight well in front of the plantar fascial attachment into the heel.

Golden Rule of Foot: Plantar Fasciitis patients hurt less walking on their heels than flat footed. If you think you have plantar fasciitis, try to walk barefoot normally, on the balls of your feet, and then on your heels. If you hurt the most on your heels, you probably do not have primary plantar fasciitis, and more bursitis, plantar fascial tears, or heel stress fractures. All three of these are diagnosed by MRI. 

The video below discusses heel evaluation.



My initial visit for plantar fasciitis typically includes:

1. Teaching the patient Support the Foot taping (www.supportthefoot.com) and giving them a few extra strips. Every podiatrist and PT will have some version of taping. 
2. Rolling ice massage with frozen sport bottle 5 minutes 3 times per day
3. Plantar fascial and achilles stretches (see video above) 3-5 times a day. Typically, gastroc and soleus stretches 1-2 times per day, and plantar fascial stretch 5 times. Nothing should hurt when you stretch however.
4. Mechanical changes based on their activities, like no barefoot around the house, and staying flat footed on the elliptical. 
5. Consideration of physical therapy, night splints, removable boot, all based on their symptoms, speed on healing needed, etc, or getting an MRI if a tear or stress fracture is suspected. 

I sure hope this helps. Rich

Free Ebook to the first One Hundred who Email

22 sent, 10 received, 78 to go!!! (updated 1-12-19) If you ordered, you should have received. One patient found it in the Spam folder. I have more to send, so please ask. I want to help!!

     I would love to offer a free ebook (500 plus pages) to the first one hundred who send their email me at drblakeshealingsole@gmail.com as a form of celebration to start the new year. I am so happy I have been able to help some of you, and I so appreciate the warm support of this book. The book can also be a gift from you to a loved one who you think will benefit. Please be patient with my mailing through Amazon website, as I will be handling the requests over the next month. As you read the book, please free feel to email me comments on your experiences, or questions that come up, as I want this to spur conservation, and I want us all to be healthier. Thank you and Happy New Year. Rich



Sesamoid Pain and Trying to Avoid Surgery: Email Advice

Dear Dr. Blake, 

I work in the US but my home is Brazil. 

I just came back from vacation in Brazil with disturbing news: the podiatrist there told me I need to get surgery on my right foot, as my two sesamoids in my right foot are compromised. One of them is split in the middle and the other one is worse, fragmented (see below). 

After looking for doctors over the Internet I came across your name and website. I have also noticed that you are able to treat patients with less invasive treatments, avoiding surgery. The prospect of a surgery is really difficult for me for different reasons: (i) my family does not reside in the US, so it would be difficult to recover and work at the same time; (ii) my work involves a lot of travelling; (iii) any invasive approach scares me.

If you believe there are any chances of curing my condition without surgery, I would like to talk to you. Could you please look at the CT scan results below? I would truly be grateful for any inputs and/or ideas you might have. 

After researching online I found that a vitamin D level exam and a bone density level exam should ideally have been carried. Neither of them were requested to me. 

Below please find the CT scan results (translated by myself from Portuguese). The exam was undertaken at Albert Einstein Hospital (considered the best hospital in the southern hemisphere)  

 
A study carried out using the fast spin-echo technique, in heavy multiplanar cuts in T1 and T2, pre and post-paramagnetic contrast, showed:

·         Attitude in hallux valgus.

·         Lateral sesamoid with fragmented appearance, with irregularities and bone sclerosis.

·         Medial hallux sesamoid with bipartite morphology with bone marrow edema suggestive of overload.

·         Other bone structures with normal spinal morphology and sign.

·         Minimal metatarsophalangeal joint effusion of the hallux.

·         Lack of significant joint effusion in the other joints.

·         Tendons without significant changes.

·         Fluid distention of the intermetatarsal bursae between the 2nd and 3rd spaces.

·         Obliteration of the plantar adipose cushion underlying the heads of the first, second and fifth metatarsals, indicating load points.

Thank you so much for your help and support. I truly appreciate it! 

Best regards,

Dr. Blake's comment: Thank you so very much for writing. As I write this, I know it must be late on the East Coast of the US. It probably does not matter at this point how you did this, but you have injured the sesamoids. Okay. Some doctors take them out after 3 months of treatment, and others like myself drag their feet delaying and hopefully preventing surgery. It is a whole spectrum. You really have to treat the injury as if you just got it. Depending on your insurance, an exogen bone stimulator distributed through Bioventus works well most of the time. This is a 9 month assignment to get the bone strong. Contrast bathes 4-7 nights a week will act like a deep flush to the tissue. Order Dr. Jill's dancer's pads to protect the sesamoids yourself, along with learning how to do spica taping, and cluffy wedges. Make sure your winter shoes are stiff to help immobilize the tissue as many hours a day as possible as you are trying to create a 0-2 pain level environment for healing. See my buddy Dr. Steve Pribut (link below) in DC for local hands on. Keep me in the loop. Good luck. Rich

I know there are some good articles supporting shockwave therapy as a noninvasive treatment for sesamoid problems, but it may be just too costly.

https://www.vitals.com/podiatrists/1zwb65/stephen-pribut

Sesamoid Fracture: Email Advice

Dr. Blake,

Happy Holidays! Thank you so much for all the time you’ve put into this blog! I’ve read through many posts regarding sesamoid injuries, and there's more info here than anywhere else.
My 15 year old daughter fractured her sesamoid and her podiatrist hasn't known what to do, so I was wondering if you could help her out.

This is what she said:
In october, I felt a pop in my foot during cross country practice, and ended up in a lot of pain. I ran one final 5k a few days after, and went to homecoming in heels that night. Horrible idea. My foot was bruised and my pain level was about an 8 (10 being the most painful).

