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Sunday, September 20, 2020

Sesamoid Injury: Email Advice

Good afternoon Dr. Blake,

I hope this email finds you and yours well. Your foot and ankle injury blog and videos have been a great resource for me as I have been dealing with a sesamoid fracture/injury since late Feb/Early March. 

Essentially, I'm not sure how I fractured my sesamoid, but I didn't have a great podiatrist at the beginning of the injury, which, coupled with the quarantine (I'm in NYC), essentially means that I lost 3 months of proper treatment right away. I had x-rays and MRI with this doctor, but everything was taken very lightly. I was told it was maybe fractured, then just an itis, with no clear plan of how to get it to heal. I had to wait til June to get an MRI (now I know I should have had one right at the beginning.) It was all downplayed a lot and I even had to ask for a boot but with no instruction of how long to wear, when to wear, include dancer's padding etc. I stayed in the boot on and off for March/April but with no dancers padding and only outside. Inside I used slippers but was sometimes barefoot. Then in May/June (what is time anymore!?) I went to an orthopedic surgeon who saw me for 15 minutes and told me to get custom insoles, which I did get and now have for sneakers. I still knew something was wrong because I still had pain walking in the sneakers and did not feel comfortable putting all the weight through the ball of my foot and it just wasn't getting better. Fast forward to July, after getting more x-rays and a CT scan with a different podiatrist, he confirmed a fracture diagnosis, put me back in the boot and now I'm using a bone stimulator. I've been in the boot since July 29th and have been using the bone stimulator since August 17. Sometimes I use it twice a day. I've attached my MRI and CT scans below (if you'd prefer access to the portal to view all the images, I can certainly provide that).
Dr. Blake's comment: So sorry for the delay, but it did not sound like you made it worse, and it is sounds like good progress now!

As I've read from so many people who have this particular injury, it is incredibly frustrating, with little understanding of it, and very prone to setbacks. Right now, I'm wondering what else I can do besides the contrast baths, taping etc. I have gone to PT but haven't gone as much since I am back in the boot and am trying not to travel extra to the city. Plus I do a lot of leg strengthening at home. Should I be refraining from walking as little as possible and pretend as if this fracture happened yesterday and not in March? 
Dr. Blake's comment: Create the 0-2 level, walking within at framework actually is better for the muscle strength, bone demineralization, sanity!! There is no guarantee of complete healing for many reasons, but 3 straight months of immobilization in the walking boot, and then another 3 months of keeping the pain between 0-2 as you wean out seems vital to alot of these injuries. Unfortunately, the initial trial of boot does not count. 

I really want it to heal, yet I feel that this is going to be another 3 months, at least. It's so sensitive and a tiny little thing seems like it causes a flare up. My legs/feet and left foot just feel off/bad from being in the boot and even up on the left foot for so long, on and off this year, and I'm honestly afraid I'm not going to remember how to be in sneakers or how to eventually transition back into wearing them.
Dr. Blake's comment: It is not a waiting game since there are some many things to do now to prepare for the weaning out of the boot period. You need to make sure that your orthotic devices and dancer's padding off weight the area (so some visits with good shoes to the podiatrist office to make sure all is well is important). You want to have perfected spica taping, and have some stiff dress shoes for the holidays so you can place in Dr. Jill's Gel Padding as protection. PT is less important now since you are back in the Immobilization Phase, but without irritating the sesamoid, you need to keep strong, flexible, and with infrequent flare ups (but they will occur even in the best situations). 

I do ride my bike sometimes (walk down the stairs in the boot, switch to sneakers with insole etc-it's a process!) but sometimes even if my steps add up to 1 mile each day, that seems to aggravate my foot. It's all very frustrating :) I really want this to fully heal as it's been many months now. If you have any additional insight on my particular case, I would be so grateful! 
Dr Blake's comment: The 4 common areas you need to deal with are: protection (just discussed with boot, orthotics with dancer's padding, dancer's padding alone, cluffy wedges, spica taping, stiff shoes, or rocker shoes like Allegria dress, or Hoka One One type), inflammation (ice and contrast bathing very important, NSAIDs and cortisone shots can slow bone healing, and PT when needed), nerve sensitivity (pain free massage 3 times daily, big toe joint gentle range of motion with your muscle strength only, occasional topical or oral nerve stabilization meds), and bone health (eating habits, low vitamin D, smoking, etc). 

Thank you so very much.

My Best,
Dr. Blake's comment: So, now to the images you so kindly sent. A question I have was there a fall or accident before your symptoms developed since they have a diagnosis of medial sesamoid chronic ligament sprain? Also, any sesamoid injury which is definitely bipartite we need to know if you have a possible turf toe injury also. This is where the ligament is sprained, and the joint can become looser, and possibly require surgery. I assume since you did not mention anything, the doctors have ruled it out, but ask them about it and also if they have done bilateral Lachman tests for joint stability. The sprain can also just cause excessive scar tissue that gets in the way. 
Possible AVN in definite bi-partite. You can fracture the junction between the 2 pieces and the treatment may be the same. 

