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Thursday, May 31, 2018

Tip for Sesamoid Problems: More Shoe Volume

     I do not think I have really focused on this aspect of sesamoid injuries but many of my patients say that the volume of the toe box area is crucial to feeling better. By this I mean less material in the orthotic near the big toe joint, more width and height of the toe box area, even skipping the laces above the first metatarsal to have more room. I am one that loves Hannafords with a lot of cush, but sometime that works against me. It requires me to experiment when patients can not maintain the required 0-2 pain level due to too much pressure. 

Wednesday, May 30, 2018

Tip for Plantar Fascial Tears: Hoka One One Shoes

Hi Dr. Blake, got the HOKA shoes, and I'm loving them.  I can move so much easier in them, and very little pain (definitely 0-2 range).  I can also put both the right and the left orthotics in, which balances things out pretty well.  I feel like I'm walking more naturally, and I think my legs are getting toned too!  Anyway, thanks a bunch, and I'll see you soon for a follow-up appointment (the 8th, I think).  

Hope you are well!  

Dr. Blake's comment: These are shoes that roll through the forefoot, limiting toe bend at push off. This is valuable for many forefoot problems and, in this case, plantar fascial tears where you are limiting toe bend and the pull of the fascia for up to 6 months post-injury. 

Sunday, May 20, 2018

Plantar Fascial Tear: Email Advice

Hi Dr. Blake,

     I had sent you my MRI disc back in January, and you confirmed what I had suspected for a while, that I indeed had a plantar fascia tear. I have to admit, I have not exactly followed your advice to the word. I did wear the boot, but only for 2 months...as it turns out, my dog had to have her third surgery in 7 months on her leg, and it was extremely difficult to help her with the boot on (she's a large dog, 70 lbs, and it required walking next to her on leash at all times, lifting her, etc.).
Dr. Blake's comment: Very understandable. I would have had you switch to Mountain Bike shoes with the cleat embedded into the shoe. Mountain Bike Shoes with Built In Cleats 

     I gradually weaned out of the boot over a few weeks. Things are not going as well as I had hoped. My foot still bothers me on a consistent basis, which I don't understand, because up until last week I hadn't even *tried* anything that should irritate it. 
Dr. Blake's comment: Were you able to attain the 0-2 pain level in the boot? You have to be in the boot for at least several months at that low pain level. If not, either go back into the boot or try the mountain bike shoes. Your orthotic devices should shift the weight into the arch and feel protected and soft under the heel. 

     One night last week I was sitting on my couch, and I thought you know what? I'm just going to give a quick run a shot. It was probably about .35 mile. I knew not to try anything crazy. I have attempted the same a few times since then, and it feels like I'm back to square one again. It doesn't necessarily bother me during the run, but afterward. My foot is still sore in the mornings (but that never really went away anyway), but it's not like PF pain...it's kind of just diffuse soreness that is more noticeable around the PF attachment to the heel...I'm wondering if this morning soreness something I'm going to have for the rest of my life? It also doesn't take as long to go away as it did at its peak.
Dr. Blake's comment: We use our general rules on time, but one person can be different than the next, unfortunately. You need to be so much better day after day before you can run. Your symptoms can mean that things are healed, but not strong. Day to day has to be good first with the boot or shoe before you can wean from the boot or shoe. Then you need to build up your walking so that you are at a minimum of 2 weeks, no pain, walking at least 30 minutes at a nice clip before you start a walk run. You probably should be wearing the boot or shoe during the day to rest the tissue, use the support the foot taping 5-6 days at a time, continue icing and try some contrast bathing to see how you feel. 

     I also noticed that, while the middle of my heel isn't sore to poke like it used to be, there is a spot that still hurts to touch, and I'm not sure why? (The spot I am pointing to in the photo.) Sneakers really seem to bother me in that spot, I have found only the crocs I use for the yard are comfortable. I have started to wonder if there is not something going on in conjunction with the tear...a nerve issue maybe? 
Dr. Blake's comment: That could be a possibility. You are pointing right to the plantar fascial attachment so that does not like unusual. You could have a plantar heel bursa. Those can be painful. Try to use the frozen sports bottle roll over the sore bottom, but do not roll into the plantar fascia tear. Only the direct bottom of your heel for 5 minutes twice daily. 

