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Sunday, June 17, 2018

Sesamoid Injury: Controlling Inflammation while Transitioning from a boot

Dr. Blake,

Unfortunately, like many of the other readers of your blog, I have suffered a non-displaced medial sesamoid fracture in my right foot in November 2017. Since December 2017 I have been in a walking boot. A few months went by, and after making zero progress I started digging for more information and found this blog along with a bunch of other resources regarding bone health. Even though I knew I was getting more than adequate amounts of calcium each day, I started taking Vitamin D in March 2018 and my symptoms started radically changing, and the injury finally started to feel like it was 'healing'. To confirm my suspicion of low vitamin D, I ordered a blood test myself (via, if any of your readers want to get one done without going to a Doctor) and found out my level was at 26 ng/ml. After finding this out, I increased my dosage, and I have been maintaining it around 50-60 ng/ml for about 3 months. 
Dr. Blake's comment: Thank you for the info on Vit D testing. 

Over these last 3 months, the pain has been primarily due to the inflammation and blood flow going to my forefoot, which I have been able to mitigate by keeping my foot elevated and icing it occasionally. I've done a decent job maintaining a 0-2 pain level as you suggest, and I feel like I am able to slowly transition out of the boot. At this point, I am able to (in the boot) put more weight through the ball of my foot simply because the inflammation is a lot milder than it was 3 months ago. My main question is, as I transition into a stiff-soled shoe with orthotics, what are the primary signs to go back into the boot temporarily?
Dr. Blake's comment: You have to maintain the 0-2 pain levels throughout. Look for patterns of what increases your pain and avoid for one month before retesting that benchmark again. As you transition from boot, you should ice twice daily whether or not you feel you need it, and contrast baths each evening. 

 During this transition period and after the transition period, is it common to have the area swell up still? I just want to get a good idea of how much inflammation I am supposed to expect as I transition into walking normally, and then transition into jogging and running months down the road.
Dr. Blake's comment: Swelling produced by an injury is a bell-shaped curve. Some people swell a lot and others don't. Swelling per say is not that important, but pain is. So, if it swells, but does not hurt, no big deal. But, the icing and contrasts and nonpainful massage are important on a daily basis. Good luck. Rich

Also, I want to say thanks for starting the blog, it looks like it has grown quite a bit and it is jam-packed with a ton of good information. I am making a donation for sure.


Tuesday, June 12, 2018

Sesamoid Injury in Soccer Player

Dear Dr. Blake,

I came across your website while researching my son’s injury.  I wanted to reach out to you to ask for your opinion on his injury.  I have mailed you a copy of his MRI and CT for your review.  I am so grateful for the information on your blog and would really appreciate it if you could take a look at his MRI and CT when they arrive at your office.
Dr. Blake's comment: Will do. 

My son, Ben (13 years old), is a very competitive soccer player.  He plays soccer on average 5-6 days a week.  During a game this past Spring (March 11th), he felt pain in his left foot.  He did not suffer any direct trauma to his foot but thinks the pain started when he planted with his left foot and went to cut right.  After the game, it was hard bearing any weight in his left foot.  We thought that perhaps he had turf toe (he was playing on turf, but wearing hard spiked soccer cleats) and had him rest for a few days.  When it appeared that he wasn’t improving, I took him to see a podiatrist on March 15th (4 days after the injury).
Dr. Blake's comment: One of the culprits is the cleat right under the sesamoid pushing up hard. Please consider removing it as part of the treatment. 

Find the Cleat right under the Sesamoid to remove or file down

The podiatrist’s X-ray showed that the medial Sesamoid was in 2 pieces.  He was not sure if it was a bipartite sesamoid that was inflamed or a fracture.  He recommended an AmnioFix injection, saying that if it was sesamoiditis is would help speed healing and it could do the same for a fracture.  I was not familiar with AmnioFix, but at the time I felt that if it could give Ben a better chance at healing, we should do it.  Looking back on it, I am upset at myself for going through the injection because it caused Ben an intense amount of pain and swelling for about 3-4 days and with the information that we found out later, I wonder if it made things worse (edema causing poor blood flow which impacted the development of AVN?) The podiatrist put him in a walking boot after the injection. I purchased a dancer’s pad for him to wear with the boot.
Dr. Blake's comment: I am not doing any of the regenerative medical treatments, like PRP or Stem Cell, or AmnioFix. I have always thought AmnioFix as a skin substitute, or collagen former that would be helpful in achilles tears or plantar fascial tears or diabetic ulcers. I, therefore, have no idea why it was put into your son. Sorry. It is hard to get info on it but it should be degraded by now. The acute inflammation should not cause any long-term AVN problems. 