I went to the podiatrist, who said I just had sesamoiditis and could run again in a week. I took an entire month off just to be safe, and when I went back to the podiatrist because I was still in pain, he said it turns out that I had a fracture. I wasn't given a boot to immobilize it.

A few weeks later I felt another painful pop in my foot, went back to the podiatrist, asked for a boot, and here I am. I’ve been wearing the boot to immobilize my foot for the past 2 weeks and my pain level is at a 0, but it is very visibly swollen. I've been icing 3x a day and am going to start contrast baths as you recommended. I bought calcium supplements and am taking vitamins as well.
Dr. Blake's comment: So you are now starting about 3 months of immobilization with 10 weeks to go. Now until Feb 15th, the boot should be your friend in creating a consistent 0-2 pain level. The icing twice a day, and the contrast baths each evening are important. Gentle massaging the area with your palms 2-3 minutes three times a day with arnica, mineral ice, hand lotion, just to desensitize the area. Make sure you bike a lot of leg strength. Unfortunately 30 minutes of running is equivalent to 2 hours of biking outdoors, but probably one hour on a stationary bike.
     This part is the easy part. Soon, the podiatrist must make a good pair of custom orthotics to protect the sesamoid. These should be ready for you at 8 weeks into the immobilization, the earliest time to start transitioning into orthotics and athletic shoes. It is imperative you keep the pain level to 0-2 during this whole process. Sometimes, as you wean from the boot, you need to wear Hoka One One shoes or Bike Shoes with embedded cleats.
     Remember also to have your Vitamin D level tested as this is a frequent cause of stress fractures. If the normal range is 30-80, I want my athletes around 55. Also, a good healthy diet is crucial to get the building blocks for fracture healing.

I am just wondering if there's anything i'm missing. Also, how would I get an exogen bone stimulator? I assume I would need a prescription. I can also send you my MRI if you would like to see it. The radiologist confirmed that I have a fracture.

Dr. Blake's comment: Yes, you can send it to Dr. Rich Blake 900 Hyde Street, San Francisco, California, 94109. The podiatrist or your pediatrician can start the Rx process for the bone stim from Bioventus called Exogen. Hope all this helps. Rich
Here's the MRI report:

Technique: Routine MRI images of the right foot
Findings:
A marker has been placed beneath the medial forefoot and great toe to indicate the site of clinical concern. There is confluent marrow edema within the medial sesamoid bone indicating a nondisplaced vertical fracture or stress fracture and edema in the underlying soft tissues. The lateral sesamoid bone of the the great toe appears normal. No metatarsal stress fracture or suspicious lesion is identified. Normal signal is present within the muscles. No Morton's neuroma or ganglion cyst is evident. The flexor and extensor tendons are intact. There is no plantar plate tear.
Conclusion:
1. Nondisplaced fracture or stress fracture of the medial sesamoid bone of the great toe and edema in the plantar soft tissues.


Again, thank you so much for the blog!

Happy Holidays!!

The patient's mom sent me the MRIs for review. Here is my response:

 I had a chance to look at the MRIs. So, clearly there is a nondisplaced stable fracture of the medial (also called tibial) sesamoid which needs some protection going forward. You can protect it in different ways as you blend the Immobilization phase into the Return to Activity. The protection can come from Dr. Jill's dancer's pads, cluffy wedges, spica taping, custom orthotics, and removable boots. The boot is to prevent her from stirring it up and some of the patients only use while walking great distances (probably 4 hours a day to rest the tissue and trying to decide which 4 hours are the most meaningful. With return to sports, you have to see if sometimes she can wear an orthotic, say in her conditioning, and sometimes Dr. Jill's padding with cluffy wedges with or without spica taping. If patients feel good, they first stop taping. I would experiment as you place her on a 6 week return to full activity program. Each week she adds more and more stressful ball of the foot activities until she is at full speed and full activity at 6 weeks. It is the push off of most concern, so speak to the coach and see how this can be arranged.

     The difference between the 2 MRIs are minimal, which is to be expected. After the first MRI, I wait 6 months to repeat and go solely on the patients feel, and if they have to limp at all (a big no no!) It is usually a mistake to remove the sesamoid protection for the next several years. Part of me saying that is because I do not know her foot mechanics (some patients have 3-4 reasons that their sesamoids can be stressed) and part of that because I know sesamoid padding will not inhibit her ability to perform at the highest level.

     Contrast bathing remains the best home treatment to flush out the sesamoid of swelling that can cut off the circulation. Try to average 3-4 nights per week, and simple ice pack after workouts. Hope all this helps. Continue to listen to the pain, even if she is competing again. Rich

Chronic Plantar Plate Injury: Email Advice

Hi Dr. Blake,

I got your email from your blog and I am hoping you can spare a minute to offer me some advice. I have read online that you have been very helpful to people suffering from this condition and I would greatly appreciate your advice.  I am a 31 year old teacher who lives in Canada and I have been suffering from pain around the second mtp joint in my right foot for about 10 years, ever since a single traumatic misstep while running barefoot. At the time of my original injury I was put in an air boot and a bone scan rules out stress fracture or necrosis etc. But the culprit for the continued pain was not found.
Dr. Blake's comment: At least bone was ruled out, could be soft tissue ligaments or nerve pain.
 Other the next 10 years the pain persisted most notably in and above the second mtp joint, while underneath the joint remained tender, it wasn’t as sore as the joint itself. I had about 5 cortisone injections into the area over the years with little improvement.
Dr. Blake's comment: Unless the doctor is injecting Morton's neuroma pain, have them limit it to short acting cortisone. Long acting cortisone can possibly hurt the ligaments.
 Finally, a podiatrist diagnosed the injury as plantar plate dysfunction about 2 years ago (ultrasound confirmed this (fluid under joint) though a recent mri showed no abnormalities of the plantar plate) and I was gaining some relief through taping and custom orthotics (though the pain in the second mtp joint was never fully alleviated, the pain under my foot had improved a lot after wearing insoles for the last year). I was also using diclo cream. My toe slightly migrated away from the big toe but it is not very noticeable.
Dr. Blake's comment: The MRI and ultrasound should have got the same results. Interesting, what was the Lachman test like?

