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Tuesday, January 19, 2021

Sesamoid Fracture: Email Advice

Hello, Dr. Blake! 

I was diagnosed with a sesamoid fracture on Nov. 18th, 2020. Throughout the two months, I have been wearing a walking boot and supplementing calcium, vitamin D, and taking a multivitamin. After two x-rays over the last two months, my doctor told me that there has been minimal healing. 
Dr. Blake's comment: Xray show only solid bone, and most of the initial fracture healing is with new skeletally immature bone that shows poorly on x-ray. Therefore, most agree that x-rays lag 1-2 months behind actual healing. Said in English, if an x-ray shows good healing in March, the bone was probably healed enough in February and probably January. So, minimal healing noted on x-ray is not really the whole story. MRIs are better for fracture identification, when x-rays are inconclusive, but you have to wait 6 months to the validation of some healing. I do x-ray for that information, and I get an MRI for that information, and I treat the sesamoid fracture and the patient based on getting them to be at 0-2 pain level as quickly as possible and then maintaining them at that level for 3 months. 

At my last visit, Jan. 14th, 2021, he felt around my foot and I didn't feel any pain (although he was very gentle). He instructed me to wear regular shoes, and ditch the walking boot so long as there is no pain. He told me to try exercising, but avoid inclines and do not run. If I continue with no pain, then he said it is okay if I go about my life with the bone still fractured. If I experience pain, he plans to take an MRI of my foot on Feb. 10th to see if he needs to remove the sesamoid bone. 
Dr. Blake's comment: I hope you just mis-understood. Continue to wear the boot until 2/18, and if you have taken it off before you read this, add a few more weeks so you can say you wore the boot for 3 months. It takes a year or more to know whether you need surgery. I am assuming that the pain in the 0-2 range while you are in the boot. Between now, and the time you are getting out of the boot, you need to have protective orthotics with dancer's pads to off weight the sesamoids, typically Hoka One One shoes are used due to their rocker. The transition from full time boot to full time out of the boot may take 2-6 weeks on average since pain level has to be your guide. 

It was May 2019 when I originally injured the bone. I noticed the pain when I had finished my third day in a row of working in the same pair of shoes (Chacos, not yet fully broken in). After a few days, the pain subsided for the most part. After several months of sporadic pain, I got an x-ray at a walk-in clinic, and they told me that nothing was wrong. After training for and running a marathon, I finally went to a foot doctor who then found the fracture using x-rays. Throughout the year or so of pain, it was never as painful as the first 24 hours of when it was originally injured. 
Dr. Blake's comment: This is great. Hopefully, the injury, while frustrating will not prove very serious when you get the MRI. You could have a normal bone that lies in multiple pieces that was fractured slightly last May, but now needs a little help to finish the healing. If there is swelling in the tissues, or seen on MRI, then contrast bathing to flush the bone and create better circulation should be done close to every night. 

To be honest, I am afraid of taking my doctor's advice of potentially living the rest of my life with the fracture in my foot. I read on your blog that it takes 2 years in some cases to heal the sesamoid bone, and it is rare that the bone does not heal. I do not want the bone to be removed; I fear the side effects of surgery may be worse than simply living with the fractured foot. Dr. Blake's comment: Yes, you will not live with a broken down. You are too smart for that. You may need an Exogen bone stimulator to help, along with spica taping, cluffy wedges, great off loading orthotics, Dr. Jills Gel Dancer's Padding, etc. 

My purpose in writing to you is to get a second opinion on my doctor's plan for my sesamoid fracture. In the meantime, I plan to wear stiff shoes and use dancer pads to keep the weight off my sesamoids in both feet. I use heat and ice on my foot as well when the swelling feels worse. 

Thank you so much for being the doctor we all need in our lives. I appreciate that you take the time to listen to people and give thorough advice. 

I hope this email finds you well. Dr. Blake's Comment: You are welcome, and good luck Rich 

Sunday, January 17, 2021

Sesamoid Fracture to Return to Activity: Email Advice for 12 Year Old

Hi Dr. Blake,
I found your information awhile ago when I was researching online about my daughter’s  sesamoid fractures and sesamoiditis. I feel like you know so much about this condition and I was wondering if I could run our situation by you and see if there is anything we are missing or should be doing. We also had an online appt with Caroline Jordan to get some ideas about dealing with a sesamoid injury.

