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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.



https://youtu.be/E0E60NpOSHg

Please, could you provide some advice to me? 

I have had foot pain since last 4.5 years that started one morning after some leg exercises in the gym (possibly causing back issue?). I felt heaviness in the left footbed when I sat cross-legged in the office after gym. Now the issue is with both feet - which are very flat, but show arch if I am dangling my feet in the air, rather than standing on them. 
Dr. Blake's comment: This is called a flexible flatfoot. The heaviness is a symptom of nerve dyskinesias, also called abnormal sensations like buzzing, burning, things crawling on your skin, or a rolled up towel under your arch or toes. 

Pain first thing in the morning has always been 3/10 level, never to the level of having to scream. The pain is worse if I walk a lot or stand at one place for more than a couple of minutes. 
Dr. Blake's comment: Yes, standing can be the worst time, since nerves like motion most of the time (like neural flossing exercises). 
The pain is around the heel area and travels up on the calves. Areas of soleus, behind the knee are always sore be it first thing in the morning or last thing in the day. The metatarsals and Achilles also have random tenderness.
Dr. Blake's comment: I always think nerve pain if there is tenderness but not swelling in the tissues. Do you have any swelling when it hurts?

Different types of insoles haven't helped. Recently I got expensive custom-made orthotics done, but I doubt them. Funny enough, I feel more comfortable wearing "Teva jetter lux slide sandals" than ASICS Kayano 25 that I am wearing with insoles. 
Dr. Blake's comment: Nerve Pain around the ankles, called tarsal tunnel syndrome or some version of it, can make patients wear the least supportive shoe or sandal so the sides of the shoe do not press against a sore spot. 

Recently I got MRI of feet done, which showed some bursa, inflammation liquid, little spur under left foot - which doctor said could be present in a healthy person's feet too.
The doctor also said that the plantar F hasn't got enough thickening to say that is an issue. He thinks I might have fat pad syndrome or something coming down from my back. I am currently waiting for my back MRI results.
Dr. Blake's comment: Yes, sounds typically double crush syndrome where the nerve is being irritated from above (even at the neck) and at the foot. The back MRI is a static exam, so will not pick up some back problems, but is a good place to start. You want to find a conservative peripheral nerve specialist, in the states they tend to be osteopaths, who will look at all the possible causes of sciatic nerve involvement. 

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

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

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



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!!!

Hello,

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

Thank you for your kindness in helping me!


Before Treatment


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

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

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

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

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


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

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

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





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

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

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

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

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

Cheilectomy: Exercise Program Post Surgery


My wife Patty's Wish came true: Sunset, Champagne, and Santorini on 60th Birthday!!! 
(4 Years Ago)



Hello Dr. Blake,

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

My doctor said I do not need any physiotherapy, he only told me to do one simple exercise 2-3 times a day, for 3-4 minutes, it would be sufficient. I am attaching a photo of my foot doing the prescribed exercise.
Please, would you be kind enough to propose me any kind of additional exercises you deem necessary so that to perfect my toe mobilization, apart from the one I am sending you?
Best Regards,

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

Dr. Blake's comment: The image below shows good motion, but it is only a stretch on the bottom structures of the foot and you need to get the weight on the lower part of the toe (you are bending the joint closest to the toenail more than the one you need to be stretching. 
And yes, if we get back to Greece, for sure we want to go the Crete and Rhodes, we will want to spend several days again on Santorini!! Unbelievable place!! You can not take your eyes away from the vistas!! We stayed at Canavas Suites in Oia Village. 

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



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

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


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

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


Friday, October 26, 2018

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

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

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

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


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


Friday, October 12, 2018

Snapping Peroneal Tendons and Nerve Hypersensitivity: Email Advice

Hi Dr. Blake,

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


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


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


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


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


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


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

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

Thursday, October 11, 2018

Recovering from Sesamoid Stress Fracture: It can be done!!

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

Wednesday, October 10, 2018

Conference in Santiago de Compostela Spain



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