Here less AVN looking with bone marrow. Bipartite pieces are different sizes

Here T2 MRI clearly shows no AVN!!

Turf Toe Possible Raised when Ligament Sprained

Sunday, September 13, 2020

AVN Sesamoid: Email Advice

Hi Dr. Blake,

I’m so happy to have found your blog and YouTube videos, and I hope you can provide some insight and guidance for my situation:

About me: 38 y/o female, chemistry professor by day, professional belly dancer by night and aspiring amateur Muay Thai fighter all day, every day (thai kickboxing).

History: late in 2019, I started noticing some pain in my left big toe upon extension. The pain was never severe, so I kept training. Nothing a little tape wouldn’t fix (or so I thought). Then the pandemic hit, and I started running a lot since my gym was closed. The pain got worse, I did less and less. Still, the pain was never terrible but it was persistent. I saw my podiatrist, and he diagnosed me with AVN of the fibular sesamoid by MRI in early June 2020. This was confirmed with spect CT in early July. My x rays were normal, there was no apparent fracture or degeneration. Both the MRI and CT showed some soft tissue inflammation/edema but no tears. I went in a boot for 6 weeks, and I was given a bone stim (ortho fix) that I’ve been wearing for 3 hours a day for almost 3 months. My pain was at a 0-2, so I have been attempting to gradually step up my activity, but it seems that it’s always 2 steps forward, 2 steps back. My PT primarily does manual therapy, and I’ve been doing toe yoga and trying to go for walks or short hikes (In the shoe recommended by my podiatrist - hoka Bondi 6). Anytime I do this, my foot starts to swell again and be painful. I am so frustrated.

Here is my dilemma - I also have some mild/moderate scoliosis, and the lack of activity has severely flared up my back pain - to the point that the idea of spine surgery has been floated by my sports med doctor. As a result of the crooked spine, I have degenerative disc disease (Several herniations, stenosis and facet joint arthritis) that I have been keeping in check by remaining fit and active. Resting my foot and doing seated exercises (like a stationary bike) has been hell on my back. Obviously, abnormal gait and wearing a boot didn’t exactly help my back either. I need to get back to my regular training/dancing schedule to ensure that my spine stays functional and I avoid back surgery.

What is the best course of action to return me to normal activity as soon as possible? In your experience, does this type of injury heal with conservative treatment and is the person able to return to their activity? I’ve scoured the literature, and the lack of studies is frustrating, and what little there is focuses on surgical treatment. How do people fare after surgery in your experience? I’m not keen on doing unnecessary surgery but I am trying to balance the needs of my back with the needs of my foot. Lastly, what is your opinion on the use of NSAIDS during AVN? I am concerned about the anti-angiogenic effects.

Thank you for taking the time to read this and consider my case.

Kind regards,

Dr. Blake's comment: Definitely switch out of the boot for your back and into some bike shoes with embedded cleats. This will provide evenness in function and weight between the two sides, something your back will be happy for. Your physical therapist should be able to put you on a program to keep your back loose and strong as you go through the foot rehab. When will you get another MRI? I usually wait 6 months, but in your case, every 3 months to see some light at the end of the tunnel with the AVN healing. In your whole discussion, you mentioned nothing about all the other things besides Hokas: orthotic devices, dancer's padding on the orthotic and separate, cluffy wedges, varus cants, spica taping, carbon plates with first ray cutouts, etc. Send me a photo of coronal view injured sesamoid both T1 and T2 weighting to see the AVN. And yes, no NSAIDs, but you should be doing contrast bathing for deep bone flush and circulation every evening. Rich 

Tuesday, September 8, 2020

Article on Hamstring Tightness and Plantar Fasciitis

     I have to admit that when patients present with plantar fasciitis I fail to measure hamstring tightness as much as I should. This is a good reminder that plantar fasciitis been be shown to be associated with achilles tightness, with pronation, with obesity, and with tight hamstrings. It is important to stretch out the tight hamstrings when plagued with plantar fascial symptoms. 

Liz, a nurse which used to work with me, discusses 7 principles of stretching while stretching the lower hamstrings. 