Here is my daughter’s situation - again any advice or thoughts you have are greatly appreciated.

My daughter is 12 years old and plays soccer. I will give you what happened month by month starting in November 2019 until now January 2021. It helps me to keep organized with how everything has gone.

November 2019
-She starting to complain of foot pain toward the end of Fall Soccer season. She had some pain in both feet but more on the right foot. She also had some knee pain. The pain would come and go and did not impact her playing. I knew that she would be getting a good 6 week break from end of November to beginning of January and made an appt with a sports podiatrist that my friend knows and this physician is involved with the podiatry care of a professional football team and seems to have a lot of experience.
Dr. Blake's comment: This was the perfect thinking. 

December 2019
-Had her appointment with the sports
podiatrist and based on the way her foot hits the ground and her mechanics it was recommended to get custom orthotics. She was fitted for the orthotics. She was on break from playing soccer.
-She was given a sort of temporary insert to put in her sneaker and cleat to try to help until her real orthotics came in
Dr. Blake's comment: Also the right idea to try to distribute the weight differently while in the soccer cleat and any training with other shoes. 

January 2020
-She went back to off season training. Her feet and knees were feeling better from the rest. Also, the off season training was 30-50% of the usual fall soccer training, so she was getting more rest days and it was less intense. 
-At the end of the month, her orthotics came in and we also started to find a cleat that would fit the orthotic. 
Dr. Blake's comment: The only thing I would of added is daily icing to cool down any inflammation that had collected during soccer. Inflammation can tend to be stubborn and outlive the periods of rest so it is still there when you return to sports. 

February 2020
-During an outdoor soccer practice, she felt a pop in her right foot when she was making a cutting type of move. She then felt pain. She was still able to finish up practice. At this point we had a follow up appt in one week at the sports podiatrist. Things were very hectic that week and we iced her feet and took that week off from practicing and her feet were feeling better.That weekend though she had 2 futsal games and felt well enough to play. 
Dr. Blake's comment: Some patients pop, snap and crackle alot when there is some inflammation. The fact that she felt well enough to play, and I assume not limp, was still okay. 
-After the 2 futsal games she could not really walk in her feet. Our follow up appt at the sports podiatrist was a few days later and the x-rays revealed 3 fractures in the one of the sesamoids in the right foot. She was put in a boot. No soccer and no exercise.
Dr. Blake's comment: So, this does not sound good, but because sesamoids can be normally in multiple pieces, and MRI has to be ordered to confirm. You also have to treat the worse case scenario which is a fracture of the sesamoid appropriately. I found 3 months in the boot is great for healing. 

March 2020
-Still in a boot
-Follow up appointment was moved back so to lockdown with Covid
Dr. Blake's comment: When a patient goes into the boot, it is to rest the tissue. The pain level in the boot has to be 0-2 for those 3 months. Caroline Jordan's video has alot of exercises you can do to keep strong. Do not do anything that makes the pain increase. 

April 2020
-Was able to get 2 telehealth appts 
-Continuing to wear boot and then toward end of April could start to stop wearing boot.
-Left foot started to hurt but not as bad.
Dr. Blake's comment: While in the boot, if you have been successful at achieving the 0-2 pain level, most podiatrists will start the gradual wean out into shoes and orthotic devices at the 2 to 2 and 1/2 month level. This is fine for some patients and at least rushed for some patients. The doctor always wants to look like a hero in the patient's eyes, but sometimes the patient/parents can be unconsciously making the doctor feel pushed to get out of the cast. This is why I keep my recommendation at 0-2 pain level, and tell the patient that we do not want to start over. 

May 2020
-Some pain still
-got an in-person appt toward the end of month
-x-rays revealed 3 fractures of sesamoid on both the right and left foot. 
-fitted for thick rehab orthotics
-plan is to be out of soccer until Spring 2021 season
-offload feet
Dr. Blake's comment: I am so sure that this was terrible news. However, it is close to impossible to get this scenario. Three fractures on both feet. #1 cause is bilateral tri-partite congenital sesamoids (that got injured). I want an MRI on both feet to know more. 