     I also noticed after every attempt at a short run, my calf gets really, really tight. I try rolling and using the stick and it doesn't seem to help at all. I know I didn't follow the protocol exactly, but I have been pretty careful, and I just feel so discouraged about the level of discomfort I still experience on a daily basis. 
Dr. Blake's comment: With plantar fascial tears, in the immobilization phase, I allow no stretching of the calf or fascia. The two weeks you are out of the boot, and feeling good, I allow patients to begin to stretch the calf, but still no the fascia. This can give symptoms of tightness, so do not be too discouraged. The next 2 months boot or shoe, ice twice daily, tape daily, stretch the calf as long as the heel is firmly on the ground three times a day. You can get PT so long as there is no stretch of the arch. 

     It is really wearing me down, I just want to feel like I have my life back again. I'm also having a heck of a time trying to find a doctor out my way, and I was wondering if you might be able to offer any advice in that regard? (I have seen 4 podiatrists in person, none of whom helped me at all, which is why I ended up finding you.) As always, thank you so much for reading and for your help!
Dr. Blake's comment: Check the members for the AAPSM (sports podiatrists) in your area!! Typically we can find someone. It is not certain that you say you are a sports podiatrist and practice a conservative meaningful approach. 

Pointing to the attachment of the Plantar Fascia at the Heel
Another email before I could respond:
Hi Dr. Blake,

     So sorry to bug you with another e-mail. I am really struggling with what kind of doctor to see. Two of the podiatrists I have seen previously were members of the American Academy of Podiatric Sports Medicine...and unfortunately, their advice was less than helpful. I thought I would make an appointment with a local foot and ankle orthopedic specialist...except the receptionist (pretty rudely) informed me he will only take on surgical cases. So, I made an appointment with their podiatrist instead, but upon finding this out my PCP told me it would essentially be a waste of time and that this particular doctor would probably prescribe a pair of orthotics and send me on my way. Should I be looking for a podiatrist, a sports medicine doctor who doesn't necessarily specialize in feet, or an orthopedic foot and ankle doctor?
Dr. Blake's comment: I am sorry. I do feel podiatry is the way to go for this. I would call the office of Dr. Stephen Pribut near DC. He is wonderful. Tell Dr. Pribut that I am asking you to see him or recommend someone close to you. My son played basketball in Wayne at Cabrini College so I know that is quite a distance. He may have the exact person for you to see. Are you in good orthotics? What shoes are you wearing? What are your running mechanics like? These are all questions we need answers to help you. Temple University has a podiatry school that may help. There used to be a Dr. Howard Palamarchuk, but I am not sure if he still practices. 

      Do you know anyone in the relative Philly area you could recommend? I am having such a hard time, and I have spent so much already on this issue, my resources are pretty limited...so I can't afford to pick the wrong place again. I also noticed that along with tenderness at that point in the photo from my previous e-mail, my foot is a bit swollen around the back of the ankle and the inner arch...not sure how much concern this warrants?
Dr. Blake's comment: These are areas that fluid from any cause can collect in. Probably not a big deal. 

As always thank you so much for your help!



Dr. Blake's response:  I will sit down this weekend and answer I promise. Rich

Hi Dr. Blake,

     Please take your time! Thank you so much for getting back to me. I somehow managed to forget to mention this...sometimes I will get a stabbing pain in that sore spot in the first photo, it comes in bursts of about 10-30 seconds, it is quick but SO painful. Feels like someone repeatedly stabbing a knife in that spot...and it happens randomly, sometimes even when I’m just sitting at my desk(???)...it happened yesterday after I finished mowing the yard, and I held my foot up thinking if I put it down the pain would be unbearable...to my shock it really didn’t make a difference. I’m not sure if this is a clue to what’s going on???
Dr. Blake's comment: When you tear the fascia, we want scar tissue to get in there and heal the injury. The scar tissue can get bound up in the local nerves giving you these symptoms. These should improve as you begin to stretch the fascia, but that is probably 3-4 months away. Good luck my friend. 

Thank you, Dr. Blake!!

I am attaching for the readers my Plantar Fascial Protocol we give patients in the office. 

https://www.drblakeshealingsole.com/2014/08/plantar-fascial-tears-top-10.html

The following is the patient's response to my questions and comments.