Sunday, September 6, 2020

It is Just the Wrong Timing of Events: Athletic and Other Injury Rehabilitation

     I am saddened when patients prolong their injuries with the Wrong Timing of their Treatments. Many times it is only because the definitive diagnosis has yet to be made. Many times it is because the health provider has too short of range of options to offer (as I do sometimes). Many times it is because the patient is impatient for a cure, or the subtleties of any treatment regimen is not followed or fully explained (and thus the patient keeps irritating things). And thus there are so many variables, so many different provider that will practice their treatment protocols, that I have found following the 0-2 pain level in all treatment phases must be followed. I know only some good physical therapists that can make you hurt and still get you better. I know that when surgery is required (1-2% of all athletic injuries) you will have more pain for awhile. But, in general, after you get the proper diagnosis, you should get better and better on a month basis (so September should be better than August, and October better than September, etc). 
     So, you develop pain with or without an injury. If the pain is between 0-2, and you can do full activities, you can probably wait a month before you see someone (and maybe the pain will go away by then). Of course, when you do see someone, you expect their diagnosis to be correct (which it normally is by the way), and month by month you get better and better (I assume 3 months on average to greatly improve if the injury requires a doctor visit). It is important in my mind to drive the pain down to 0-2 as quickly as possible (a week for sure), and then keep it there. This could initially be done by stopping an activity, put in a cast, and/or up on crutches. This is how you know you have the right diagnosis and treatment plan. You should be able to increase function, with no increase in pain, month by month. Of course, if your diagnosis requires a cast or boot or surgery, you may not be able to start that progression to full function for several months. In these cases, the diagnosis is definitive from the start (verified by xray or MRI or ultrasound).
     So, that is the Right Timing of Events: Injury or Pain Development, Proper Diagnosis and Treatment, Pain Quickly Down to 0-2, and Pain Kept There as Full Function Returns. Sounds simple, but it gets messed up all the time due to the limitations on medicine listed above. And, we can add insurance issues that block both diagnosis (say inability to get MRI) and treatment (do not cover the expensive bone stimulator you need). The patient is carefully moved through the phases of rehabilitation (immobilization, re-strengthening, and return to activity) and all goes well. 
     I will give you 2 recent examples of the Wrong Timing of Events. The first was a patient that partially tore her achilles, pain level 6-7, limping. She went to the local hospital clinic, and received 3 stem cell injections one month apart as her only treatment. No cast. No driving the pain to 0-2. And, no better, so 5 months later comes to me for a second opinion. This is one of the top hospitals in the country, or so they advertise.  The second was a patient whose plantar fasciitis was improving with orthotics, taping, icing and stretching, but when she had a flare from running too much on the weekend, when the pain got to 5-6 from the 0-2, all the doctor did was put some more padding on her orthotic devices and give her a Rx for PT. This does not sound bad, but she had never had this much pain, and it took 3 weeks to see the PT for the first session (which is typically just information gathering). So, one month went by, the heel padding had made her worse, the PT really not started, and her pain from limping had increased to 6-7 levels. The doctor had a second chance to right the ship, but again the orthotics were adjusted, and taping was applied which did not help. She clearly had a severe flare of her plantar fasciitis or a new injury. After seeking a second opinion, due to the level of pain, an MRI revealed a calcaneal stress fracture, and definitive treatment started. So, when the pain you are treating gets worse, ask yourself if you still believe in your working diagnosis first, and ask how can I reduce this patients pain to 0-2. 

Friday, September 4, 2020

Bi-Partite vs Fracture in the Sesamoid Bones

Hey, I came across your site yesterday while doing some research. I have been dealing with some pain on the side of my left big toe joint since December of last year. I initially went to a local orthopedic where they x-ray both feet and they said I have bipartite sesamoid on both feet. They didn't really have any answers as to why I am experiencing pain though. I am able to run fine but and the pain is more of an annoyance than a debilitating pain. I can run for 3 hours or even do hike/runs for 6 hours and the pain doesn't get any worse. I would say the pain level is between 4-6.
Dr. Blake's comment: To most of my patients, pain levels over 2 and they are going to the doctor, and over 5 they are not running at all. 

Just walking around the pain is at a 1-2.

I recently went to a podiatrist foot and ankle specialist and he immediately said I in fact have a fractured sesamoid on my left but the right is a bipartite sesamoid.
Dr. Blake's comment: Only an MRI is conclusive, but to me they both look bi- and tri-partite with smooth borders. Sesamoids that are in multiple pieces congenitally can get irritated, even the junction between the bone fragments sprained or fractured. If you are not getting an MRI, you have to go by the amount of swelling, the level of pain, and use comparison xrays 3 months apart or so that will show a change. A broken bone will change and the xrays after 3 months will show that difference. Month to month changes will be less definitive. Unfortunately, when I have a decision between fracture and bipartite, and I can not get a definitive MRI, I treat it as a fracture with a cam walker for 3 months and I definitely do not allow my patients to go over pain level 2. 

He said I could try some custom orthotics or have surgery to remove it and that would fix the issue. Attached are images of the x-rays.
Dr. Blake's comment: To do surgery on a probable in your case non-fractured sesamoid is pretty absurd. So, custom orthotics (which should be only one of 10 things you are doing for your sesamoid to drive the pain now and let this heal: removable boot, hoka one one rocker shoes, spica taping, dancer's padding, cluffy wedges, activity modification, icing, contrast bathing, bone stimulator, and some PT to get their advice). 