June 2020
-rehab orthotics came in
-wear rehab orthotics
-off load feet
Dr Blake's comment: I am assuming off load means dancer's padding. 

July 2020
-continue rehab orthotics
-mentally feeling very sad about not being able to play
Dr. Blake's comment: Between the Pandemic and this injury, she must have been very sad

August 2020
-continue rehab orthotics
-appointment with Caroline Jordan to see about how to deal with this injury
-started Physical Therapy - working on strengthening overall body while still offloading foot
Dr. Blake's comment: I am so thankful for Caroline. This is the appropriate approach, limit weight bearing, maintain 0-2 pain levels, get cardio and core and lower extremity strength work. I have not mentioned, but get a Vitamin D level to see if she isn't low which could make it hard for bones to heal. Also, remember the 3 sources of pain. Especially after 3 months of an injury, it seems like all 3 can be important to deal with. You are using mechanically treatments, so make sure that you are icing for the inflammation daily, and add one of the nerve treatments like non-painful massage to the area for 2 minutes twice daily. 

September 2020
-continuing Physical Therapy offloading foot and rehab orthotics

October 2020
-X-Rays reveal Right Sesamoid fractures almost healed and Left Sesamoid fractures improving
-Continuing Rehab Orthotics and Physical Therapy offloading feet
Dr. Blake's comment: So, bi- and tri-partite (2 or 3 pieces) congenitally separated sesamoids never start healing. There is no reason to. So, we can assume from this that she had the misfortune of having a rare bone injury. I still want the MRI and now I definitely want to know about her bone health. Also, she sesamoid fractures can be due to hard ground and soccer spikes overloading her bones, was she in a spiked cleat with one of the spikes under the sesamoids. 

November 2020
-Continue Rehab Orthotics and Physical Therapy offloading feet

December 2020
-X-Rays reveal both Right and Left Sesamoid fractures clinically healed
-Physical therapy begins to gradually increase loading feet in small increments
Dr. Blake's comments: Great news, but they can be healed, but very weak due to the off loading. The progression has to be gradual from here, and I wish that there were never any time limit (like unfortunately an upcoming soccer season). So important to not have the pain over 0-2, except for an occasional transitory jab of pain. The coaches and parents have to watch her like a hawk for any limping. Of course, you have to assume it is only 80% healed as you move forward, with ice after sports drills, and no NSAIDs at all which slow down bone healing. 

January 2020
-Physical Therapy continues to increase loading feet and moving towards integrating soccer 
-Physical Therapist and Soccer Coach talk and agree on plan to gradually work on in corporations her back into off season practice drills
-fitted for sports orthotics to fit in cleats
-finding appropriate cleats to wear with sports orthotics
Dr. Blake's comment: This is all perfect. Remember, if there is any increase in pain with practice, she can not participate again until it is back down to baseline (0-2). Some patients are restricted to light drills for awhile every other or every third day. 

So far, she has been to 3 off season practices / her pain level has ranged between a 0-7. Is this normal? Should we get an MRI? What do you suggest we do?
Dr. Blake's comment: This is where the timing of the pain is necessary to advise you. What is the baseline pain during the day? What pain level during weight bearing activities? What is her pain after practice? Is there any swelling or redness? When her pain is over 2, what is she doing? These and any others will be added to this post.  I hope some of my thought process helped. Yes, an MRI of both feet would be great, but you may not need at all now. Since we have both feet supposed with three fractures each, you should answer individually for each foot. Rich 
I really appreciate any thoughts you have on her case.


The Mom’s response to my questions:

Hi Dr. Blake,

Thank you! Here are the answers to the questions and I have a thought of what might be going on and wanted to see what you think. Everything you mentioned makes sense. I am sorry for the long email. My wheels are turning about a few thoughts I have about what is going on.