I decided to take him to see a Foot and Ankle Orthopedist the following week.  He thought that the distal fragment of the medial sesamoid “looked funny” so he ordered an MRI.  I have enclosed the MRI.  The MRI showed edema, sclerosis, and avascular necrosis of the distal fractured portion of the medial sesamoid.  I’m wondering if the swelling/inflammation from the AmnioFix injection caused the AVN or made it worse.  Can AVN happen so quickly-9 days passed from the date of injury to the day the MRI was taken? Could he have had this injury “brewing” for a while (he never complained of foot pain)? The doctor told Ben to wear the boot and dancer’s pad for the next month and return for a follow-up.  I asked the doctor if an Exogen Bone Stimulator was a good idea and he said that it was okay to use and gave us an order for the machine.  He has been using it daily for 20 minutes since March 29th.
Dr. Blake's comment: Please talk to the Exogen rep for me about the age restriction. I know the bone has to be skeletally mature, but not aware of recent studies on age. Did see some studies that 13 was the earliest including in the Exogen study. It is hard to imagine in a child that some short-term swelling will lead to AVN. I have not seen it. I have seen AVN occur when a year has passed and the inflammation was never under control due to inadequate treatments.

We returned to the orthopedist on April 23 for a follow-up.  He did a CT scan in his office and said that “the bone did not fragment, but still showed AVN” and Ben could transition into an orthotic as soon as possible and if he felt good, he didn’t need to return to his office for any follow-up.  He didn’t indicate that Ben should be restricted in any way or need physical therapy.  Because of what I read on your website, I thought that 6 weeks was a little premature to be out of the boot, especially with AVN.  
Dr. Blake's comment: Yes, first of all, you need the boot to achieve the 0-2 pain level? Sometimes you need an orthotic or dancer's padding to accomplish that. If I can good pain wise, and I have good 0-2 pain control, I will begin weaning from the boot and orthotic to shoe and orthotic at 10 weeks. As long as the pain does not go higher. Keep him in the foot for at least 4 more weeks. 
     If we are worried about AVN, then contrast bathing twice daily, Exogen bone stim if good for his age, and weight bearing as long as we keep the pain between 0-2. Also, bone health should be important with proper Vit D, Calcium, protein, perhaps asking a nutritionist if there are diet changes to make to ensure stronger bone. 

I was disappointed to have Ben discharged from his care without any type of follow-up or plan for returning to play.  Instead, I decided to follow your recommendations of 12 weeks in the boot with dancer’s pad, daily bone stim,  and daily contrast baths.  I’ve had him on Vitamin D3, calcium, and magnesium since the beginning of the injury.  Ben has also been doing body weight exercises and using the rowing machine while wearing the boot.  
Dr. Blake's comment: Great, what pain level are we having?  

Ben reached the 12-week mark on June 3rd and his been weaning out of the boot and into a Hoka shoe with the orthotics.  The orthotic had to be a very low profile in order to eventually fit into a soccer shoe. The orthotic has a carbon fiber plate with the metatarsal cutout and dancer’s pad for the left foot.  The right orthotic does not have the carbon fiber plate or dancer’s pad (only has the metatarsal cutout). Ben has very high arches which probably contributed to his injury (along with wearing hard spiked cleats on turf and perhaps overtraining).  This past week, Ben says he feels good and has no pain with walking.  He says he gets a little bit of pain if he puts a lot of pressure on his left foot to “test the orthotic”.  He has some pain with palpation of the area to the side of the medial sesamoid (along the base of the big toe)-he describes it as “tingling pain”.  He has not done any running or jumping.
Dr. Blake's comment: Wow, this sounds wonderful. You are doing a super job. All of those symptoms fit in the 0-2 range. Palpable pain can be normal well after a person is back running with full activity due to some nerve hypersensitivity. Massage the area for 2 minutes twice daily with the palm of your hand. The massage is for desensitization and cannot be painful. 

Thank you for taking the time to read this and look at Ben’s scans.  I want to make sure that we haven’t missed anything and if there is anything else we should be doing.  Do the orthotics that he has sound appropriate for his injury/needs? Should I also be spica taping him? Continue with bone stim and contrast baths? Any recommendations that you have on how to progress his activity from here would be greatly appreciated.  He is tolerating the orthotics and can walk about 1 mile without pain.  
Dr. Blake's comment: Definitely needs another pair for normal athletic shoes that can have more bulk (more padding, more dancer's protection, more arch?) As he begins to increase activity (longer walks, then walk-run program) experiment how spica taping and cluffy wedges feel. Check about the bone stim for his age. Contrast bathing until a new MRI 6 months after the first one, or we have stopped worrying about AVN (bone death). 

How do we know if the bone has healed and no longer has AVN?  I’ve read that it can take up to a year for a bone with AVN to come back. Is it safe for him to play soccer before we have proof that the bone is okay?  It has been extremely difficult for him to sit out the last 3 months and the competitive nature of his team/league makes it difficult to come back after a prolonged injury.  However, I’d rather be safe than sorry.
Dr. Blake's comment: It can take one or two years to know that a devitalized bone has revitalized (I know big words for me). Typically, we first follow the symptoms, as long as we are doing the above bone stim, contrasts, bone health, weight bearing. If the symptoms and disability (inability to play soccer) are stalled at 6 months, a CT scan and another MRI are ordered. The signs of AVN are bone fragmentation and no marrow signal from the bone. This is getting the buggy before the horse right now. 

Thank you for taking the time to read this long message!  I so appreciate it.  The information from your blog has been so helpful!
Dr. Blake's comment: Thank you. Sounds like you are doing wonderfully. Look forward to seeing the images. Good Luck. Rich

The Patient's mother responded: 

Dr. Blake,

Thank you so much for your recommendations.  Looking forward to hearing your thoughts on Ben’s films.