If I get the surgery will I be able to run again? I am a competitive trail and ultra runner and I also race mountain bikes.
Dr. Blake's comment: Typically, unless you are the 1 in 10 that gets some complication, or has other unknown factors at play, you can run again, but the sesamoid bone will have to always be protected. Always. And this is why patients fight getting the right diagnosis and right treatment no matter how long it takes. Good luck Rich 


Monday, August 31, 2020

Thank You Dr. Jane Denton for the Denton Modification

     Today is the last day I am practicing Podiatry with Dr. Jane Denton. She says she is around for September some, but nothing is fixed. So, after asking her advice for 38 years and using her brilliant orthotic modification for lateral stability for almost 35 years, I am finally saying thank you publicly. 
     Dr. Denton's modification has improved the stability for thousands of my thankful patients. A patient of mine last week told me that the difference in a good vs great professional is only in subtleties. The Denton modification is subtle, but powerful. It has been the difference in making my orthotic devices, and overall treatment, a success in both pronators and supinators alike. It is a vital part of the Inverted Orthotic Technique for severe pronators, and a crucial element of every orthotic device designed for supinators. I am attaching a video of the orthotic components crucial for supinators, and a photo of the Denton modification.
     So, Dr Jane Denton, I personally, and the world of podiatry, thanks you anytime the Denton modification is applied to an orthotic device. It always makes a difference, sometimes big and sometimes small, but it is always helpful in treating my patients. I will miss you. Rich 

Here is the Denton applied before ground down even with the floor or base of the shoe. 

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Friday, August 28, 2020

Designing Orthotic Devices with Temporary felt support to predict Pain Relief

 The red is the outline of the orthotic device I am making for this patient. The pink is the placement of support the patient will have as a front section to the orthotic device. The patient experimented for several weeks to find the most comfortable placement utilizing the 1/8 inch adhesive felt I gave her. This will save us a lot of time in making her orthotic devices comfortable. 

Thursday, August 20, 2020

Recent Interview for Spanish Podiatry on Biomechanics I Enjoyed Doing

Here I present during a Spanish interview 3 biomechanical cases with the thought process. Rich

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Wednesday, August 19, 2020

Inverted Orthotic Technique: The Reason the Device Works Still A Mystery??

As most of you know, I inverted an orthotic device almost 40 years ago that has been very successful. It has been the only orthotic device documented to help children outgrow their flat feet for instant. Yet, it is hard for researchers to grasp why. It is meant to change motion while walking or running into less pronation. Yet, studies have had a hard time studying this. The YouTube link below and the Podiatry Arena thread following is a wonderful example of this decision. The article they are referring to was on 11 symptomatic runners who when switched from standard orthotic devices to Inverted Orthotic Devices got better. But when studied, they could not find out why. I am actually learning a ton from these discussions and have my own theories. First of all, the study was done using the outside of the heel area of the shoe to represent the heel of the foot and this can be totally off. Secondly, the Inverted Orthotic Device is made for each foot individually, with different degrees for the right and left foot. And, when the foot does not respond, a redo is done to get it as perfect as possible. This was not done with the research. All patients, both right and left feet, got the same orthotic correction. In my mind, as a research project it was a failure from the beginning. This being said, it is my life's work, and I will continue to help it along as I can.

Technique in Performing Biomechanical Tests are Crucial: Article on Achilles Evaluation

It is great that 43 years after I was taught how to properly examination the tightness of the achilles tendon, that the below article documents it is still ideal. The article also warns us about being sloppy with our examination techniques as errors can occur. Rich

Dr. Bruce Williams on Pressure Mapping

I am excited about adding pressure mapping to my practice over the next month for my patients. I will continue to treat my patients the same, and begin to collect data from them with an in-shoe pressure device. It will take me awhile to learn how my patients will benefit, but I respect Dr. Williams who was interviewed and he feels after the learning curve of a few months, the impact will be apparent. Rich

Great Article on Nerve Pain and Making the Diagnosis in Athletes

I have just starting treating a patient with 2 years of pain unable to get anywhere in treatment. She sent me this article this morning that I read from a physical therapist on nerve pain. I would have to say I agree with so much of this article, and although I am not sure yet if it applies totally to my patient, is a good discussion of the 3rd source of pain in my patient. The 3 sources of pain, each demanding separate treatments at times, are: mechanical sources (like your foot pronates too much or your hip muscles are not strong enough), inflammatory (where swelling in the tissues causes pain from injury or systemic causes), and finally nerve pain (which can be local like Morton's neuroma, referred pain from the spine, or combination of local and up-the-chain problems). 
The one aspect not discussed, and also may apply to my patient, is nerve overload with chronic symptoms. This basically means that there was a mechanical injury, that even with complete heeling, can leave you with nerve hypersensitivity, which now months later is the reason that you do not feel any better. This nerve hypersensivity can also need nerve treatments over mechanical ones. 
So, as I try to sort this all out for my patient, the body will continue giving us clues which can help if we listen. Rich

Sunday, August 16, 2020

Stage II PTTD: Email Advice

Dr. Blake --

Thanks so much for your blog, it's great.  I had a few questions I was hoping you might be willing to help me with.  Feel free to share on the blog so long as I am anonymized.