Here are our answers, comments, and questions:

1. We are not nearly icing enough. Alicia does not regularly ice. How much should she ice at this point? Should it be done automatically on a schedule or just when she feels pain?
Dr. Blake’s comment: The problem for most patients is that they only do it for pain, instead of trying to avoid the pain of inflammation. Icing a small superficial bone like the sesamoid is maximum 10 minutes, after every time she does anything that could make it hurt (like weight bearing drills), and 3 times a day for now. You never ice before a workout  up to one hour. An ice pack reusable is preferable. 

2. Would our doctor know at this point if the sesamoids were definitely bilateral tri-partite or actually fractures? So if the pieces of the sesamoids merge together it would show healed fractures? I remember our doctor saying he was not sure at first if her sesamoids were naturally in 2 pieces and that some people are born that way. Dr. Blake’s comment: Unfortunately there is no definite here. It is a good sign that the sesamoids showed healing since congenital bi- and tri-partite sesamoids always look broken. It is academic now if she goes back to full activity. However, an MRI should be ordered if you hit a plateau on the healing. 

3. When I keep mentioning offloading I mean to not put more on her feet - she could just do a regular day to day getting around, but no additional weight bearing exercises on her feet. I am not sure if I am using that word correctly. We have never used a dancer’s pad and I am not sure I know what it is. Is it like a cushion you can stick on your foot or in a shoe to kind of act like an orthotic? Dr. Blake’s comment:
See how the dancer’s padding floats the big toe joint

Get Dr. Jill’s Dancer’s padding both right and left and both sizes: 1/8th inch and 1/4 inch. These usually take alittle effort finding the right position for their hole, and discovering which side you need. These however only supplement the dancer’s pad built into the orthotic device, or can be attached later. I will try to show one below that is simply added to the shoe insert. 

4. She did get her Vitamin D Levels checked in August 2020 for her bloodwork for her well visit and her Vitamin D levels were normal.
Dr. Blake’s comment: With Vitamin D, I always want to know the value and the normal range for the lab she got it!! Very important that athletes function at the middle of that range, not at the low end of normal. 

5. How do you do the nerve treatment of non-painful massage? Do patients do it thenselves? I know that the physical therapist did more of that in the beginning of physical therapy. He also did cupping on the sesamoid area, which he could not give definite feedback that it was really doing something, but he has had positive feedback from his patients. My daughter says that cupping makes her feet feet feel better, but they are doing it less and less now. Dr. Blake’s comment: Sorry, I have no experience with cupping for a sesamoid injury. Does not make sense to me, but having no experience really does not qualify me to comment. Neuropathic treatment for right now is just her taking the palm of her hands and some hand or face lotion and massaging the area for 2 minutes. As long as the area does not hurt, the biofeedback to the brain is that she is fine and the sometimes hyper sensitive nerves in the area relax. 

6. I remember that our doctor did not want to bring her mood down because she was already so upset. He told me when she was not in the room and after the x-rays showed healing that he was so happy her x-rays showed healing because this was a bad injury. 
Dr. Blake’s comment: Sounds like a very deceit human being!!

7, Our doctor also told me that the reason these fractures happened was due to the way her foot hits the ground when she runs and that this sesamoid area was receiving so much more grinding every time she runs that it was just a matter of time that fractures were going to happen. My understanding was that the only way we could have avoided this was get her into orthodics as soon as she started to play sports when she was little. He also mentioned that basically we have to protect her from herself - meaning her mechanics and structure was causing this so we need to use orthodics, correct footwear, adding more rest days, going by what her feet feel like. That she is going to be the player that will be icing more, stretching more, may need to take days where she watches practices because her feet need to rest, that she may need to do other forms of cardio like biking instead of more running to balance her feet and she may have to plan her activities to make sure she is giving herself the best options to play.
Dr. Blake’s comment: Sounds incredible!! A very good plan moving forward. 

8. She was wearing cleats with the spike under the sesamoid. I am finding most cleats have a spike in that area - is there any cleats that do not have that spike there? Our doctor wanted her to start with turf shoes. We got her both cleats and turf shoes. She said that the turf shoes are not comfortable at all and her feet feel worse and feels like she cannot move the way she wants to. Both of the cleats and turf shoes are able to fit her rehab orthotics. Dr Blake’s comment: I usually remove one half of the cleat at the start. This is a cleat related problem for sure. The turf shoes is a good idea, but dancer’s padding is needed. If you remove half of the cleat under the sesamoid, and spend some time in practice in the turf shoes, she will be having a lot less stress on the sesamoids. 