Recently, Because I was still having pain, and a joint drawer test (same as the Lachman test) indicates my second mtp was not stable, I was offered a second mtp osteotomy by an orthopedist surgeon but he thought I should try prp beforehand, just to see if the joint would respond. The doctor who administered the prp injected it into the top of my second mtp and also directly into the plantar plate, this is where my current dismay began.
Dr. Blake's comment: The surgeon must have been going to due something else to repair the ligament.

Since the prp injection 3 weeks ago, my plantar plate feels as sore as it did when I was initially injured 10 years ago. Experiencing this renewed pain on the bottom of my foot makes me realize how much it had improved with taping and orthotics over the last year and how all of my pain was actually coming from the joint itself (and notably felt on the top of the foot rather than the bottom). Now I am worried that the trauma of the prp needle and the injection of the fluid may have made my injury on the bottom of my foot worse. It has been 3 weeks and the area can still not bare weight .

Can you offer any advice regarding my current predicament ? Do you think prp could cause more damage ? Should I expect the prp to take longer to heal due to the  rigid nature of the plantar plate ligament and it’s lack of blood supply? . Should I treat the site as a new rupture (and try and immobilize for 6-8 weeks) or follow prp post-procedure guidelines and keep using the area as normal in a stiff soles shoe? Also, if/when this pain on the bottom of my foot is alleviated, should I consider the second mtp osteotomy to address the original issue of second mtp joint pain ?

Thank you very much for your time - I hope to hear from you!
Dr. Blake's comment: The PRP from the bottom was hitting all the nerves in the area and is very painful in general. Yes, if you can not bear wear, go into a removable boot for the next month or so, and ice now. I know you are not supposed to ice with PRP as it is trying to make a new injury and mount an immune response. Get this calmed down, and you hopefully will have found this helpful to you. In one month, if you are not much better, I would seek an MRI to see what the tissue looks like. Too early to talk about surgery. I hope this helps some. Rich


The patient then responded:

Thank you for getting back to me so quickly! I will begin icing my plantar plate and get into a boot for the next month. Do you think the pain is likely causes by inflammation or upset nerves rather than additional tears in the ligament due to the needle? Dr. Blake's comment: Yes.

I realize a needle point is a fairly small implement so I’m scratching my head as to how much pain I am in 3 weeks later. I spoke to my brother-in-law who is a physiatrist and he says it is rather unlikely a needle could do any real damage.... I have a follow up with the orthopaedic surgeon in two days so I’m wondering if you have any advice on things to mention to or ask him ? Dr. Blake's comment: Yes, talk to him about another MRI in a few months, PT to calm the joint down, ask him if he does just ligament repair of the joint (not osteotomy). I guess if the second metatarsal is very long, an osteotomy should be in the discussion, but many surgeons just sew the ligament  where it is torn and place the patient on Budin Splints for a year to hold the toe from moving. You can also not fix the tear, but sew the joint on top tight for the least rehabilitation. I had a podiatry surgeon tell me they did that on some professional basketball players to get them back faster. You can talk about a arthrogram where they inject dye into the joint to see if there still is a tear. If the dye leaks from the joint, the tear is still present. Ask his or her advice on calming the nerves down quicker. Should you be using topicals like Neuro Eze or Lidoderm patches. They have compounding medications for nerves by RX. Does he/she believe it is nerves or inflammation or both. What about a 6-8 day course of oral cortisone to calm it down?

 As I know that it will be too early to make a decision on a procedure due to the post-prp pain but I figure I’ll keep the appointment so he can at least take a look at the area and I can bring him up to speed. Also, I purchased a portable TENS machine and I am wondering if you think this would be suitable to use on the area ? Dr. Blake's comment: If you know how to use it. You may need a PT to instruct you the best way, especially how low to start so you do not irritate things more.

Thanks again for your help! It seems like it is nearly impossible to find information on this topic online so I truly appreciate your time and effort .

Best, 

Heart Rate Watches: Keeping in the Target Zone

     I am currently on the search for a heart rate watch, since I want to exercise safely, but have some heart problems to manage. I have given up basketball since I could not stay in the safe Training Zone. The rule with heart rate is 220-age= Maximum Heart Rate. I am 65 in a few days. Medicare here I am!! But, when you do the math, my max heart rate is 155 and my training zone is 132 (85%) to 109 (70%). In basketball, I was at 150 after a few strolls down the court in a pickup game. Friends and mentors of mine have collapsed and died from massive heart attacks, and these smart watches may have saved their lives. I need one that will work overseas, and be as accurate as a chest strap device. Wish me luck!!




https://www.tomsguide.com/us/heart-rate-monitor,review-2885.html

Nerve Pain and Diet

https://health.usnews.com/wellness/food/articles/2018-01-03/eating-to-promote-a-healthy-nervous-system


This article talks about the nervous system and relationships to the foods we eat. If you suffer from any type of nerve pain, consider reviewing this for some help.

Sesamoid Injury and Hallux Rigidus: Email Advice

This wonderful patient has both sesamoid pain and hallux rigidus pain on the left foot. He flew to see me twice because of this blog. He is also having low back pain and I had recommended our back doc to see him also. He is an avid hiker and is trying to avoid surgery. He taught me that Dr. Jill's dancer's pads make a huge difference even on top of my best orthotic devices with their own dancer's padding and I have been recommending that to patients since. They experiment with the 1/8 to 1/4 inch heights of the Dr. Jill's dancer's pads. This email was sent one month after I saw him.

https://www.amazon.com/s/ref=sr_pg_2?rh=i%3Aaps%2Ck%3Apedifix+sesamoid&page=2&keywords=pedifix+sesamoid&ie=UTF8&qid=1546714515

Rich,

Just wanted to update you my progress and clarify a few points. Feel free to use any relevant parts of this in your blog!

