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Sunday, December 16, 2018

Tarsal Tunnel Syndrome and Asthma

This article shows the complex relationships within our bodies. Here a chronic issue like asthma has been linked to a neurological condition. We really do it know what it means except that there are inter-relationships among disease processes.

Foot Cradles: Pressure off Feet at Night

Metatarsal Pain: Email Advice

Dear Dr. Blake,

I am so grateful I found your blog a month ago after suffering strange left foot problems for over a year!

In August 2017 I unexpectedly was taking care of my 84 yr old mother-in-law (stroke victim) who lives on 20 acres in the country with the clothes on my back and a pair of cheap flip flops for a week. Of course, I developed Plantar Fasciitis in my left foot - wearing non-supportive shoes all day long!

Fast forward, I had 2 visits to my family doctor (who gave me steroid pills, told me to ice 3x daily and do foot exercises), saw a Podiatrist (who saw me 10 minutes, barely touched my foot for $330, gave me an injection and suggested orthotic inserts for $450) and then I saw my Chiropractor, who adjusted my foot, did x-rays (they were normal but I have a heel spur) and made me orthotic inserts for $250. 

After wearing the Chiro orthotic devices for one month, I developed additional forefoot pain but the heel pain subsided greatly. I removed those inserts because it appeared they were the cause of my forefoot pain. Immediately, the forefoot pain was less, but the heel pain came back strongly within one day of not wearing the inserts. Upon my examination, it appeared the arch was too high in the Chiro orthotic inserts, so I went back to the Podiatrist in June 2018 and got the $450 hard plastic 3/4 custom inserts which had a definite lower arch.

I continued to wear the hard custom orthotic inserts and my heel pain completely subsided but the forefoot pain got worse. So I bought a variety of OTC inserts trying to find a solution. I went back to my family doctor who told me I have a mechanical problem, gave me steroid pills and told me to stay off my feet and do contrast therapy. I don't want to keep doing steroids! At that time, I averaged 9 k to 13 k steps a day because I am very active person, so now I have cut back to 6 k-8 k steps daily and try to rest my foot.

After reading several sections of your blog, I have determined I have 2nd metatarsal capsulitis, with beginning hammertoes on digits 2, 3, 4 and a definite Bunion, stage 2-3 on my left foot. I have lost strength in my left foot since June 2018. I can barely spread my toes now and the hallux joint seems 'lax' and does poorly with resistance testing when trying to dorsi-flex the toe. I bought shoes with bigger toe boxes. I bought some Yoga toes but I haven't used much since they hurt my smaller toes. I also have Stage 2 bunion on my right foot, but no issues other than my right foot gets overloaded from compensating for the left foot!
Dr. Blake's comment: Try cutting off the part of the Yoga Toes to the 4th and 5th toes. 

Without actually examining me personally, (I live in Texas), can you at least give me general advice on what I am doing currently? I am attaching a picture of my foot and insert.

I am taping the second digit and sometimes the third digit per your video instructions. This seems to be helping. I am icing the ball of foot 3 times daily for 15-20 minutes. I am doing the alphabet with my foot and rolling my arch on a tennis ball every morning. I am doing your doming exercise 2-3 times daily (10-12 reps) with both feet and place my sock rolled up between Hallux and 2nd digit space to 'straighten' the toe. I have placed a homemade MT pad using felt from Hobby Lobby taped to my insert (I couldn't find anything in stores - I was desperate to relieve the pain!).
Dr. Blake's comment: If you feel better after the icing, continue. If you do not feel better, it may be too long, so reduce the icing to 5-10 minutes. 

Q 1. I notice that after awhile, I will have pain/cramping in the lateral side of my foot (5th MT) even though the 'pebble sensation' in 2nd MT is reduced greatly by the pad and topside swelling has gone down. Yay! Is this pain caused by 'loading pressure' from the arch in the orthotic support? Or from the MT pad? Or both? It seems like one thing fixes one issue, but then causes another issues. Any Ideas? Solutions? So far I am continuing with the pad and dealing with the lateral pain.
Dr. Blake's comment: Yes, probably from orthotic devices, limping, etc. Try to alternate what you have on your foot several times a daily, one being no orthotic devices. 

Q 2. Is it okay to do the doming exercises while dealing with the capsulitis? Will the doming exercises strengthen my Hallux? Any suggestions for getting back strength in that big toe and all my toes of left foot? I continue to try and spread the toes and I also flex the toes after doing the alphabet.
Dr. Blake's comment: As soon as you can do single leg balancing, see the cut out I prescribe for sesamoids so you can do the same idea and float any sore area, you will really start to strengthen your foot and toes. 