Hi Dr. Blake,

     I had sent you my MRI disc back in January, and you confirmed what I had suspected for a while, that I indeed had a plantar fascia tear. I have to admit, I have not exactly followed your advice to the word. I did wear the boot, but only for 2 months...as it turns out, my dog had to have her third surgery in 7 months on her leg, and it was extremely difficult to help her with the boot on (she's a large dog, 70 lbs, and it required walking next to her on leash at all times, lifting her, etc.).
Dr. Blake's comment: Very understandable. I would have had you switch to Mountain Bike shoes with the cleat embedded into the shoe. Mountain Bike Shoes with Built In Cleats
Is something like a Hoka One One an acceptable alternative? (I have an old pair I can try before buying new to see if they seem to help at all.) Dr. Blake's comment: Not as good, but you can alternate back and forth for the next 4-6 months. 

     I gradually weaned out of the boot over a few weeks. Things are not going as well as I had hoped. My foot still bothers me on a consistent basis, which I don't understand, because up until last week I hadn't even *tried* anything that should irritate it. 
Dr. Blake's comment: Were you able to attain the 0-2 pain level in the boot? You have to be in the boot for at least several months at that low pain level. If not, either go back into the boot or try the mountain bike shoes. Your orthotic devices should shift the weight into the arch and feel protected and soft under the heel.
Yes, after the first week my foot adjusted to the boot and it really wasn't painful wearing it at all, which is also one of the reasons I felt it wouldn't be too terrible to wean out of it at 2 months when I needed to help my pup! Dr. Blake's comment: Your beautiful dog's photo did not transfer over. The boot did its job, but what you went into after was inadequate to continue the immobilization. It also could have been the orthotics, not taping, doing too much with the new found freedom. 

     One night last week I was sitting on my couch, and I thought you know what? I'm just going to give a quick run a shot. It was probably about .35 mile. I knew not to try anything crazy. I have attempted the same a few times since then, and it feels like I'm back to square one again. It doesn't necessarily bother me during the run, but afterward. My foot is still sore in the mornings (but that never really went away anyway), but it's not like PF pain...it's kind of just diffuse soreness that is more noticeable around the PF attachment to the heel...I'm wondering if this morning soreness something I'm going to have for the rest of my life? It also doesn't take as long to go away as it did at its peak.
Dr. Blake's comment: We use our general rules on time, but one person can be different than the next, unfortunately. You need to be so much better day after day before you can run. Your symptoms can mean that things are healed, but not strong. Day to day has to be good first with the boot or shoe before you can wean from the boot or shoe. Then you need to build up your walking so that you are at a minimum of 2 weeks, no pain, walking at least 30 minutes at a nice clip before you start a walk run. You probably should be wearing the boot or shoe during the day to rest the tissue, use the support the foot taping 5-6 days at a time, continue icing and try some contrast bathing to see how you feel. 
I can't even walk my other golden without pain, so I should have known better than to attempt a run, but I was having a "good" day so I thought I'd test the waters, and also I'll admit I was getting impatient. Dr. Blake's comment: In my world, we need to talk in terms of a consistently good week, over a run of good days, before attempting the next level of activity. That would have been a walk-run program as outlined in my blog. 

     I also noticed that, while the middle of my heel isn't sore to poke like it used to be, there is a spot that still hurts to touch, and I'm not sure why? (The spot I am pointing to in the photo.) Sneakers really seem to bother me in that spot, I have found only the crocs I use for the yard are comfortable. I have started to wonder if there is not something going on in conjunction with the tear...a nerve issue maybe? 
Dr. Blake's comment: That could be a possibility. You are pointing right to the plantar fascial attachment so that does not like unusual. You could have a plantar heel bursa. Those can be painful. Try to use the frozen sports bottle roll over the sore bottom, but do not roll into the plantar fascia tear. Only the direct bottom of your heel for 5 minutes twice daily. 
If it's an inflamed bursa, is it safe at this point to get an injection? Or should I avoid them indefinitely in that foot since it has a history of a tear and that would only further compromise the integrity of the plantar fascia? Before I used to have pain directly in the center of the heel (red circle), now it seems to emanate out from the sore spot into the side of the arch (yellow) and the actual heel has little to no pain...but I should be icing where the circle is? Dr. Blake's comment: Yes, that is where you ice. The bursae are under the heel. Are you having any pain there? Does not sound like a good idea to inject. Yes, I fear the plantar re-tearing some. 