I spoke to the Exogen rep about the age limitations on the bone stimulator and he said that studies have not been done on children, but it has been used in kids Ben’s age without any negative effects (that we know of).

Side View of the Tibial Sesamoid with 2 fragments looking nonfractured and smooth edges, but the distal fragment (closest to the toe on the left side) looking sclerotic (sign of AVN) brighter white than other fragment.

Take care!

Dr. Blake's review of the images sent: CT, and MRI. Selected images presented. 

                                                               Again the tibial sesamoid on the left side looking more sclerotic in its distal or bigger fragment, but the two pieces look typically bi-partite (round, smooth edges). The trauma appears only to the distal fragment.

These are side by side comparison of the tibial sesamoid in T2 MRI where the normal bone is dark and inflammation shows up as white, and T1 where normal bone is white. See this distal fragment does not change consistency. This is very unlike a new injury where trauma to a bone would make it white on T2. Possible AVN? Probable old AVN! MRI after 6 months of Exogen, contrasts, weight bearing will be conclusive. Long wait I know. 

 Here the arrow above points to a medial collateral ligament irregularity. Also, note the tremendous swelling on the whole joint. This points to a Turf Toe injury which is acute (3 months old). Taping of the joint crucial to allow healing. This could be a reason to do surgery to sew up the ligament or consider PRP or prolotherapy. However, no joint instability has been found, so again I would wait for the followup MRI. I would do even if the joint is doing well.

 These 3 CT scan reconstructions are conclusive to me. The 2 fragments have the classic appearance of a bipartite sesamoid, round, different sizes, smooth edges at the junction. The distal fragment with the possible AVN looks healthy, nonfragmented, just like the uninjured fibular sesamoid. Good sign!!

Monday, June 11, 2018

Sesamoid Injury: Email Advice

Hello Dr. Blake,

 I am a 26-year-old female from Windsor, Ontario, Canada. 

I am struggling with a fibular sesamoid injury which occurred in January 2018. I read your posts regarding sesamoid injuries on your blog and found them very helpful! 

I've had two x-rays, a bone scan, and an MRI so far and unfortunately, I have not been able to get a clear answer from the health care professionals here in Windsor. The radiology reports from both of the x-rays and the MRI indicated no fracture or focal bone lesion, however, I have gone to see three podiatrists who all claim that there is a fibular sesamoid fracture. The report from the MRI (which I finally had in May 2018) stated that there was lateral sesamoid bone marrow edema and the conclusion was sesamoiditis. One of the radiologists also thought there might be a "crack in my big toe." 
Dr. Blake's comment: Sesamoiditis with bone edema can be the same treatment and injury as a stress fracture. You can not see a small stress fracture, but it causes bone edema as your body attempts healing. So, they can look the same, and we are really forced to treat the possible fracture because that has long-term complications like the need for surgery that we want to avoid. 

I admit I did not stay off of my foot when I was originally injured in January since the diagnosis was unclear. I am very active and do a lot of walking at work (sometimes wearing heels). However, despite staying off of my foot for the past month I am still in a lot of pain and have not seen improvement. I am also struggling with circulation issues (despite trying contrast baths). I am wondering if there is underlying etiology that may have been missed. 
Dr. Blake's comment: For bone health and tissue strength, along with swelling reduction, weight bearing to tolerance is crucial. Yes, you can not push through pain, but rest (getting off your feet for an extended time, does not help either. 

Due to our healthcare system in Canada, I am not able to get in to see a specialist until September 2018. I was wondering if you would be so kind to have a look at my MRI or x-rays and give me your clinical opinion? I could mail or e-mail them to you and I would be happy to pay you for your time as well! Please let me know if this would be okay with you. 
Dr. Blake's comment: Yes, please mail a disc to Dr. Rich Blake 900 Hyde Street, San Francisco, California, 94109. No charge for this. Contact my friend Dr. Shannon Frizzell at OOLAB (Ontario Orthotic Lab) in Hamilton, Ontario to see how you can get a good orthotic to protect the sesamoid. 

Thank-you for providing such thorough and detailed information on your blog. It has helped me immensely so far! 

Thank-you for your time, 

Wednesday, June 6, 2018

Resolution of Foot Nerve Pain: Email Advice


You asked for 2-week feedback on my heel problem (, but I had some delays waiting for Neuro-Eze and traveling over Memorial weekend, so here's my 3-week feedback on the neuropathy.

I was impressed with your question about low back and sciatica because I do have a recently collapsed disc L4-L5, and experienced sciatica for the first time in the LEFT hip and leg in April. That faded away in a few weeks, then the heel problem manifested in the RIGHT heel, triggering by stretching, but I assume it could also be due to the damaged lumbar disc and sciatic nerve.

I strictly limited my walking, switched from your permanent orthotics (thin foam) to your temporary orthotics (memory foam) for their rearward arch placement and heel cushioning, and followed your treatment instructions (neural flossing, Neuro-Eze, knee-bent lifting, warm water) rigorously for three weeks. Heel pain was gone after two weeks, but I continue to feel the occasional twinge when barefoot on a hard surface or inadvertently stretching the achilles.