I'm in my mid-40s, am very overpronated in both feet, and have long-term PTTD in my right foot.  I used to be an active runner (many half-marathons, one full) prior to these problems.  Here's the details (all about right foot):

*  Started having ankle and arch pain (in retrospect, classic PTTD pain) in 2009.  Podiatrist believed pain related to accessory navicular.  Kidner procedure performed, hard orthotics prescribed.
Dr. Blake's comment: For the reader's benefit, the posterior tibial tendon is the most powerful tendon to support the arch. 10% of people have that tendon weakened by having an extra bone at its attachment into the navicular. This extra bone is called os navicularis, accessory navicular, or os tibial externum. The posterior tibial tendon is weakened when some of the tendon does not attach where it should to support the arch, it attaches into this extra bone. It would be like 30-40% of the achilles tendon not attaching into the heel bone, but just hanging out up the leg somewhere. 

* Generally pain-free until mid-2016.  Mild flare-ups occasionally.  Podiatrist recommended that I give up running, so I did.  I walk a lot for exercise (and still do), probably 15-20 miles per week.  I wore orthotics religiously, but my footwear was not the greatest (I loved wearing Chuck Taylors with orthotics, podiatrist said that was fine as long as I wore orthotics).

* Got new podiatrist in mid-2016.  Asked if I could try running again.  He said okay.  Started running in neutral New Balances with orthotics.  No issues for a week, then on a run felt sharp pain inside of foot and ankle.  Wore boot for a while and it got a bit better, but pain continued off-and-on for a year.
Dr. Blake's comment: With Neutral shoes, you need a lot of support from the orthotics, with stability shoes, you need less. Hard to know what did it, as it could have just been weak. You are not commenting on strengthening, but post Kidner you should be on life long posterior tibial strengthening. Simple maintenance 3 days a week. I have attached my video of the exercises. 

* MRI in 2017 showed partial PTTD tear.  Podiatrist (who is also foot/ankle surgeon) says surgery may be needed if no improvement.  Got second and third opinions in Dec. 2017/Jan. 2018 from good surgeons (including Clifford Jeng at Mercy Medical in Baltimore).  All had same general take: PTTD stage 2, surgery likely needed, FDL/MDCO.  In this timeframe, I also tried UCBLs and a Richie Brace, which I could not tolerate very well (painful).

* I have small kids, so I told doctors that I'd like to grin and bear it if I could and push off surgery until kids were older if possible.  All said fine, and who knows, it could improve on its own.
Dr. Blake's comment: That is very unlikely, but Stage 2 is not a surgical stage. See if you can get some version of the Inverted Technique for PTTD, or at least varus wedge your current orthotics. Get the Aircast PTTD Airlift Brace and learn to tape like the video below. 

* The very good news: it did improve on its own.  Been basically pain-free for almost 2 years now. 
Dr. Blake's comment: I am humbly happy I was wrong!!LOL
 Dr. Jeng recommended Brooks Beasts to me, which have been great.  I wear them or Brooks Addictions (their similar overpronation product for walking) religiously, with orthotics.  I wear a Bioskin trilok brace on right foot if I can't wear the Brooks (e.g., dress shoes).
Dr. Blake's comment: I am glad you bring this up. The Brooks Beast is an orthotic in a shoe, so when you add another orthotic, you have amazing support. The Brooks Ariel is the women's version of the Beast. 

I had a few questions,if you are willing and have time to respond.

*  As long as things continue okay, can I avoid surgery?  Dr. Jeng implied this when he told me that he doesn't do surgery on feet that don't hurt.  (Interestingly, he said that the overpronation on my left foot is as bad as the right, but it's completely asymptomatic -- this happens all the time, he said.)
Dr. Blake's comment: Usually this condition is bilateral, with one side many years in front of the other. It is a degenerative process so no one can guarantee that you remain asymptomatic. With your history, you stay in good shoes, keep strong, tape and brace when you are in over load (backpacking trip), ice when needed, and stay away from activities that put severe demands on your tendon (like downhill skiing is better then snow boarding, or running flats are better than rocky hill trails). I have many patients in Stage 2 for the last 30 years and doing great, and some progressed over 10-20 years and needed surgery. I think the flareup you had was a good lesson for you. Never treat flareups as anything but another episode that you have to rehab from. That is the mind set you have to have. 

* Any chance I can run again, trying your walk-run program? 
Dr. Blake's comment: I love to have my patients run, and the walk run program is perfect. You run every other or even every third day. You run with the Brooks Beasts, with orthotics, on level ground. I would personally not start this until you are at 2 sets of 25 Level 6 resistance bands (which will take you 6 months to get to and then maintain 3 days a week). Running is so nature to our bodies, and thus innately safe, but we can do anything too much. 

 I very much would like to run again, I miss it.  I'd wear Beasts, orthotics, and the Tri-Lok.  I am willing to risk a small chance of recurrence (10%, say), but don't want to roll the dice with a more substantial chance.  Doctors I have seen have told me not to, though I get sense some of them don't understand runners.  So, I would take your advice to not chance it (if that is your perspective) very seriously.  I'd very much like to run again, but if I am really rolling the dice on a recurrence or worse if I run again, I understand that.  (I have also been told that it's very unlikely I could ever run after FDL/MDCO anyway.)
Dr. Blake's comment: To my above comment, do the posterior tibial taping also to hedge your bet. 