1. The trigger point injection (lidocaine) by Dr. Hong did not help my lower back at all. In fact, since sitting aggravates the pain, it was much worse after the long wait in his office, and I had a very challenging flight back to Indiana to visit family that weekend. But pain did gradually fade, as always. I'm still researching ideas for treatment, but at this point I don't have much hope of preventing recurrences. I know seating and bedding are hugely important - the friends I was staying with have no ergonomic furniture, and I blame that for most of my pain while staying in the Bay Area.

2. Your little suggestion of icing the sesamoid after every walk/hike has worked wonders to sustain my mobility. For the past month, I've been able to restore much of my cardio conditioning due to that little trick - icing and resting 2 or 3 days after each hike before heading out again. I'm still limited in distance and terrain, but assume that will gradually improve.

3. Still unable to find carbon foot plates with sesamoid cutout, but I did get the basic plates from Dr. Jill. Unfortunately despite their thinness, I still can't use them for two main reasons: (a) combined with orthotics, they occupy too much space in footwear. I'd have to buy new shoes at least a half size larger. (b) The hardness of the carbon plates under the thin cushioning of my blue orthotics seems to create too much stress on the sesamoid, and using them with the Hannaford's is out of the question because of total thickness.
Dr. Blake's comment: I understand. I guess you have to take the full plate and have a shoe repair shop grind out the sesamoid area so you are still overall immobilizing for the hallux rigidus while off weighting the sesamoid. Sorry to send you on a wild goose chase.

4. Need a little clarification on sesamoid condition. Referring to the radiology I had at St. Francis in September, am I to assume that there was probably a partial stress fracture of that sesamoid last year, and that the surface of the bone has since healed, leaving only the internal healing process to complete? I understand that at my age there's probably a fine line between some types of injury and arthritis.
Dr. Blake's comment: Between the sesamoid irregularities and the first metatarsal irregularities, it is difficult to actually tell what is healing (strong enough to take normal load) and what still needs time. I know you can co-exist with most of this stuff with some protection and be very active.

5. Regarding the Exogen ultrasound device, you mentioned that the device itself could be causing the sesamoid to appear "hot" in the radiology images. I remember that last year, you recommended to stop using the device 3 months before a follow-up MRI, but I didn't do that this year. Is there a point in the coming year at which I should stop using the device, to let the tissue "calm down"?

Thanks again!
Dr. Blake's comment: You are welcome. Next August, based on where you are at with your symptoms, let's decide what images, if any, are needed. This year, 2019, hopefully you will be exercising a lot. Happy New Year. Rich

Accessory Navicular: Email Advice

Dear Dr Blake,

My daughter was diagnosed with accessory Navicular syndrome in August of 2018. She is a competitive dancer and started complaining of pain in her foot in January of 2018. Initially I thought it was just pain of dancing as she had not hurt herself. We used some wraps, massage, and creams and kept dancing.
Dr. Blake's comment: The accessory navicular is an extra bone in the arch that begins forming around 8-9 years old and is fully formed by 16, probably even earlier. The posterior tibial tendon, the strongest arch muscle, attaches into it instead of where it should to support the arch. It has to work harder to support the arch and symptoms can develop. Because patients with accessory navicular have arch stabilization problems with the tendon, they typically develop flatfeet. 10% of patients have accessory naviculars and 30% of those it is on both sides. In doing the math, 3% of patients may bilateral accessory naviculars. There attachment to the normal bone (navicular) can be strong or weak, and it is the weak ones that get symptoms. It is typically an arch sprain scenario treated with the proper phases of rehabilitation: Immobilization, Re-Strengthening, and Return to Activity. It typically responds well to treatment, so it is troublesome when they do not and we need to find out if the rehab was just done improperly, or if there is a reason surgery is needed to remove the bone. It can take good investigation.

In May it became pretty painful so we went to our regular doctor who suggested some physical therapy. We continued through end of competition season in July and did try outs and then went back to the regular doctor- she did an x ray and noted she seemed to have an accessory navicular bone. At the time only one foot was hurting her. Her left foot.

We were sent to specialist who initially tried her with inserts.
Dr. Blake's comment: This is one part of the Immobilization Phase. You are trying to get the pain level consistently to 0-2. Common treatments in the Immobilization Phase are: Removable boots (also called cam walkers), Posterior Tibial Dysfunction Brace from Aircast, Posterior Tibial taping either circumferential or up the leg in a J Strap design, Orthotics with strong medial arch support, activity modification, etc.

After three weeks, we went back and he adjusted her inserts and tried limits n dance (so no ballet which was more painful).
Dr. Blake's comment: This was good so the Immobilization Phase was being treated by orthotic devices and activity modification, but the Re-strengthening program should begin soon. Were you getting the pain down to 0-2? The use of Anti-Inflammatory measures are normal during the Immobilization Phase, to limit the actual amount of immobilization, by icing 3 times a day to calm the symptoms. I like to begin strengthening asap so typically posterior tibial strengthening begins now, along with single leg balancing, metatarsal doming, peroneus longus strengthening, and gastrocnemius and soleus work with double and single heel raises. Everyday she is in pain, you typically lose 1% of strength, and you only gain back 1/4 to 1/2% back a day. Begin now.

After 3 weeks we went back. She still had pain, so he made her sit out of dance for three weeks, icing and ibuprofen. 

She still had pain so he booted her. She was booted initially for three weeks (no activity) other than walking to class.
Dr. Blake's comment: So, now the Immobilization Phase has boot, orthotics, activity modification and some anti-inflammatory measures.