9. Here are pain levels and when:
Just relaxing or doing things at home - 0-3
Soccer and Running - can go up to 7 Dr. Blake’s comment: (this is where the sesamoid is still being overloaded)
If it goes up to 5-7 it may last 1-2 hours after practice. It is back to 0-2 when she wakes up the next morning, Dr. Blake’s comment: This is a great sign!! More icing after practice, 2 hours later, and right before bed. She can try icing for 20 minutes 2 hours before practice to see how she does. 
The 7 pain level had been when using her regular sneakers with the rehab orthodic during the indoor practice on a kind of turf rug. They cannot wear cleats in the indoor places where they are training. Dr. Blake’s comment: Here she is most vulnerable. She may need in this environment the addition of Dr. Jills Gel Dancer’s Padding, spica’s taping and cluffy wedges (which are all in my blog—use the search area). She may also need to change the orthotics or shoes. 
She says she feels her rehab orthodics shift in her sneakers when she is doing soccer moves. Dr. Blake’s comment: Probably have to be redone full width of the sneaker (can send the lab the sneaker insert). If the lab is redoing for more width, have the doctor decide if more arch and more dancer’s padding (called Reverse Morton’s Extension) can be added. 
She says the cleats with the orthodics feel better than when she is exercising in her sneakers with the rehab orthotics. Dr. Blake’s comment: It is always good that one mechanical environment actually feels better than another. This means mechanical changes can help. Something has to be done to the other environment to make them equal. 
This is only for the right foot. She says her left foot has been fine. Dr. Blake’s comment: Hooray!! However, unless there is a reason, whatever you do to the right at least half should be done on the left for balance. 1/4 inch dancer’s padding right should be balanced by 1/8 inch dancers padding left. 
She has never noticed any swelling or redness in either feet. Dr. Blake’s comment: When dealing with sesamoid fractures, they should produce an inflammatory response. Did anyone ever comment on any swelling in this process? 
She also told me that her rehab orthodics in her sneakers used to feel better when she first got them. Dr. Blake’s comment: This needs to be investigated. 

10. She walks barefoot in the house - she says it is more comfortable. Is this ok to do? Dr Blake’s comment: Get some Oofos sandals for the house to protect these feet.

11. Could this be what could be causing the problems right now in practice or aggravating things:
- if her Rehab Orthodics are shifting when she is trying to do indoor training - could it be not off loading due to bumping into the sesamoid area? Correct
- is the reason she is doing a little better with the cleats outdoors is because the cleats are new and holding the rehab orthodics in place more so they are doing their job better off loading? Correct, and the ground gives more!!
- the x-rays show she is still growing - if her feet grew a little could the sesamoid area of the orthodic not be in the right place and not off loading like it should? Typically dancer’s padding that float the sesamoids are pretty big. However, do the lipstick test for me. Put a little lipstick (any shade will do!!LOL) on a que tip (sp??) and mark the exact spot she hurts. Then place her foot into the shoe and see where the mark ends up as far towards the toes. Ignore any smug mark getting the lipstick mark in the shoe. This will tell you exactly where to put the dancer’s padding to protect the sesamoid. You can of course due this better if you remove all the laces. 
- she just got fitted for sports orthodics but maybe if her feet grew she is going to need a mew pair of rehab orthodics as well. 
- is this just too much too soon - should she be taking the steps to get back more slowly?
Dr. Blake’s comment: This is a busy time in the rehabilitation and getting the pain down to 0-2 for all activities is ideal. I do not want these 3-7 pain levels at all. You may have to step back from those activities until orthotics are changed, you shave the spike, you learn to spica tape, you ice more, you learn cluffy wedges, etc. 
- should she hold off on soccer practice or monitored running at physical therapy until it is determine if she did grow and the orthodics are shifting or that the shoes are a little looser from wearing them for a number of months and making the orthodics shift? Do the lipstick test, get the orthotics wider, add the dancer’s pads, etc. 
- with the sesamoid area on the orthodics - do you need to be more vigilant about making sure that she has not grown and moved out of that sesamoid off loading area?
-should I push to get an MRI at this point? Dr. Blake’s comment: I am not sure what the MRI would tell us over the above discussion. However, in treating sesamoids, I always tell patients when they get an MRI it is there first of at least 2. The second one is 6 months down the line to check healing. We can assume good healing now and that the right biomechanics and inflammatory and neuropathic treatments are not yet in place. If you get them in place, and you still can not keep the pain between 0-2, MRI is completely indicated. I sure hope this has been helpful. Rich 