After 3 weeks I switched back to permanent orthotics and have walked about 5 miles since, resulting in no pain but again, minor twinges in the heel. My feet seem to be missing the arch and cushioning of the memory foam orthotics, which really relieve pressure on the heel!

Questions at this point:

1. How long should I continue the neural flossing and Neuro-Eze, considering that pain has been gone for a week?
Dr. Blake's comment: Thank you for the wonderful feedback!! Once the nerve is irritated at the lumbar spine, or along the sciatic nerve, the abnormal sensations called dyskinesias can linger for quite awhile (meaning months and months). You sort of have to pay attention, but you sort of do not. I like the Neuro-Eze three times a day for two weeks longer than the pain, then one month at twice daily. The self-massage is probably as important at this stage as the medication itself. Consider the neuro-flossing through August 1st (almost 2 more months because that gets the basic problem of the sciatic nerve settled down). 

2. Do you see any issue with using the memory foam orthotics? Dr. Blake's comment: No, you can continue with the full-length Hannafords, unless it upsets some other problem. Sounds like it helps the heel the best, and that makes sense, between the heel cushion and the transfer of weight into the arch off the heel. 

3. In the short term, how much is this neuropathy likely to be affected by walking? Should I be really cautious about resuming activity? Dr. Blake's comment: Walking should be wonderful as each step is a rhythmical neural floss. Possibly the stress on your back may be worse up or down steep hills, but I am not sure. Just go easy on hills. 

4. What about stretching? When and how can I resume (cautious) back stretches, hamstring, calf, etc.? Dr. Blake's comment: This I would bring up to a physical therapist. I know when I herniated my disc, they were cautious about stretching for several months, but that was in the acute phase. It depends where most of the tension on the nerve is: sometimes calf, sometimes hamstring, sometimes piriformis, sometimes low back. Just know that prolonged stretch can trigger it for awhile, but it sounds like it is relaxing fine. You can do short 10 second stretches with less pull than normal first to see how you feel. I would wait until July probably. 

5. What about long-term? Is this sort of condition likely to recur, or to limit my activity permanently, without more aggressive treatment? Dr. Blake's comment: I would not expect any long-term disability. I play basketball several days a week but have some dyskinesias from time to time. Months and months can go by without issues. Make sure with your back issues that you are fully rehabbing your back on a daily basis. Hope this helps. Rich

Thanks again!

Monday, June 4, 2018

Short Leg Syndrome: Email Advice

Hi Dr. Blake

I came across your blog and have found it really helpful, thank you for posting there. I hope you don't mind but I was hoping for some basic advice.

I have been suffering from low back pain and right anterior hip for about 3-4 years and have seen a variety of medical professionals (physios, chiros, orthos etc) with limited success. I have been getting contradictory advice from different medical professions so hoped you could help. 

A physiotherapist told me 1 year ago I had a true LLD (Limb Length Discrepancy) of approx 1 cm (measured by looking at my ankle bones with me lying down) and I got an orthotic made with 0.5cm (~50% of my LLD) heel lift in my short right leg. This didn't really help with my symptoms after wearing it for about half a year. 6 months ago a chiropractor told me based on x-rays I had a 1.6cm true LLD so advised me to up my heel lift to 1.5cm. Again this extra lift hasn't really helped with my symptoms after wearing it for 4-5months and I found it caused some foot pain as it was a very high heel lift.

Recently I have been working another physiotherapist who believes a lot LLD are functional so has been giving me a correct exercise programme aimed at addressing this. 

I am very confused about whether I have a true or functional LLD. My chiro x-rays were taken standing in my bare feet so I thought this proved it a true LLD as it measures the tops of the femurs being off by 1.6cms (see pics below).

Any advice you could offer would be much appreciated.

Thank you in advance

Kind Regards

Before Lifts

After Lifts

Dr. Blake's comment: Thank you so very much. It is so hard to know all the causes of your problem and being a podiatrist, I am very limited in the advice I could give you. First of all, when you put in the lifts, the spine looked so much better with the hip and sacral base still low. Also, it looks like some of the most compression of the spine without the lift is around L1 and L2. This can give both anterior hip and low back pain easily. Please have a Nerve Conduction Study with EMG to see what is involved. Also, have an MRI of the Low Back and see if L1 and L2 are injured. Then decisions can be made. 
     From my viewpoint, I would use around 15 mm for 3 months under the left as close to full length and see what symptoms change. Of course, if there is increasing pain, blame the lifts, and remove. If no untoward effects, I hope after 3 months you can go up to 20 mm. You have some scoliosis and need to be put on a program of back strengthening and stretching that is appropriate for your curves. Typically, the concave side of the curve gets tighter, and the convex side looser, so you stretch the concave side and strengthen the convex side.  
     To do this correctly you have to have several shoes with the full-length built up on the outside of the shoe that you can stay with for the 3-month experiment. You have to have some full-length lifts of 1/8 th inch to put in your right side if you need to lessen the overall lift for a while.  Hope this helps some. Rich

The Patient then Responded:

Thanks so much for your reply. 