She still had pain so he kept her booted and had her start physical therapy a mix of land a water therapy. She got ill and could not return for an additional 5 weeks so her boot was on for a total of 8 weeks. She had physical therapy during those 5 weeks. He took her out of her boot. Her right foot felt better although with much walking she still had some pain. Her right foot had begun to bother her.
Dr. Blake's comment: So, the boot was on the left side, and now the right side was a problem also. I think I get it. The accessory navicular is a biomechanical issue. This means that without an actual injury, which she did not have, the pain comes from a tissue overload during overuse. The accessory navicular is a weak spot of her arch that got irritated. You can make it less of a weak spot by strengthening (by gradually building up to 2 sets of 25 Level 6 theraband). While you do that, you have to relie on a slow progression of activity, taping, orthotics, and anti-inflammatory.  

We did additional physical therapy (it is December at this point) and he did xrays on both feet. he indicated that she also had accessory navicular on her right foot but it was less pronounced. 

I requested an MRI even though he said he normally did one just if surgery was being considered. I was unable to go to the visit after the MRI but we had done a lot of walking around the day before and her right foot was really bothering her. Up to this point she had started back to one class in dance and we decided to limit her competitive dances and the amount of dance for next year (she normally dances 15 hours a week).
Dr. Blake's comment: So, learn the posterior tibial taping for class, both J Strap and Circumferential. She should stay in the boot for the worse side, alternating sides as needed, while she dances. You should be taping and orthotic devises in the boot. Let me know what the MRI showed. She should get one on the right side also.
     At this point, it is also important to know what pain level she has in every environment: getting up first steps, in the boot, in the orthotics, when she is taped, how the brace feels, in class, after class. Since some of these athletes need surgery, and if you are trying to prevent that scenario, we need to do everything right.

At the visit my husband indicated her continued pain (more on the left foot than the right) and the doctor said that her tendon looked pretty good... that her accessory navicular was worse on the left side and that next steps were to go back to dance and see if she could tolerate the pain. If she could not, it sounded like surgery would be our next option. I am concerned that it feels like he has given up and it seems like our options are having pain when doing the activity she loves the most or surgery.
Dr. Blake's comment: This is the first part of your email that makes no sense. It sometimes is generated by the patient saying that dance is her whole life and she/he must do it. The doctor who is trying to be compassionate then gives in since it is not life threatening and allows the athlete to go back to the sport. But, to cover themselves, they throw in something about surgery in the conversation. Overall, it is not smart medicine. It is a bad decision to dance over a 0-2 pain level. I know some kids that really can not tell the difference between 2 and 5, only know 0 and 10. For those kids, you have to make sure that they do not limp in their sport. You have to have the coach watching carefully, they can not participate again until the symptoms have calmed back down. You also need to watch and see how inflamed the activity gets it. Typically, these are hard jobs. Try to get your daughter to understand and verbalize the entire pain scale from 0-10 and what each number means.
     It is trying to maintain the 0-2 pain level that we perfect the orthotic support, that we figure out the right way of taping, that we find out how much to ice, rest, etc.

I am concerned if we go back to dance that her pain problems will come back. I am concerned we have not done enough to address her issues.
Dr. Blake's comment: To dance at all, she needs to be able to walk with her injury taped for 30 minutes keeping the pain between 0-2. In dance, there are so many motions, she first has to find the one that do and don't bother her. She can test those motions every other week, but not daily. I always feel a dancer should dance as part of her rehab, but not if it elicits the pain over 2 or causes her to limp to avoid. Like my sport of basketball, dance has some much you can do and not hurt, that she should be able to be on a program that will not hurt her, enable her to workout, and continue to allow the injury to heal.

My daughter does have very flat feet.  She does continue to use her inserts which she loves. Her inserts don't really work in her dance shoes.
Dr. Blake's comment: Some version of hapad medial longitudinal arch pads should help in the dance shoes along with taping.

Any suggestions on what to do next are appreciated. We live in the Dallas area and I am considering trying to get a referral to a different specialist for a second opinion. The first specialist is not necessarily a childrens specialist.
Dr. Blake's comment:Yes, see if the schools in Dallas have a foot specialist they recommend highly.


https://www.bing.com/search?q=dance+schools+dallas+tx&src=IE-SearchBox&FORM=IENAD2

Any suggestions on what to try next or help on where to go would be greatly appreciated.

Thanks!
Dr. Blake's comment: I sure hope this helps some. Have her listen to her body, get used to 0-2 pain levels, get good at taping and icing.
Rich

Sore Metatarsals in a Runner: Email Advice

Dear Dr. Blake, 

Thank you for your website. I'm 60 years old, been running for 48 years with a variety of training regimes (hills, long runs, track intervals).  ~14 months ago at the beach, stepped on a stone barefoot in the left metatarsal 2nd/3rd area.  It hurt but seemed ok when running in shoes. It relaxes and hurts less when running (even fast hard intervals forefoot striking). But upon rest or ice later, it tightens wicked and hurts, especially barefoot walking on a hard floor (which I try to avoid).  Got progressively worse. 

X-ray is normal. MRI does show swelling maybe bone bruise (results below).  Sports Doctor refuses to give a cortisone shot. Skin is very thick and hard to do iontophoresis. I ice it, gently stretch calf and plantar.  I cut back on running. On stationary bike, the metatarsal hangs off front of pedal. Arch supports worn religiously 6 weeks didn't help. Looking into Hokas shoes.  Would ultrasound and Ice/hot water contrasts help?  I assume the running re-injurs it(?).  Other advice would be welcome.  Feel free to post this on your site. Thanks

MRI FINDINGS:

BONE MARROW: Bone marrow edema is seen within the tuft of the first distal phalanx and the lateral hallux sesamoid. No fracture lines are identified.

SOFT TISSUES: There is ill-defined soft tissue edema plantar to the heads of the second and third metatarsals. No focal drainable fluid collections are identified. The myotendinous structures are unremarkable.