     I also noticed after every attempt at a short run, my calf gets really, really tight. I try rolling and using the stick and it doesn't seem to help at all. I know I didn't follow the protocol exactly, but I have been pretty careful, and I just feel so discouraged about the level of discomfort I still experience on a daily basis. 
Dr. Blake's comment: With plantar fascial tears, in the immobilization phase, I allow no stretching of the calf or fascia. The two weeks you are out of the boot, and feeling good, I allow patients to begin to stretch the calf, but still no the fascia. This can give symptoms of tightness, so do not be too discouraged. The next 2 months boot or shoe, ice twice daily, tape daily, stretch the calf as long as the heel is firmly on the ground three times a day. You can get PT so long as there is no stretch of the arch. 
I have KT Tape, is that ok to use? Dr. Blake's comment: yes, there are many ways to tape with good results. Start with KT to see how it works for you. 

     It is really wearing me down, I just want to feel like I have my life back again. I'm also having a heck of a time trying to find a doctor out my way, and I was wondering if you might be able to offer any advice in that regard? (I have seen 4 podiatrists in person, none of whom helped me at all, which is why I ended up finding you.) As always, thank you so much for reading and for your help!
Dr. Blake's comment: Check the members for the AAPSM (sports podiatrists) in your area!! Typically we can find someone. It is not certain that you say you are a sports podiatrist and practice a conservative meaningful approach. 

Another email before I could respond:
Hi Dr. Blake,

     So sorry to bug you with another e-mail. I am really struggling with what kind of doctor to see. Two of the podiatrists I have seen previously were members of the American Academy of Podiatric Sports Medicine...and unfortunately, their advice was less than helpful. I thought I would make an appointment with a local foot and ankle orthopedic specialist...except the receptionist (pretty rudely) informed me he will only take on surgical cases. So, I made an appointment with their podiatrist instead, but upon finding this out my PCP told me it would essentially be a waste of time and that this particular doctor would probably prescribe a pair of orthotics and send me on my way. Should I be looking for a podiatrist, a sports medicine doctor who doesn't necessarily specialize in feet, or an orthopedic foot and ankle doctor?
Dr. Blake's comment: I am sorry. I do feel podiatry is the way to go for this. I would call the office of Dr. Stephen Pribut near DC. He is wonderful. Tell Dr. Pribut that I am asking you to see him or recommend someone close to you. My son played basketball in Wayne at Cabrini College so I know that is quite a distance. He may have the exact person for you to see. Are you in good orthotics? What shoes are you wearing? What are your running mechanics like? These are all questions we need answers to help you. Temple University has a podiatry school that may help. There used to be a Dr. Howard Palamarchuk, but I am not sure if he still practices. 
Before I received your reply I made an appointment with another podiatrist who is also a runner for next week. If that doesn't work out, I will definitely call Dr. Pribut, thank you!!! 

      Do you know anyone in the relative Philly area you could recommend? I am having such a hard time, and I have spent so much already on this issue, my resources are pretty limited...so I can't afford to pick the wrong place again. I also noticed that along with tenderness at that point in the photo from my previous e-mail, my foot is a bit swollen around the back of the ankle and the inner arch...not sure how much concern this warrants?
Dr. Blake's comment: These are areas that fluid from any cause can collect in. Probably not a big deal.
Ok!

As always thank you so much for your help!

Dr. Blake's response:  I will sit down this weekend and answer I promise. Rich

Hi Dr. Blake,

     Please take your time! Thank you so much for getting back to me. I somehow managed to forget to mention this...sometimes I will get a stabbing pain in that sore spot in the first photo, it comes in bursts of about 10-30 seconds, it is quick but SO painful. Feels like someone repeatedly stabbing a knife in that spot...and it happens randomly, sometimes even when I’m just sitting at my desk(???)...it happened yesterday after I finished mowing the yard, and I held my foot up thinking if I put it down the pain would be unbearable...to my shock it really didn’t make a difference. I’m not sure if this is a clue to what’s going on???
Dr. Blake's comment: When you tear the fascia, we want scar tissue to get in there and heal the injury. The scar tissue can get bound up in the local nerves giving you these symptoms. These should improve as you begin to stretch the fascia, but that is probably 3-4 months away. Good luck my friend. 
That makes sense to me!

Thank you, Dr. Blake!!

I am attaching for the readers my Plantar Fascial Protocol we give patients in the office. 

Tuesday, May 15, 2018

Followup on Foot Fracture and Nerve Pain

This patient broke her toe and developed severe nerve pain afterwards. This post is also included on her original post of 4/5/18. This is a wonderful example of how active we have to be in our treatment to get the right healing plan working. 