* If it was not too risky to run again, are Beasts/orthotics,Tri-Lok a good strategy? SEE ABOVE

* Are you aware of any business-type shoes that might work for someone like me?  I know they probably don't sell dress shoes with support like Beasts, but something in the ballpark would be nice so I don't have to wear a brace when I have to wear business shoes.
Dr. Blake's Comment: You can take a sturdy pair of Men's dress shoes (Wright, Allen Edmond, etc) and apply a 1/8th inch varus wedge to the out sole by a cobbler. Works like a charm for PTTD
Dr. Blake's comment: Of course, they blend it in. Good luck. Rich 
I very much appreciate any thoughts you may have.  I of course will take them in the spirit offered and not as specific medical advice, because you are not my doctor and haven't seen me in person.

Thanks again for your blog and doing this for folks!


Friday, August 14, 2020

Foot Nerve Pain: Email Advice

Good afternoon,

I recently read a blog of yours pertaining to a sesamoid injury. Her questions and your answers were exactly what I am going through. It brought me to tears to finally read someone discussing my EXACT symptoms that I have been dealing with for 4.5 months. I have a few questions and some information of what I have done/currently doing.

1. I stepped on glass back in March. A small shard of glass entered my toe and came out perfectly in contact within a couple of hours. I hit a nerve in my toe apparently (or so I think) as I had immediate pain in my toe that was not in the area that the glass had entered. Due to Covid it took a while for me to get in to a doctor. For 2.5 weeks I taped my toe and walked on the ball of my foot or outside of my foot and lifted my big toe constantly. All of this was done by walking barefoot on my hardwood floors. 

2. I continued to have a change in gait for many weeks to come and continued to walk on the hardwood floors putting additional pressure on my ball of foot by lifting my toe. 

3. I have seen a total of 6 doctors, I go to PT 2x per week for ultrasound and ASTYM and strengthening, and I also do virtual meetings with Caroline Jordan out in California. I have had a few xrays done as well as an MRI. The MRI only showed some inflammation directly above the sesamoid bones.
Dr. Blake's comment: For my reader's sake, Caroline Jordan worked with another great podiatrist, Dr. Arlene Hoffman, also in San Francisco, and chronicled her healing and exercise program for a sesamoid injury. Here is a link to one of the YouTube videos.
4. I had lots of nerve pain initially with my injury. So much so that I wanted to always keep my foot elevated to help with the inflammation and keep any additional pressure off my nerves. I could barely walk into the other room or have a sheet touch my foot:

5. I now wear a Hoka bondi outside and Fresh Foam More shoes indoors. I only go barefoot in the shower. I have nerve like pain only in my sesamoid area (poking, pinching, burning) and into my big toe sometimes as well but less often then months prior. I do get a small bubble in the webbed area between my first and second toe as well as in my second joint in my big toe. My foot is sensitive to the temperate changes in the shower. I really don’t look forward to showering for this reason. I’m using ice about 10 mins a day. I take turmeric, liquid fish oil, and vitamin D supplement (after reading your blog).  I will soon be getting custom orthotics made. 

What exercises or stretches should I be doing?
Dr. Blake's comment: The treatment should be nerve focused. Nerve love motion, ice 5 minutes only, and warm compresses more. Nerves therefore love neural flossing or simple range of motion of the toe and ankle, but no prolonged stretches. Nerves do not like pressure, so make sure that the orthotics off weight the area. Nerves love massage, if it is non painful, so use Neuro Eze or Neuro One to massage 3-4 times a day. Both over the counter products. 

Is nerve pain normal with sesamoiditis?
Dr. Blake's comment: The nerves are superhighways to your brain, that is why they unconsciously force us into mega protection mode. You injured the nerve twice that runs from your toe to your sesamoid (same nerve I suspect). First, you traumatized with glass, and secondly, you traumatized it by either holding your big toe in the air, or walking on the nerve under the sesamoid. Luckily you should have been walking slow enough not to injure the sesamoid badly (alittle maybe??)

Are there any sandals that are okay to wear for short periods of time?
Dr. Blake's comment: Oofos sandals would be my best bet now due to the softness. 

I know healing time periods vary, but does there seem to be an average amount of time?
Dr. Blake's comment: The mantra I use is "Look at a nerve funny, and it hurts for nine months". You are 5 months along, and you are improving. The reason you wrote (I read between lines sometimes) is that you do not want to have a setback and start over again. 

What can I do for the nerve pain in the mean time as I heal?
Dr. Blake's comment: Start with the above, and when they are all in place, you can add other nerve treatments if your symptoms warrant: flossing, massage with topical, warm or ice, off weight with orthotics or gel pads, soft sandals, and no prolonged pressure or stretching. Keep me in the loop, and I will try to answer. Rich 

Thank you so very much for posting! This has been one of the most emotional times in my life and have felt quite alone until coming across blogs posted by kind people such as yourself. 