JOINTS: There are mild degenerative changes of the first

metatarsophalangeal joint. There is no joint effusion. There is no

synovial proliferation. This study is not optimized for detailed

evaluation of ligamentous structures of the hind foot, midfoot or forefoot although they appear grossly unremarkable.

 Budin splint over the 2nd and 3rd toes together

 Various Hapads and accommodative pads to protect or cushion metatarsals (be creative!!)

Hapad Longitudinal Medial Arch but used as Metatarsal Pad within Shoe

Dr. Blake's comment:

     The MRI report sounds like the 2nd and 3rd metatarsals have been bruised, not broken. I hope the doctors have evaluated the lateral sesamoid well, and the MRI findings are only from the stress you normally put on them. See my video on off weighting the sore area with hapad longitudinal medial arch pads behind the sore 2nd and 3rd met heads, and 1/8 to 3/16 th inch adhesive felt to off weight the 2 and 3 (weight has to be put on the 1st, 4th and 5th). You can also try a Budin splint to immobize the motion of the 2nd and 3rd MPJs. Typically you buy the single loop and put both toes into it. Start with easy tension for a few days to get used to it before tightening it more. This is separate from the Hapad. If both work some, you can use the Hapad and tape the toes down each time. Ice massage twice a day for 5 minutes. I like ionotophoresis (electrical only) for this. I hope this helps some. Rich

https://youtu.be/-v9IrSucQpE

https://youtu.be/928DwpwEaXE

Lisfranc's Injury: Email Advice

Hi there Dr. Blake. 

I found your blog and many of your recommendations online and was hoping to discuss with you my injury. I experienced a partial tear to my Lisfranc on September 12 while playing soccer.

Here is a quick profile of me:

Age 37

Weight 180

Height 5'11"

In good physical shape. Could stand to lose 5-10 lbs especially since the injury because I have ceased all activity and have gained some weight. 

No medical issues. 

It took approximately 1 week to diagnose after the injury. An MRI was conducted showing that I had a "high-grade partial thickness tear of the Lisfranc ligament at the second metatarsal base attachment. No widening of the Lisfranc joint.  Low-grade sprain of intermetatarsal ligament at the second-third metatarsal bases. Mild bone marrow edema at the second metatarsal base."

Weight bearing X-rays were taken of both feet and further demonstrated that there was no widening of the Lisfranc joint.

I was advised to continue to use a "tall (nearly knee high) aircast fracuture walking boot" at all times (except sleeping and bathing) for 10 weeks. I have been using this boot, religiously. I believe it prohibits the transfer of weight from my heel to the forefoot. I have experience no pain whatesoever when using the boot.  Sometimes when I am in bed I have slight discomfort however its only been about 5 weeks and I have 5 more to go. 

The reason I am reaching out to you is that I am nervous. I am a very athletic person. I have been playing competitive tennis at the 4.5 level three times a week for over a decade and hope to return to the sport as soon as feasible. I have spent the past 5 weeks using the aircast boot mentioned above and have no problem getting around but I have noticed muscle atrophy in my calf. 

It is unclear to me how I will know that I am healed in five weeks and I am very interested in learning what to do to prevent re-injury or pain as I return to walking and then running and then tennis. I am also an avid snowboarder which I hope to be able to do this season. 

There seems to be some mixed messaging. Some say no weigh on the foot, others suggested that the aircast walking boot was fine, especially if I have no pain. Any insight you can provide would be much appreciated.


Dr. Blake's comment: I am a few months from answering this because of the holidays and trips, so I am not sure where you are now over 3 months since the injury. If you send more information, I will place on this same post. As I read your discussion above the part I got nervous about was the return to activity as soon as possible. Do not set time limits, but go through the rehabilitation step by step. There can be some plateaus along the way where you are stuck for some reason (need different orthotics, need a better way to tape, the bone injury needs longer to heal, etc). Stay in the 0-2 pain level throughout. For every day you are in a boot, it takes 2 days to rehab back the strength, range of motion, etc. So, 10 weeks in the boot, means another 20 weeks working with a PT or trainer. If you are doing well, you are 3-4 weeks out of the boot now, and hopefully in supportive orthotics (the lisfranc's is an arch injury) and taping the arch with exercise. You should be strengthening particularly the 5 supportive Lisfranc's tendons: anterior tibial, posterior tibial, peroneus longus and flexors and extensors that run into the toes. Lisfranc's injuries usually need to be taped for the longest time with activity (leukotape the strongest, and Rocktape or KT tape more flexible). Ice twice a day, and do contrast bathing each evening. Email me with an current update so I am help further. I am sorry for my lateness. Rich

Big Toe Joint Injury Rock Climbing: Part 2

This is a follow-up post from a March 2018 rock climbing injury where the patient hung by her big toe for 45 straight minutes injuring the soft tissue and nerves. The original thought was sesamoid fracture, but there was not trauma, and the x-rays and MRI proved that they were bi-partite, with the left lateral sesamoid hot enough on MRI to call it stress fracture (probably the stress across the bipartite junction between the two fragments).  The general rule I use is that the nerves need 9 months of being good to them to heal or calm down. She started treating the nerves 3 months ago I believe.


https://www.drblakeshealingsole.com/2018/09/injury-to-fibular-sesamoid-in-rock.html

Dr. Blake, 

Happy Holidays! It's so nice to hear from you! I'm doing really well. I'm going to PT twice a week, still using exogen daily, taking 10 mg amitriptyline daily, and I've been able to start wearing Hoka One Bondi and Dansko clogs. These have saved my life. I've been able to return to most of my daily activities. Pain comes and goes but overall is much better. I've seen another orthopedic surgeon and he agrees with everything my sports medicine doctor has been doing to treat nerve pain. He suggested I continue to protect the sesamoid with rigid sole shoes and keep weight off the toe. It was good to get that reassurance in the treatment plan; however, I'm struggling a bit with how far I should be pushing things in PT.
Dr. Blake's comment: No need to push things until June 2019 as the thought of you bending too far or jumping on it prematurely scares me. Get stronger all the way up from feet to core. Get cardio with biking and gradually increasing walking up to 2-3 hours in your Hokas. Spica tape when you need to. Experiment with gentle massage 2 times a day up to 3-5 minutes to the area to desensitize as long as it is non-painful. Do neural flossing twice daily, and you can massage with neuro-eze or neuro-one both sold on Amazon. See if they will prescribe Lidoderm patches or a prescription nerve topical gel as long as it is covered by your insurance (they can be expensive if not). Try massage after a warm face cloth is applied under saran wrap to heat the area for 5 minutes.