I had 2 questions if you could find the time

  1. You advise I use a shoe with a lift on the outside of the shoe as opposed to a heel lift or orthotic with heel lift in the short leg? Using a heel lift is obviously easier to manage as it can be moved from shoe to shoe as opposed to being tied to shoes that have to be built up. A heel lift is a bad idea for an LLD of what I have (1.6cm)? Dr. Blake's comment: I think heel lifts can produce more instability at the heel over a full-length lift. You can limit your shoe wearing with full length lifts tapered at the toes, although there is so much crowding at this amount that it may make it hard. So much of this process is experimentation to see how you feel. All I am suggesting is that you try one or two pairs of shoes built up to see the difference. It is a $50 experiment per shoe and can be removed if it does not work. So many patients feel so much more stable, actually lifted more than shoe inserts, and so much better shoe fit overall. It becomes an individual decision, but so many of my patients prefer it. Try it on one pair of shoes. Nothing to lose but time. Here is my video playlist on short leg syndrome:        
  2. You suggest I go up to 2cm even though my x-ray shows my LLD is 1.6cm and wondered why 2cm? Dr. Blake's comment: If I have labeled the image entitled "after lifts" correctly in the images above, you are still not level completely at the hips, and probably most importantly base of the spine. We call it Sacral Base Unevenness and it is more important to a lot of patients that this be level than leg length correction at the hips. If you look at how L5 sits on top of the sacrum, you can see that the sacrum still falls to the left. Once you have the lifts in, taking this one xray called AP Pelvic Standing with 20 mm lift under the left side should be done. You can send me the image. 

Thanks again

Kind Regards

Saturday, June 2, 2018

Sesamoiditis: Email Advice

Hi Dr. Blake,

      It's been a while and I wanted to give you an update on my case. So last I messaged you in January I had just got the cast put on for my sesamoiditis. I had the cast removed in early April, 11 weeks with the cast on. After the removal, the doctor told me to wear the boot to walk in and gradually go into walking. I was confused as to what I was feeling, I had pain all over my foot, maybe from the cast immobilizing my foot for so long. I went back to see the doctor again, I reported to him that I'm walking with shoes, but I still have pain and that now I walk with a limp. He made custom orthotics for me.
Dr. Blake's comment: Here is the reading I did of this patient's first MRI in January when he sent it up to me. 

 I reviewed the MRI which shows you have bone edema in both the tibial and fibular sesamoids, and also the joint, and also the soft tissue. It is one unhappy joint. For mineralization of the bones, we needed protected weight bearing with orthotics, dancer's pads. You need to be doing icing twice a day and contrasts once a day. You need to see if you can get the Exogen 5000 bone stim, like Harry Potter's broom!! You need some PT to de-inflame the joint, and help with the off-weighting. No surgery since more than one thing wrong. A new MRI in 6 months to check progress. No NSAIDS or cortisone shots since they are bad for bone healing. No surgery should be needed, but it may take awhile for impact sports again. Has your overall bone health been checked? Questions? Rich

      I still had pain so I added dancers pad under the orthotics to relieve my sesamoids and help with the pain. The doctor was not very happy that I added dancers pad to the orthotics. The orthotic only relieved my sesamoids by 1/8 of an inch. After watching your videos I learned that I have plantar flexed 1st metatarsal, it's nearly 1/2 inch! I tried explaining that to my doctor and he asked where did I learn that and he immediately shut me down and told me not to look up anything on the internet. 
Dr. Blake's comment: This is the price we have to pay, but you have to create that 0-2 pain level. Did you try a cluffy wedge also? You are the one with the foot pain, but him. Doctors can be insulted by Dr. Google, but as patients, we got to try various things to get our individual situations under control. Thanks for watching my video by the way. I attached it here for the readers. 

He told me to remove the dancers pad, I did not as without it I would have pain during walking. I then went back again for another follow up. I reported again that pain and swelling continues, even after having a cast and taking work off for nearly 3 months. He pushed and pushed towards a corticosteroid shot. He said to me it's the shot or we are out of options, unless we go to surgery. I went with the shot. I was incredibly sad that I went with the shot. But me and my wife just had a baby and she needs help, so I'm out of options. The shot was painful, doctor told me he will only give me one shot and make it half the recommended dose. After nearly 2 months later, I went back, I reported that pain and swelling remained. He told me there is nothing else he can do. I told him that now I have electric pain above my 1st and 2nd toes whenever I lift my toes up and also told him that I have pain on the fat pad of the sesamoid but right where the skin folds to curl the big toe down. He said it maybe nerve irritation from the cast. He said there is nothing else he could do about it, so he sent me to a Pain Management doctor, I just went to go see this doctor last week. He put me in Meloxicam 7.5mg for pain and inflammation 2 times a day for a month, and he also put me on Gabapentin 300mg for 3 times a day for a month for nerve pain... I don't know what else to do. It seems like things are getting worse, I now walk funny, my injured foot no longer flexes up or down straight, it curves out then in while I flex up and down, now I'm having nerve pain 😩 more and more issues. I've always been a naturalist, no drugs or meds, but now I feel that with the corticosteroid shot, and now these meds, I'm straying from my beliefs, but there is nothing else that I know of what to do. I've done so much research and it's driving me crazy the thought of not being able to walk or run pain free ever again 😩 If you know of a specialist in southern California that you know and recommend, I would really appreciate it.
Dr. Blake's comment: I am sorry. Demand another MRI so we can compare. I think the first MRI is our baseline, with the second invaluable to know how things are healing. In Los Angeles you can try my go-to guy, Dr. Dan Altshuler, also Dr. Arnie Ross is an orthotic guru, and Dr. Doug Ritchie I know well. All podiatrists. 