Kind regards

Tuesday, August 11, 2020

Foot Nerve Pain: Where does it come from?

Hi Dr. Blake,

I have enjoyed reading your blog and felt inclined to send in a question regarding my foot pain.

I developed a lot of pain right under my big toe in my left foot (not in the ball of the foot, but the underside of the toe itself) about a year and a half ago. The pain had first started cropping up with rock climbing and got progressively worse over time. I got a cortisone shot from a podiatrist that did not help at all and I could barely walk (was in a boot/using a knee scooter) for several months. I ended up having 2 more cortisone shots in that toe over the course of the next year (the 2nd two shots did help, they were from a different doctor than the first time and spaced 4 months apart). I had improved to the point that I was able to do my day to day activities, but still could only walk for about 10 minutes at a time without causing a flare up of pain. 
Dr. Blake's comment: Do you know what he was injecting? Ligament, joint, nerve?

At the one year mark, my right big toe started experiencing the same symptoms and the bulk of the pain simply switched over to my right foot. My left toe stopped bothering me and my right toe became the problem.
Dr. Blake's comment: The only explanation was a nerve problem from your back. The position of your toe in rock climbing put to much tension on the local nerve. This same nerve, typically originating from L3/L4 or L4/L5 nerve roots in the back, was painful due to double crush. This means the nerve is being irritated at the foot and back combined. A slight change in your spine would make the symptoms jump to the other foot. That can could be from limping or protecting for a year, or a primary back problem. 

I limped around and tried to manage it with anti-inflamatories for 3 months before deciding to get a cortisone shot in my right big toe. As soon as I got the shot, I had a TON of pain in the ball of my foot closer to my 3rd and 4th toes (probably an inch below the base of my toes). The doctor I was seeing at the time diagnosed it as a morton's neuroma.
Dr. Blake's comment: Cortisone is for inflammation, which many times there is none. Cortisone if injected into the nerve, a superhighway in your foot and leg, can cause pain in many nerves. Morton's neuromas take many years to develop. 

The big toe pain either went away from the cortisone shot or was masked temporarily, and this new pain in the ball of my foot became the main problem. It pretty much made it so that I could not walk for more than 1-2 minutes here and there to get around my house. It also became painful to drive. I felt some relief by using a metatarsal pad to offload the area, but was still in pain. After 2 months, the big toe pain started returning and it would just depend on the day what would hurt more, the toe or the ball of my foot. My guess is that whatever help the cortisone was giving had worn off. 
Dr. Blake's comment: Yes, but cortisone is not a predictable way of helping nerve pain, so please limit. 

I began seeing a new doctor who ordered an MRI. The MRI showed a "stress reaction" in my big toe, but did not show much for the ball of the foot problem. My new doctor advised me to take a vitamin D supplement and to immobilize the toe for a month in a walking boot. After the month was up, my big toe felt a lot better, but I still had pain in the ball of my foot. 
Dr. Blake's comment: It is hard to know if the boot helped the stress reaction, or just not moving the toe helped you not to irritate the nerve. Did you ever have an MRI of the left? 
The new doctor diagnosed it as "metatarsalgia". He said it was possible that it could be a neuroma, but it was unclear from my symptoms. He gave me a steroid injection from the top of my foot down in the 3rd-4th webspace. This definitely helped and the ball of my foot feel much better. HOWEVER, I now have a similar pain in the ball of my left foot (sort of below 3rd and 4th toe or 4th-5th...hard to pinpoint). I again am unsure if this new pain is metatarsalgia, morton's neuroma or something else. It is worse some days than others. Offloading with a metatarsal pad helps. My doctor has prescribed 6-8 weeks of physical therapy so I am planning to try that next. 
Dr. Blake's comment: You are making me a little dizzy!! LOL Only irritable nerves behave like this. Has your back or any other part of your spine, up to your neck, been an issue in the past? 

My questions for you are: 
What advice do you have to finally kick this pain? I feel like I'm playing a game of whack a mole....when one problem improves another one always seems to pop up!
Dr. Blake's comment: The problem with this is probably not finding the true source of the nerve issues. All of the pain would have to be primarily from the low back or higher. That would make the foot nerves sensitive, and as you favor one problem you then set off the other side. At least, this is the most common cause. I do like the "mole game" analogy. Research in your area PTs that are in the national neurologic physical therapy association as these peripheral nerves are not so mysterious to them. I am glad the cortisone is calming things down locally. 

Do you think my ball of foot pain is morton's neuroma? 
Dr. Blake's comment: No! You can have morton's neuromas that have never bothered you, and normally never will, unless something like this happens. Morton's neuroma has a surgical side that I would avoid thinking about. Typically, it is merely a local neuritis that the cortisone great for. So, I would call this neuritis over neuroma from now on. Yes, I am opinionated!!
Nerve problems present 1/3 of the time as pain (you, unfortunately). 1/3 of the time as a mixture of pain and numbness. And, 1/3 of the time as numbness with funny feels of transient burning, bugs crawling around, tingling, vibration. The more pain involved, the more treatment, even though these scenarios present with the same pathology. Sad!