PT has definitely helped and the therapists broke up a lot of scar tissue in the big toe joint that seems to have really helped mobilization of the toe joint. I still tend to get most of my pain in the areas the areas point to below.

The arrows are pointing to the front of the ligament (called joint capsule) before it attaches to the big toe itself. This is definitely more Turf Toe symptoms.

The Physical therapist doesn't know why my pain is here. I'm assuming this is still part of the nerve damage. I still feel a lot of scar tissue too. Could there be another problem related to the scar tissue? Dr. Blake's comment: Yes, the scar tissue from the ligament injury from prolonged tension is the body's way of trying to heal and make itself stronger. Try doing the self mobilization from the video below. Typically scar tissue starts to naturally thin out 9-12 months post injury or surgery anyway.

 https://youtu.be/FBTeWbdGrzs  

The doctor and the physical therapist want me to get back into more flexible shoes soon and their goal is to get me back to walking barefoot and back to all activity. Ultimately that's my goal too but I don't want to rush it. However, I still don't feel much pain from the actual sesamoid bipartite area. That seems to maybe have stabilized.  Dr. Blake's comment: First try barefoot walking on a grass field or shag carpet with the toe spica taped for 15 minutes to see how it feels. Try the OOFOS sandals with the Dr. Jill's dancer's pad to longer and longer periods also.

How would you suggest I progress with returning to activity? I'm afraid to upset the sesamoid but if the nerve pain I'm still having could be reduced by starting to flex the joint and start walking. They have suggested I walk in the pool starting chest deep to see how that feels and eventually move to shallower and shallower water. I have not yet tried this but will soon.  I've been doing more and more balancing activities which cause pain in the areas pointed out above when my weight shifts there. 

Dr. Blake's comment: Try the balancing with the toe spica taped and some off weighting of the sesamoid. You can be doing high level activity by the end of next year, but still need some off weighting and spica taping at times. I find walking in a pool is great for hip and knee rehabilitation, but not good for feet. The foot takes all the stress of balancing and pushing off in any height of water, the deeper the harder for the foot. Increase walking with the protection mentioned above, increase biking, increase strengthening the core and lower extremity, increase poses with protection like Yoga and Tai Chi and single leg balancing. Go 9 months with the Exogen. I hope this helps. Rich

I tried Tens unit but it seems to aggravate the nerve more so I stopped. 

Any additional advice you can give would be helpful! 

Thanks again!!

Sesamoid AVN improved by Shockwave and HBO treatments: Sesamoid Relief

This was a response to my blog post. This wonderful patient sent me 2 articles on the use of Shockwave therapy on AVN for sesamoids.


https://www.drblakeshealingsole.com/2018/12/sesamoid-injury-with-possible-avn-email.html




Thank you for your answer Rich :)
I will follow your advices and ask my doc about a CT scan and Vitamin D check.

I am attaching 2 articles about the use of shockwave therapy in sesamoid injuries, for sure it will be of interest for you.

About the help/use of HBO I did not find any reports in English, but here in Germany you find this information on many medical websites (mainly for AVN in the hip and knee). I had contact with one doc who confirmed that he personally made good experience in treating bone marrow edema and AVN in the foot (ankle and sesamoids) with HBO.

I keep you updated.
Have a good start in the new year!


Dr. Blake's comment:
The 2 articles are following:


1)   Saxena A, Yun A, Patel R, Gerdesmeyer L, and Maffuli N. Radial Soundwave for Sesamoidopathy in Athletes: Pilot Study. J.Foot Ankle Surg 55(2016): 1333-1335


The treatment protocol that showed promise was 3 treatments 1 week apart. The treatments were 2500 pulses per session, 2.4 Bar and 13 Hz.


2)   Thompson D, Malliaropoulos N, and Padhiar N. Sesamoid Osteonecrosis treated with Radial Extracorporeal Shockwave Therapy. Brit Med Journal Case Report 2017 (accepted 5 May 2017).


The treatment protocol that showed promise was 8 sessions, 2000 pulses per session, 1.2 to 1.8 Bar of pressure to patient tolerance, 5 Hz.


I am so excited that another help for these sesamoid injuries with avascular necrosis has settled in. I currently have 2 patients that are fine, but any running keeps irritating the sesamoid area with some avn issues. With new techniques, medicine has to find the place for it. When do we offer it to patients, at the first sign of problems, or only after bone stimulator for 9 months? For me now, it is for the few patients (less than 5%) that seem to have issues after extensive treatment and are considering sesamoid removal. But, it may be appropriate much earlier in the treatment.

Cartiva vs. Arthrosurface vs Modified Keller for Hallux Rigidus: Email Advice

Dear Dr. Blake,


I hope you’re doing well. 