Hi Dr Blake,

I wanted to give you and your blog readers an update...

I was worried after fracturing my toe (4th toe on left foot) I was developing CRPS because I have other nerve issues.  I fractured my toe on Feb 2 and the pain just got worse.  My foot turned ice cold blue and was like that for over a week plus my fracture wasn't healing and I was having shooting nerve pain/burning in my foot.  I am wearing a boot and have a scooter.  I did the following to try to heal my foot (which I found some of it on the blog from another reader):

  • Went to a new anesthesiologist who just moved here from Cleveland Clinic and specializes in CRPS.  I was lucky to get a next day appt with her.  She was very nice and felt that it wasn't CRPS.  She did give me Cymbalta - which I didn't take since I am sensitive to medication.
  • Bought a used bone stimulator and used it twice a day (based on recommendations from several doctors - including Dr Blake)
  • Light massaging to increase the blood flow
  • Putting leg up when sitting or lying down
  • Started taking (all of these without fillers) each day:
    • 1200 mg of R-Alpha lipoic acid
    • 1200 mg of NAC
    • 2000 mg of vitamin C (powder to mix in water with cranberry concentrate)
    • 600 mg of Calcium Citrate (powder to mix in water with cranberry concentrate)
    • 5000 mg of vitamin D
    • Magnesium citrate
  • I am taking some herbs as well
    • Stinging nettle tincture (without alcohol)
    • Horsetail (without alcohol)
    • Comfrey tincture rubbing on skin over fracture and applying DMSO on top for better absorption.  I purchased Heiltrophen on Amazon - the bottle and dropper are glass which is important because DMSO absorbs everything.  I applied with clean hands and washed them afterwards without soap.
    • I tried Dr Christopher's Syrup and Ointment for bone and tissue repair a friend recommended.  Tastes and smells awful.  Lots of stars on Amazon but I couldn't stand it to take it consistently.
  • Mirroring 
    • My friend let me borrow a mirror so I am doing some mirroring exercises I found on youtube.
  • Went to Orthopedic surgeon (I wanted a second opinion in addition to my very good podiatrist just because the foot wasn't healing).  I was lucky that the orthopedic doctor for the feet of the US ski team had an appt.  Really nice guy - he just confirmed what my podiatrist had recommended)  He said I needed to be off the foot for 6 weeks and gave me a clearance for work.
So I am happy to say after 6 weeks on my protocol,  that the pain is almost gone from my foot.  I don't have the shooting nerve pain in my big toe and the burning is less.  I am able to walk very short distances without the boot.  It isn't keeping me up at night.  It looks like I am on a positive trajectory.  I think it will still be a while before I really feel comfortable walking longer distances and doing my normal routine but at least, it is getting better.

Thank you so much Dr Blake for your support and help.  

Friday, May 11, 2018

Hallux Varus after Sesamoid Removal Years Later

Hello Dr. Blake,

I have just spoken with your nurse/receptionist and she suggested I describe my foot concern to you.
I had sesamoid surgery on both my feet twenty-five years ago in Pasadena California.
Up until last summer, my feet were handling my everyday wear and exercise just fine.  
But, in the summer, I decided to wear a flat sandal with no side support.  In one month my large toe on my left foot began moving off my sandal!!!  At night I experienced shooting nerve pain from my ankle up to my knee, consistently for weeks.  I saw my podiatrist and he put me in a boot.  Had no other suggestions.  I then saw three prominent foot surgeons.  They all suggested “orthotics.”  
One of the surgeons gave me a shot of prednisone in the big toe of my bad foot.  
This did help with my nerve pain and foot discomfort.  




In caring for my foot I bought wide enough shoes to fully support the expanded width of my left foot and my disfigurement. 
I am athletic and always have been.  Since my foot alteration, I am walking with orthotics.   
One week ago, I was trying to make an appointment and was required to walk for at least 35 minutes in a sandal which has good support for both my arch and bunion area. Well, I thought.  I am normally paranoid to wear only a few pairs of shoes that work with my condition.   
The result was concerning.  My foot feels that it has become disfigured even more.  

I have been compensating for the past year, to not put full weight on my left foot.  Currently, I am having knee pain in my right knee.  I transfer my weight constantly.   I have taken a bad fall heading up the stairs because of my foot alteration. Every step I take is now is a concern to me.  

My question is are you a surgeon and do you know how to repair a condition like mine?  If not, do you know a surgeon who can which you recommend? 
I appreciate your time and consideration. 