Q 3. I tried the gel toe separators for my bunions - they hurt a lot inside my shoe-seemed too hard/big. Suggestions for alternatives and how important is it that technique for me?
Dr. Blake's comment: Not appropriate now while you are dealing with the capsulitis 2nd, too much pressure on the 2nd toe. 

Q 4. Use the Yoga Toes less time until they don't cause pain in the smaller toes?
Dr. Blake's comment: Try my technique for cutting the part that separates the 3rd and 4th toes, and separates the 4th and 5th toes. If still painful, try the less intense Yoga Gems. 

Thank you again for reading and answering my email. I was going to donate to your blog and when the site asked me my address, it stated something about contacting you regarding your privacy practices about my address. Can you tell me those or where you have them posted so I can donate with comfort? Thank you again.
Dr. Blake's comment: Thank you for the gesture. That must be a new Pay Pal privacy rule. Your email is never shared with anyone by me. 

Further comments: It is not unusual for a patient to hurt their heal, limp, and then hurt the front of the foot. The inserts, could have been made by anyone, custom or over the counter, probably had a hard spot right under the 2nd metatarsal that bruised the soft tissue. 5 minutes of ice massage is better than just sitting on an ice pack if you know the sport. I have a video on protecting a sore spot that may help you. I do have to say how proud I am of how you are attacking this problem and quite logically. Keep me in the loop. Rich

Saturday, December 15, 2018

Nerve Pain in the foot: Email Advice

Dear Dr. Richard,
I am miserable an in need of urgent help.

I am a 37 year old female. I fractured my right foot (Jones fracture) on August 24 2018. I was put in a cam boot and after one month started initial weight bearing with the boot and then on the 8 week mark when the x-ray showed that the fracture has healed I was told to get out of the boot and start walking.

Several days after I started walking, I developed severe pain on the top of my foot (between the 3rd and 4th metatarsals) that made me limp badly and also on the ball of my foot that I could feel the most when walking barefoot. I went to see a foot and ankle specialist who suspected a stress fracture. He asked for an MRI and an ultrasound and both showed  no stress fractures. They also did not show any soft tissue issues, neuroma, etc. 
Dr. Blake's comment: This would appear then to be nerve irritation since it is never seen on x-ray, ultrasound, or MRI like bone or soft tissue injuries would be seen. 

The doctor gave me non steroidal anti-inflammatory (600 mg) one pill a day for 20 days and he asked me to rest my foot. This kind of got rid of the dorsal pain but the pain in the ball of my foot remains severe.

The pain cannot be felt if I touch my foot neither from the top or if I touch the ball. It is not there when I’m resting either but it shoots up when I walk or bear weight. It is the worst when I walk barefoot and when the foot spreads. 

I went to see the doctor again and he tested for neuroma but there was no click. He couldn’t figure out what it is but he says he suspects a soft tissue inflammation. He gave me two steroid shots in the areas shown in picture 1 below. He targeted those areas because this is where I thought the pain generates from. It has been a week and the shots did not help at all. I still have severe pain in my foot. Picture two below demonstrates where the general area of my pain is. And as mentioned, it is the worst when the foot spreads.
Please help I am very desperate as I have not really been walking since my fracture and I am becoming severely depressed. I was an active person before this and now I cannot even go to the toilet without having severe foot pain.
All the best,
Dr. Blake's comment: This has to be nerve irritation which will not show up on tests, but since nerves are super highways to the pain, they can give the most severe pain. Neuromas are long developing problems at the nerve, so I would not expect this to be one. You and your doctor need to find the nerve that is causing the pain with using only long acting local anesthetic, not cortisone at least until you find it. Then a treatment pain can be designed. See my post below on these diagnostic tests. You will be fine, so hang in there. You have ruled out major problems, so a local very painful pinched nerve should be the cause of this pain. Keep me in the loop. Rich
PS. The pain can be coming from above your foot also due to limping for awhile and upsetting the delicate balance of your body. See my video on foot pain from back causes.

Sunday, December 9, 2018

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.

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,

Thursday, December 6, 2018

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.

Discussion from a patient who just had the procedure.

Monday, December 3, 2018

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 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

Tuesday, November 13, 2018

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. 

Saturday, October 27, 2018

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.

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). 

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

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!!!


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

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.

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