 I writing to ask your opinion on options for revisions to a failed Cartiva implant that I had done a year ago to address my long term hallux rigidus.  My problems started 25 years ago with a traumatic injury. While running on a road median, I managed to step into a hole that was obscured by long grass.  I went down like the coyote in the roadrunner cartoons, but had no noticeable injuries other than some minor grass burns.  I ran for another 2 miles and felt fine until I stopped running. I took ~5 steps walking then felt intense pain in my right big toe joint.  I iced it, took a couple weeks off, and thought I had recovered until a year later when I started feeling pain in the joint and an X-ray showed I had developed arthritis. After years of reading about this condition, my best guess is that I jammed the joint severely, and the trauma resulted in longer term deterioration of the cartilage.  I was able to run with orthotics for about 20 years, but eventually couldn’t get orthotics that helped.  I had to stop running about 4 years ago because I had worn out the medial meniscus in my right knee, probably from compensation for the hallux rigidus.  I started using a dancers pad instead of orthotics since the orthotics offloaded the big toe, but onloaded the outside of my foot which put more load on the medial side of my knee.  I shifted my cardio to rowing or an elliptical machine, which don’t aggravate the toe or my knee, but the hallux rigidus still caused my daily discomfort from just walking . ( I’ve read your blog for years and realize that I’ve been more fortunate than many people with this condition, but it eventually caught up with me.)
Dr. Blake's comment: This is normal that 20 years after an old injury, the deterioration begins to give us symptoms. I am happy that you got those 20 years of running on apparently great orthotic devices. Kudos to the provider who made them!!

I had avoided surgery because I was advised years ago that the surgical options aren’t great (a fact that I’ve confirmed in researching the condition other doctor’s recommendations).  About 18 months ago I came across reports of the Cartiva implant, which seemed attractive because of the published high success rate, seemed less invasive than a metal implant like Arthosurface, and because it had been used in Europe for 10 years so I presumed it was a well understood procedure.   I got a list of surgeons trained in Cartiva procedure, and saw one who had done it over 50 times, and eventually had the operation in Dec 2017.  I had lots of post op swelling and pain, tried physical therapy 7 months after the operation which took care of badly knotted muscles in my foot and ankle, but a follow up x-ray last Oct showed the inplant had subsided into the hallux bone so I had very little space in the joint.  I’ve attached a paper I found recently that describes the failure mechanism.  Anecdotally it seems that the success rate in America is less than the initial clinical trial paper, and I know the guidance on recovery times and the implant procedure have changed since I had my operation.
Dr. Blake's comment: It seems like 10-20% failure rate for implants is normal over a 5 year period. You chose well finding someone with experience at least. I am glad these are being converted to Arthrosurface hemicap so you can avoid fusion for now. I attached the Arthosurface blog and a video of the conversion. The Cartiva does take out very little original bone, so seems perfect (remember I am not a surgeon but I try to be logical) to convert to the Arthrosurface. I do not know why the Cartiva literature does not talk about cheilectomies first or Arthrosurface to try to avoid surgery. But I am happy to learn if someone knows.

The orthopedic surgeon who did my Cartiva implant said my only option for revision was a fusion, something I’ve been trying to avoid.  There’s a video on youtube that shows an Arthosurface hemicap revision after a failed Cartiva, so I got a list of doctors in my area for an Arthosurface consult. (Just because a procedure has been done once doesn’t mean it’s widely recommended).  I went to a podiatrist who does surgery, who turned out to have done both Cartiva and Arthosurface procedure (he didn’t show up when I got a list of doctors certified for Cartiva when I was looking for doctors in 2017).  We had a very informative conversation about various options for my toe.   First, he said my surgeon had done a good job on my Cartiva procedure (good joint alignment, good scar, etc)  He said his experience with Cartiva was not as good as the original clinical results, and the surgical guidance for Cartiva  had changed in the past year to leave the implant sticking further out to account for implant subsidence into the bone. He did not recommend an Arthosurface procedure, saying that I’d likely need another procedure in a few years.   After talking about fusion for a while, looking at X-rays, he thought I was too limited,  and suggested that a Keeler procedure would be a good alternative to fusion with similar long term results.  His opinion was that an orthopedic surgeon would favor a fusion as more robust, but that a podiatric surgeon would favor options that preserved natural motion.  I’ve found one reference that discussed the Keeler procedure for hallux rigidus and found comparable long term results to fusion, but would welcome your opinion. I’ve found shoe and supplement combinations that limit my discomfort, but I would like to get my toe taken care of sometime in the next few months.
Dr. Blake's comment: The Keller procedure removes most of the base of the big toe at the joint. The joint would not hurt and you could use it. The procedure permanently weakens the joint, but orthotics, taping, strengthening, could help. You can not run with your knee anyway. It is not high tech!!! Must be good then!! If you let me know where you live, I can send you a list of sports podiatrists that you can run this by. Interesting!! I sure hope I have helped you.

Here is an article supporting Modified Keller to Arthrodesis (joint fusion)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918259/

Best Regards




This article states that synthetic cartilage implants have a 10% chance of removal and joint fusion in 2 years, and another 8% more by 5 years.
https://www.ncbi.nlm.nih.gov/pubmed/30501401


Another article on synthetic cartilage noted excellent results with only 1 of 27 or 4% needing fusion, 2 of the original patients lost to follow up.
https://www.ncbi.nlm.nih.gov/pubmed/27909032




This article states that it is a viable surgery before fusion is recommended.


https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0891842217300952?returnurl=null&referrer=null

Our office uses the Hemi-Cap from ArthroSurface. This article shows no conversion to fusion after 3 years.

https://www.ncbi.nlm.nih.gov/pubmed/22545290

Another excellent article on Hemi-Cap. 13% were revised by 3 years in some way. "At 60 months, all patients reported excellent satisfaction with their current state and would repeat the procedure. Implant survivorship was 87% at 5 years. Of the 30 implants, 4 were revised at 3 years."

https://www.ncbi.nlm.nih.gov/pubmed/23407017


Here is the arthrosurface blog
https://www.arthrosurface.com/blog/




Here is the revision from Cartiva to ArthroSurface.


https://youtu.be/VHHlDAT_eLA