Dr. Blake's comment:

     Thanks for the email. It sounds like Hallux Varus where the big toe moves away from the 2nd toe. If that is the case, surgical correction is necessary to realign the joint. Care has to be taken not to make the joint too tight, causing a limitus condition, and thus causing more of a problem. Send me a photo of your foot for this post to make sure we are talking about the same thing. Also tell me what sesamoid was removed many years ago. It makes sense that the fibular or lateral sesamoid was removed making it easier for this to occur. 
     Since you are 400 miles from me, and our surgeon (I only perform rehab), here is a list. My go-to guy in that area has always been Dr. Altchuler (Santa Monica) 310-451-8045. But, I have confidence in Franklin Kase (Burbank) 818-848-5583, Brian Hong (Oxnard) 805-988-3338, a member of my class Leslie Levy (Valencia) 661-254-0795 and Jan Tepper (Upland) 909-920-0884. Use my name as the referring podiatrist. After they exam you, you want to get two surgical opinions. They may be one, and then get the name of the doc they would have it done if them. Keep me in the loop. Rich

Further comment: Thank you so sending me the above photos. It almost looks like a breakdown higher up your arch, then typical Hallux Varus. This will take a good workup. Please get some 1/4 inch adhesive felt from www.mooremedical.com and apply to the medial side of the big toe when you are wearing shoes to push it over towards the second. Also, get an OTC arch support from Sole or Powerstep and begin to wear that it comfortable. Keep me informed. Rich

Thursday, May 10, 2018

Foot Pain from Hamstring Stretch: Probably Nerve Irritation

Rich,

     Your treatment plan for the fractured sesamoid in my left foot is going well, especially since I got Dr. Jill's 1/4" felt met pads, which work better with your orthotics than the 1/8" felt I was using for months. I've been able to increase my weekly walking distance gradually to about half what it was before the injury, but last week I suddenly developed a new problem in the right heel which has immobilized me again.
Dr. Blake's comment: Thank you for that feedback. I will try to tell all my sesamoid patients to experiment with the Dr. Jills product, even with their orthotics. So happy you are off the long plateau you were on. 

     Before starting a hike, I was doing a standing hamstring stretch with leg elevated onto the tailgate of my truck (I had already done my other stretches, including the "wall" stretch for calves). Toward the end of the stretch, I flexed my toes back toward my knee, and when I set my foot back on the ground (wearing heavy hiking boots and orthotics as always), I felt a sudden sharp pain in my heel.
Dr. Blake's comment: This is nerve irritation at the end of the sciatic nerve branch that feeds the bottom of the heel. The sciatic nerve is most stretched, and potentially irritated, with the hip flexed, the knee straight, and the ankle bent. Maximum stretch. It only takes slightly bending the knees or not pulling up the foot towards your chest, or both, to relax the nerve. So, you irritated the nerve deeply. 
Here similar situation with hip flexed, knee straight, and toes pulling up towards knee

     I had no idea what was happening and went on with my hike, being super-mindful about walking slowly, taking short steps and trying to focus weight away from that heel and onto the arch and toe, meanwhile just feeling discomfort in the right heel rather than outright pain. But the next morning when I woke up, I couldn't put any weight on that heel without bad pain.
Dr. Blake's comment: Have you a history of sciatic on that side or any low back or spine in general issues? These can be the first low grade irritation, that makes the sciatic nerve grouchy, but the stretch does you in. Nerves love motion, not prolonged stretches. 

     I ALWAYS wear your orthotics with the heavy boots, except when in the shower, and I've been really good about stretching, so this new problem really stumps me. The pain is under the center of the heel, and gets worse as the foot flexes and the back of the leg stretches (e.g. when doing a "wall stretch"). You say on your blog that PF develops slowly, so I initially thought it might be bursitis. But I don't do anything that results in impact on the heel - all I do is walking. And the pain seems to have been triggered simply by a routine stretching movement.
Dr. Blake's comment: Yes, see my video on neural flossing, get some Neuro-Eze to massage 3 times a day, avoid  low back, hamstring, or achilles stretching until it is better. Lift everything with your knees bent. Soak in warm water to see if it helps. Give me feedback within the next 2 weeks. 

I've been doing the ice bottle roll combined with mild stretching for a week with no improvement. I understand these things are sometimes tough to diagnose, but in any event I haven't had good results with our local podiatrist and thought I'd run it by you first. Feel free to post to blog if desired.