Again thank you so much! 

Thursday, January 14, 2021

Big Toe Non Union of a Fracture: Email Advice

Hello Dr. Blake, 

I broke my big toe 6 months ago by 1st proximal phalanx. 

It wasn’t too painful. While it was ‘healing’ I developed pain under my big toe which I thought was pain from the break. It turns out I developed sesamoiditis. 

Also my toe is now a healed nonunion. I have been significantly impacted with pain most of the time. Walking even short distances was almost impossible for a while. 

Even now it almost always hurts some to walk at all. I had a boot for 2 weeks at 3.5 months. I am getting PT which seems to help with general pain in toes but not pain on bottom of foot. 

I was able to snowshoe on soft snow but hard ground is painful. I can swim with some pain and can’t push off wall with that foot. Biking hurts some. MRI showed no fracture or inflammation of sesamoids which presumably means tendinitis or capsulitis.

 I have arthritis which I had before break but it wasn’t painful. MRI 3 months ago shows inflammation under 1st metatarsal area. Tight shoes make pain worse even if soft. Touching spot on bottom of foot with shoes or ground hurts.  I am also now getting similar but less pain in other foot. I have a bone stimulator for toe now. 

Is it possible to get better? Is cortisone a bad idea? If it hurts so badly wouldn’t that mean the bones are sore? Is there any treatment for tendons if that is it? Do ultrasound or other treatments work? What should I ask my doctor at this point?

Thanks for ideas.

Dr. Blake's comment:

     So sorry to hear! A non union of the big toe typically requires surgery! Has this been offered? The bone stim is great but the toe has to be completely immobilized for 3-6 months while the bone is trying to heal! Typically any tendinitis or sesamoiditis is secondary to abnormal gait from the nonunion. So, do the best to heal the non-union or have the non-union surgically pinned. Hope this helps and I hope I understood the situation adequately. And, cortisone could help the joint capsulitis, but not good for bones trying to heal. Rich

Wednesday, January 13, 2021

Varus Wedging: A Simple but Powerful Means of Seeing if Correcting Pronation will Help An Area Painful

     Many of my patients not only come into the office with foot and ankle injuries (my speciality), but want to know if I can help their back, hips, knees, shins, etc. I start the process by watching them walk, and run if they are a runner. I try to correlate their symptoms with gait problems seen (like over pronation, over supination (aka under pronation), short leg syndrome, tight or weak muscles, and other instabilities. If the patient presents with over pronation, and has symptoms that even can be loosely tied to that motion, I prefer to use a varus wedge of 1/8 or 1/4 inch to see if removing some of the pronation will help them. You can apply the varus wedge (here I am using 1/4 inch rubber cork from JMS Plastics) to any insole, here the patient had a blue Superfeet insole. The wedge can be heel only, orthotic length only, or full length, all depending on the location of the motion (contact phase, midstance phase, or propulsive phase).
If the pronation is only at heel strike (contact phase), then a heel wedge may be all you need. If the pronation is during midstance, then an orthotic length wedge is normally used. And, if the pronation is during the propulsive phase (or in a runner's forefoot strike pattern), the wedge has to go out to the toes. 
The photo above shows the bottom of the right orthotic (on the left of the photo) with an orthotic length varus wedge of 1/4 inch, and the bottom of the left orthotic (on the right of the photo) with a full length 1/4 inch varus wedge. I love to tell my patients that sometimes this wedges are more important than an MRI of the involved area as success in reducing symptoms can help with long term treatment. 