PS: I sent you a picture, I know it's so hard to figure it out, but in the sesamoid region, the skin is red... when I press it to hold it and release it, the area around it returns to normal colorfast but the location where it's red does not. I explained this to my doctor he said not to worry about it, and he got on me for looking online and always looking at the color of my foot. By the way, he shot down my request for another MRI or CT Scan said😣 no sense getting a scan if there is still inflammation. I told him a bone scan then, he said nope, we already know the condition of the bone.
Dr. Blake's comment: I know there are 2 sides of everything so I will not judge. In a separate email, you are sending me a new MRI so we can see. The redness is sympathetic nerve vasodilatation. It is a sign of nerve hypersensitivity which we called vasomotor insufficiency. The pain doctor probably knows about it. The gabapentin may have to be increased up to 2400 mg per day or mixed with other drugs. Topical nerve creams should be massaged in 3 times a day. You have to treat the nerve component as well as the mechanics and inflammatory. 

Thanks for taking the time to read this, I truly do appreciate it.

Best regards,

Chronic Foot and Ankle Pain post Illness: Spiraling Out of Control

Hello Dr. Blake,

I came across your blog in search for help for a chronic bilateral foot/ankle/leg problem that I've had for over a year now in which I've had a hard time getting a diagnosis for. I was hoping that I could give you some information and you could possibly offer me your thoughts, as I'm desperate.

First, let me say that I'm 52 years of age and am 5'6 and 120 lbs.

During the Winter of 2016-2017, I experienced a very stubborn bout of diverticulitis in which I have prescribed Augmentin (4 courses) for 4 months. I was mostly bedridden during this time. Once I had recovered in early May 2017, as expected, I had a severe amount of atrophy in my legs. I proceeded to do a lot of stretching, mostly of the calves and began walking (in unsupported shoes, unfortunately) about a quarter a mile a day. On my second day of walking, I came home with discomfort in my feet, ankles, hips and lumbar areas which is unusual for me. The following day the discomfort had dissipated.

Within a week, I developed pain in the left foot/ankle, mostly in the front of the ankle (retinaculum area) as well as pain around the outside of the ankle (peroneal) which traveled a few inches up into my lower calf.  I immediately saw an Orthopedic who did x-rays and suggested that I stay off my foot and ice it. Over the following weeks, the pain began to worsen and I visited the local Urgent Care, ER, and my primary care physician. All thought it was a sprain and I was told to stay off of my feet and to elevate and ice.

A month later, I did go back to see the Orthopedic, as the pain had gotten worse and I was beginning to get the same pain in the right foot/ankle. He suggested visiting a Rheumatologist and offered me ankle sleeves and to use a CAM walker boot when making small trips around the house. He recommended remaining off my feet as much as possible. Oddly enough, during this entire time, I never had pain while walking but several hours later.

I went to see a Rheumatologist and all testing was normal. (RA, and autoimmune disorders)

At this time, I went to see a Podiatrist who did x-rays and said that I had a dropped navicular bone and very mild PTTD. He made me a pair of custom orthotics and I wore them 15 minutes, 3 times a day. On the 3rd day, my feet and ankles were in so much pain, I cried and could no longer wear them. I understand that orthotics have a break-in period but my feet felt like they were shattering while wearing them. He then suggested that I try a pair of PowerSteps to get used to and he'd build them up as needed. (See attachments) I began having more areas of my feet/ankles hurting and was getting terrible tightness in my peroneal muscles in which I began seeing a massotherapist.  

Over the past year, I've seen about 50+ specialists. Neuro's, Neuromuscular's, Rheumatologists, Vascular, certified Foot and Ankle Surgeons, additional Podiatrists, Spinal Surgeons, Neurosurgeons and the list goes on. I was MRI'd from head to toe, blood work, etc. I wouldn't be surprised if the total for all of those appt.'s and tests exceeded $300K. Nothing was ever found. Everything from spinal issues to neuromuscular diseases to RSDS/CRPS, etc. have been ruled out.
Dr. Blake's comment: I am sorry!!

During the past year, my legs have atrophied even more. I've tried PT on 3 occasions which always made my pain worse, so various physicians told me to discontinue therapy. (Land therapy caused mild swelling in the feet and aquatic therapy made my feet hurt worse in general)

What's strange is this all presented as outer ankle pain (peroneal) and went up the side of my calf a few inches. Within a month, the other foot/ankle and leg had begun to hurt in the same places.

I'm only "on" my feet about 30 minutes a day. My pain is still bilateral causing both feet to hurt, my sinus tarsi, achilles, peroneals and calves. Oddly enough, I've never experienced pain in my Post Tib around my inner ankle nor have my arches hurt terribly.