Thanks,



https://youtu.be/E0E60NpOSHg

Tuesday, May 8, 2018

One Sided Anterior Pelvic Tilt

As a podiatrist, I treat pronation or supination or short leg syndrome, and other causes of the pelvis becoming dropped on one side with its resultant hip and back problems. This is a good video talking about a left sided pelvic drop around the sacro-iliac joint and 3 exercises to help that. When I examine these patients, I initially do not know if the left side is dropped or the right side raised. If the left side is dropped and there is noticeably more pronation on that side, the left side is probably dropped. The body loves symmetry of motion and as I work on correcting the asymmetry at the foot, a PT, trainer, osteopath, or chiropractor will be working on raising the left side so that it is symmetrical with the right in the end. This is an easily observed problem, so one can easily to follow its success. Of course, the problem can be from acute trauma where the SI joint gets stuck up or down, or from chronic asymmetry of the right side of the body working different than the left. Both can lead to back, pelvic, and hip problems. Again, this is very common, and normally easily treated, at least logically treated. I have also attached two other videos which bring up good, but difference thoughts. I carefully reviewed these videos to make sure the exercises were safe for you. https://youtu.be/Pf-4SSI_obQ This may be a good starting point also. When you watch the video, I would be recommended just working on the dropped side that is anterior rotated to bring it back up. You can do the double side just to sense the differnce between the 2 sides. https://youtu.be/93p5YXdYF40 This is also a wonderful look at self assessment and several corrective exercises. Remember, start easly and there should never be pain. The last exercise shown should be fluid with no holding positions. I hope these help. https://youtu.be/pQA1IadG51Y

Tuesday, May 1, 2018

Nerve Pain flared with Removable Boot

Dr. Blake,
I have been following your blog for years and have a question about neuromas. Mine was under control for 5 years (with custom orthotics, met pad, wide shoes) until I was in a boot for PTT on the other foot and it flared. Since then I've not been able to get ahead of the irritation/inflammation cycle. Twice I've irritated it to a new level, most recently trying acupuncture. Before the acupuncture, I could wear Birkenstocks in the house without symptoms but now even standing for a short time will bring on symptoms and only elevating my foot keeps the symptoms away. Shoes, tight socks, sleeping (I now wear a Birkenstock at night), driving especially, all irritate it. I have had two cortisone shots which didn't help (I was told at least one was not long-acting).  

My question is at this point even if I was to do nothing that irritates it ( which I guess would mean keeping it up all the time), would the scar tissue around the nerve decrease in size? Also, does Neuro Eze work to shrink the nerve or just help with symptoms? At this point, it seems like my only options are some kind of intervention, cortisone, alcohol shots or surgery. What would you do in my position? Thank you so much

Dr. Blake's Response:
     Thanks for the email. It sounds like you irritated the nerve, more than caused inflammation (since the shots should have helped an inflammatory problem). It could have been the unevenness to your spine of the boot that caused a sciatic nerve irritation affecting the foot. I would approach it this way for the next month. 

  1. Neuro-Eze topical three times a day as a non-painful massage
  2. Neural Flossing three times a day.
  3. Experiment on removing the met pad which can irritate an irritated nerve. 
  4. Try contrast baths with 4 minutes warm and 1 minute cold alternating for 20 minutes twice daily
  5. Avoid the bend at the toes with the boot on the neuroma side with orthotics, or a mountain bike shoe with a flat bottom, or a Hoka One One shoe (they have a couple of versions that are wider in the front). 
  6. Avoid barefoot (try Oofos sandals or Halfinger sandals for home)
  7. Avoid shots and acupuncture on the sore foot. Acupuncture on the opposite hand or earlobe can be considered. 
  8. Look into a 2 month trial of Quell. 
  9. Try a scooter to off weight at home and museums if the other side can take the weight. 
  10. Since it appears to be nerve pain, consider seeing a pain specialist for oral intervention (at least an evening dose of Lyrica, etc.).
  11. Create an environment for May of 3-4 level pain, and find out what you can and can not do. 
  12. In June, we will try to increase your activity, and lower the pain to 2-3 consistently. 
  13. You make want someone to really evaluate double crush syndrome, and fully examine your spine (low back to neck). The trigger of the foot pain can be anywhere up the chain, including hamstrings, piriformis, cervical neck discs, etc.)
Hope this helps get you thinking. Rich