What do you think is the best way to heal the ball of foot pain that I have described?
Dr. Blake's comment: So, I would use 5 minute ice soaks, if tolerated, several times daily. I would get a pair of Hoka One One shoes or other stiff shoes that your toes do not bend alot. I would have the advice of a PT and Physiatrist about your back and peripheral nerve sensations. If someone agrees that you trust, then trying to calm the nerves down with topical medications like Neuro Eze, Lidoderm patches, TENS units, oral medications. Sometimes we are icing the back, and using warm water soaks for the foot. Find what predictably helps some, and stick with it for 3-6 months to slow down this roller coaster. The met pads seem to help for one so that should be part of your treatment. Come up with 5-7 times over the next month that have some positive affect. I hope this helps some. Rich 

Thanks so much!

Monday, August 10, 2020

Why Do I Watch Someone Walk?

My whole practice of Podiatry has gait evaluation as its foundation. I found this wonderful video last night on the components of gait, when things are right and when things are wrong. The happiness of a Podiatrist is somehow tied to the number of hours spent watching patients year after year walking and running. The happiness comes from truly helping patients with shoe selection, inserts, gait re-training, muscle stretching and strengthening, etc, all tied to injuries and preventing the same injury reoccurring year after year. Gait Evaluation can point to the Root of the problem, or at least one of its components.

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Sunday, August 9, 2020

Shin Splint Discussion: Part III

This is Part III of a discussion on Shin Splints. The links to Part I and II are attached. Here we will talk about treatments when the pain is all in the leg. Even though this discussion is geared for the podiatrist, patients can get a favor of what is important in their treatment.

Common Mechanical Changes for Shin Splints

  1. Strengthening of Involved Muscle Group

  2. Stretching of the Involved Muscle Group

  3. Reducing the Suspected Pronation or Supination Tendencies

  4. Stretching the Achilles Complex

  5. Strengthening the Achilles Complex

  6. Custom Orthotic Devices particularly for Forefoot to Rearfoot Alignment Issues Involved

  7. Training Decisions

  8. Consideration of Bone Involvement

Strengthening of Involved Muscle Group is crucial in all 4 types of Shin Splints.

What is important is good muscle testing principles and you will need to learn

how to differentiate the muscles in each group. It is well taught how to

differentiate testing of the gastrocnemius (knee straight) and soleus

(knee bent) in the posterior group with the other groups *equally

challenging. It is important to know if it is the posterior tibial,

flexor hallucis longus,or flexor digitorum longus giving the medial ankle

pain. Or, if it is the peroneus longus or brevis that hurts when testing against

resistance the lateral compartment. Or, if it is the anterior tibial or another

one of the extensors producing the anterior shin splint. 

Stretching of the Involved Muscle Group is typically only done for the

anterior or posterior muscle/tendon groups. You should know the general

rules for stretching,but remember stretching should never hurt or the tightness

actually gets worse. I recommend stretching an involved group 3 times a day

so I can get to 100 stretches within a month for my next followup visit

generally. It typically takes stretching 3 times a day to gain.

Reducing the Suspected Pronation or Supination Tendencies with varus

or valgus wedges, taping, arch supports, shoe changes, custom orthotics,

and strengthening exercises occurs when youthink the pronation or supination

observed in gait or activity is related to the type of shin splint. 

Stretching the Achilles Complex is vital to most sports injuries when

there is equinus forces. However, it is so important to be able to reliably

measure for this equinus because over stretching a normal or hyper flexible

achilles tendon will do more harm than good. Tight achilles has been known

to be involved in all 4 shin splint types. 

Strengthening the Achilles Complex is vital when the achilles is weak.

The acid test for normal achilles strength is 25 single leg heel raises with

the knee straight (gastrocnemius) and 12 single leg heel raises with the knee

bent (soleus). These are typically done in the evening. 

Custom Orthotic Devices particularly for Forefoot to Rearfoot Alignment

Issues Involved is your classic Root design. Doctors not trained in Root

biomechanics tend to use more metatarsal pads and anterior orthotic bars and

posts, and combinations of all may be needed. Not only is forefoot support great

for the correction of pronation or supination tendencies, the metatarsal support

provided can be crucial for long flexor or extensor produced medial or anterior

shin splints. 

Training Decisions for shin splints is universally to lighten the load on the

injured tissue. And for those athletes who seek treatment, the chance of a

stress fracture is high. The runner must cross train with biking as the

mainstay alternative. Since both hill work and speed work are more stressful,

slow distance training is the first goal to accomplish. Each sport involved

will have different strategies at lightening the stress first, and then

gradually re-introducing these same stresses. 

Consideration of Bone Involvement is very important in shin splints.

There are yearly reported cases of compound fractures in runners ignoring

the shin splint symptoms only to have the stress fracture become a through

and through fracture. I have had 27 year olds with shin splints have the bone

density of 80 year olds. It is important to remember Shin Splints can be bone

pain primarily, and verifying the patient has good bone health is crucial.