Since August of 2017, I gave up my ability to walk stairs, squat down to pick something off the floor and many other things that involve moving the feet and ankles. I find the best position when sitting is to have my feet flat on the floor, as this causes the least amount of pain. I can do these activities, but hours later, I'm in miserable pain for days.

This problem has also caused my knee to pronate inward and I've also begun to experience extremely tight muscles around my hip, groin and IT band that cause me some grief. I have no leg length discrepancy as confirmed by x-rays.

I see a Chiropractor for my hip which he adjusts, but unfortunately, the relief is short-lived. It tightens back up within an hour. I have had luck with Massotherapy in which she works with my feet, calves, and hips using cross friction techniques. Massotherapy has reduced the minor swelling that I have in my feet/ankles but returns upon use. The relief lasts the evening. I did try acupuncture, it did nothing for me except leave me with bruises on my legs.

I do have a pronation problem, more so on the left foot and the left is generally worse than the right. My ankle also rolls in as I walk. I have flexible flatfeet and my ankle slides inward but in no way goes anywhere near the floor. My arches aren't like a pancake, either. I can slide my fingers under my inner arch while bearing weight. (See attachments) I've had 2 MRI's in which no tears or inflammation were found, as well as an ultrasound of both ankles to look at the integrity of the tendons, ligaments, etc. Both of those tests proved to be normal. I can do a single heel raise on both feet with no problems during the act but increases my pain levels hours later. I've tried multiple shoes for stabilization and have noticed that slipping the shoes on and taking them off causes the symptoms to go through the roof.
Dr. Blake's comment: This is nerve hypersensitivity or allodynia.

I recently saw my original Podiatrist again who said that I've progressed to PTTD Stage 2. I don't know how this could be with next to no activity or walking in a year. Most of my appointments have been in a wheelchair.

My Podiatrist is in the process of making me a new pair of orthotics to help with the pain/stability. He used plaster instead of the foam foot boxes. He said these will stabilize my feet and not allow my ankle to pronate inward which he believes will help me. I truly hope so because the pair that I had last Summer brought me to tears within 15 minutes and I had much less pain back then.

I'm just so perplexed as to why all of my MRI's/ultrasounds have been clear, I can do single heel raises, yet have Stage 2 PTTD according to my podiatrist.
Dr. Blake's comment: You are probably just so much weaker, so your arch is lower now, temporarily until we can improve the strength. This is the key to me. With nerve pain, you have normal MRIs. See comments below. You may have to consider epidurals, sympathetic blocks, or Calmare Pain Therapy. Most start with orals like Lyrica.

Could atrophy be a contributing factor in all of this? (I have a very significant amount in my legs) Would gaining some muscle help my situation? I'd be willing to try just about anything but it's hard trying to find an exercise (or even strengthening) that can be done from a bed or while sitting without much foot/ankle movement.
Dr. Blake's comment: Yes, you were set up for this with the diverticulitis, and sickness in general, that started giving you symptoms from this atrophy. Every day that has passed that you have not had normal activity, you have gotten weaker and weaker and weaker. The question is how to reverse this trend. 

During my research online, it appears that most podiatrists use custom AFO's (like a Richie Brace or similar) along with stretching and physical therapy and have had good outcomes in Stages 2 and 3. I'm perplexed as to why my podiatrist didn't suggest this given my previous experience with his custom orthotics.
Dr. Blake's comment: Unsure also. The Richie Brace or AFOs can undersupport a painful arch at the same time letting the leg take some pressure. 

To reiterate, I can walk stairs and walk pretty normally when I have to. The pain appears several hours later and is quite disabling for days.
Dr. Blake's comment: What happens when your muscles are weak, but functional which yours are, that the joints sag a little bit more than normal, and this stresses the nerve endings. The nerves want to protect you so they hurt telling you that you have a problem. They are your friends in this regards. So, we need strengthening work of all sorts, as long as you can recover. Can you swim with floats at the ankles? Can you ride a stationary bike with the seat lowered so there is less stress on the ankle? Can you do active range of motion like ankle circles twice daily and then ice afterward? Were your original orthotics adjust for 25% of the original arch (if they have a deep heel cup they will still be stable but less irritative)? You really fit into the functional rehabilitation 6-week programs that they put CRPS patients in. The therapists who run these are great at teaching you when to honor the pain and when to push through the pain. We need short walks daily with ice afterward for the weight bearing. You may need oral medications to keep the pain down so you can exercise more. These would be the pain medications like gabapentin, Lyrica, Elavil, Pamelor, Cymbalta, etc. 

I've attached several pictures of my pitiful looking built up Powersteps that I've been wearing when weight bearing. I never go barefoot, even for a trip to the bathroom in the middle of the night. I've also attached pictures of my feet for signs of pronation. I don't know if I truly do have PTTD Stage 2 or perhaps a milder version or something completely different. I often wonder if atrophy could be a significant impact on my pain.
Dr. Blake's comment: I would blame this all on atrophy, forget the advice to rest some more, be on crutches, and move more. It may be an every other day program since you will need time to recover and need time for a pain specialist to get you on the right cocktail of meds. The meds are built up over time until you reach the desired result, then stabilized for 2 solid months, and then the process of slowing weaning off them happens. 

While I understand that you can't diagnose me through my attachments, if you have any thoughts or advice, I'd be grateful hearing them. I certainly don't want bilateral flatfoot reconstruction and feel after meeting with my podiatrist last week, I'm in a race against time due to progression. I'd prefer to try as many conservative measures as possible. If I lived closer, I'd make it see you but unfortunately, I'm in the Cleveland Ohio area.
Dr. Blake's comment: First of all, I looked at the photos you sent and saw a little pronation, worse on the left, but there should be no need for any foot surgery. Secondly, I hope the loss of Game 1 to my Golden State Warriors was not too upsetting to you. It was sad to see little LeBron crying over some of the calls. Look online for the organization of neurophysical therapists, and find a good pain specialist. In California, we would have you lathering up the noneuphoric cannabis!!

I absolutely love your blog! It's so informative and I think it's wonderful how you take the time to help others out. Had I known how to post this there, I would have.
I apologize for the length of this, it's been a tough year.
Dr. Blake's comment: I have added an article on Augmentin and muscle weakness. It could have been the dagger that broke your back. Not sure how long this weakness continues once you stop, but it could have added to the normal weakness of being sick. This is not uncommon. I wish you well my friend. Rich

Thank you in advance,

The patient then responded:

Hello Dr. Blake,
I can't thank you enough for taking the time to read over my history and symptoms.
I recently received my 2nd set of custom rigid orthotics. (See above) They have good arch support, a deep heel cup and prevent my ankles from pronating. This is the first pair that I've been able to comfortably wear with reduced pain. The mild swelling that I had in the retinaculum in the front of the ankles, as well as the swelling on either side of the achilles, is now gone. This was within 24 hours of wearing them. I've been told the break-in period for these is an hour a day with a steady increase. I was told that if my pain increased to back off a bit to let my legs/ankles and feet recover.
Dr. Blake's comment: You are always dealing with 3 types of pain: mechanical, inflammatory, and neuropathic. I am glad you finally got some mechanical relief. 
Thank you for the information on nerve hypersensitivity. Not one physician could explain why wearing socks or shoes would increase the pain in my feet/calves. I've noticed that foot baths with jets increased the pain as well as when physicians manipulated my feet. 
Dr. Blake's comment: Yes, the nerve aspect of pain syndromes is not taught, or appreciated, by doctors and therapists in general. 
I have seen several pain management physicians and was refused any types of blocks. The only relief that was offered to me was a spinal cord stimulator in which my insurance company would not cover. As for medications, I have tried the majority that you have mentioned but were not well tolerated. Hopefully, with the use of these orthotics, they'll allow me to build muscle with a tolerable amount of pain. The past few days, I've been able to take short walks (5-10 minutes) with tolerable pain. (No sinus tarsi pain, arch pain, but calf pain which I'm assuming is due to a different foot position)
Dr. Blake's comment: In my mind, with weak muscles, strength, not an invasive procedure like spinal cord stimulator, is what you need. Many rejections to meds like Lyrica is because the doctors start the patient on too high of a dose. If you can research the starting dose of the nerve meds again, I can tell you where to start. 
I will try using the local pool with floats around my ankles, as well as a recumbent bike and ankle circles as my body permits. Thank you for this suggestion. Even though I'm within the Cleveland Clinic healthcare system, many physical therapists don't really know what to do with rehabbing feet/ankles. (My previous 3 visits proved this as I was pushed so hard with the "no pain no gain" attitude that I came home in excruciating pain on each occasion). I did look up the organization of neurophysical therapists and have found several in my area, thank you for the suggestion. 
Is noneuphoric cannabis CBD oil? If so, that is legal in Ohio and they make a lotion that I could try on my legs/ankles and feet. 
Dr. Blake's comment: Yes, CBD. 
When my husband and I brought up atrophy, all of the specialists said that atrophy doesn't cause pain. We were pretty confident there was indeed a connection. Thank you for confirming this. as well as it's connection to Augmentin.
Dr. Blake's comment: Here is an article discussing muscle atrophy to pain. It is so common!!
I do realize that this is going to be a long recovery. You're the first doctor that has instilled hope that there is a way out of this pain without surgical intervention. 
Hopefully, I can find some happiness in Game 2 tomorrow. The first game was a real nail-biter. They're both great teams but the Cavs only bought one superstar! On a side note, no one will ever compare to his Airness. His skill on the court was phenomenal, he had such grace, charisma, and class. That's something that seems to be lost in this day and age. 
Dr. Blake's comment: Too bad you have not had the pleasure of watching Stephen Curry through season after season as I have had. Unbelievable!! But Michael was also unbelievable. LeBron is a physical specimen and talent that may never come around again. But something is missing from his game, maybe a humanness that you see more than me. 
Thank you again for all of your help/advice and thoughts. You've provided me with hope which I haven't had in a very long time. 
I sent you a small Paypal donation this evening to help with your blog. You're a true gem of a doctor to help others as you do. I really admire you. 
Thanks again and Take Care,