Tuesday, January 12, 2021

Repost: General Advice for Patients with Foot Pain or Numbness Related to Nerves

Dear Dr. Richard,

I live in London, U.K. My job is in I.T. - so desk based all day.

I came across your blog today, looks very informative. I actually saw the video where you talked about pain around the heel possibly due to back issues.

Please, could you provide some advice to me? 

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

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

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

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

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

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

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

See if Lidoderm patches can be prescribed for a month trial. Begin 3 weeks experiments of the supplements that help nerve pain. 
1.      Lipoic Acid 300mg 2x/day
2.      Acetyl-L-Carnitine 2000 mg/day
3.      Inositol 500-1000mg/day
4.      Vit B6 50mg/day
5.      Vit B12 1000mcg/day
6.      Vit E (up to 1,600units/day)
7.      Thyroid Natural Supplements

Diet for Nerve Pain

Here was the advice I gave to another patient:

 Nerve Pain is helped by some combination of the following (many of these topics are in the blog already):
  • Neural Flossing three times daily (find out if sitting or laying techniques more productive)
  • Nerve Pain supplements like B12, Vit C, (gradually you add one per month to check effectiveness so you would wait on this right now) etc 
  • Some topical nerve cream applied 4 times daily (NeuroEze or Rx)
  • Heat over ice
  • No sciatic nerve/calf stretching (find out everything postural wise that is tasking your sciatic nerve from beds, sitting chairs, standing habits, workout techniques). 
  • Oral meds (start with evening doses only of Lyrica, Neurontin, or Cymbalta). 
  • Epidural injections into the L5 nerve root
  • Soft based orthotic devices like Hannafords
  • See if there is a Calmare Pain Therapy center near you 
  • Sometimes TENS and Capsaicin is helpful (but you have to go through 14-20 days of more pain first)
Hope this points you in the right direction. Rich

Monday, January 11, 2021

Stretching Principle #3: No Bouncing!!

•#3    Do not bounce while stretching, hold steady.

The third stretching principle I would want all of my patient doing was to hold the stretch steady and not bounce or move in any way. We have talked about holding the stretch for 30-60 seconds (Principle #1). It is also to important when doing 2 or 3 sets to alternate between the sides right and left (Principle #2). Therefore, stretching should be relaxing, non hurried, and gentle to the body. These principles can be applied to any stretch you perform, and I have individual examples of problems when these rules are broken. I usually have my patients demonstrate how they stretch and I look to see if they are breaking any of my rules. 

Sunday, January 10, 2021

Plantar Fasciitis: Top 10 Treatments

Plantar Fasciitis


The top 10 common treatments for plantar fasciitis:


1. Plantar Fascial wall stretch for 30 seconds 5-10x/day

2. Rolling ice massage 2-3x/day for 5 minutes

3. No negative heel stretches

4. Avoid barefoot walking (something like dansko sandal at home)

5. OTC or custom orthotic devices to transfer weight into the  arch (you must feel that the   heel is protected and weight is in the arch)

6. Physical therapy or acupuncture (2x/week for 4 weeks and then re-evaluate)

7. Posterior sleeping splints when morning soreness over 5 minutes (these can be used at any time as rest splints when you are going to sit 30 minutes or more)

8. Low dye/arch taping daily initially and then with strenuous activity (Try Quick Tape from for tape that works and lasts up to a week)

9. Activity modification to avoid “bad pain”

10. Calf stretches (straight and bent knee) 2x/day

This can be such a stubborn problem that it is easy to get very frustrated. Very few people need surgery (even if you have a heel spur noted on x ray) for this since there are so many options for treatment. I once did a thorough review of the literature and found easily 72 different treatment options that made sense. These treatment options are so numerous that we are normally limited only by our time and imaginations to develop a successful treatment plan. Each week (or every 2 week interval) there should be improvement once active treatment begins. If improvement plateaus, make a change. Analyzing what is working and what is not working should be part of the process.

When treating plantar fasciitis we typically deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanical support (transference of pressure from the painful areas to non-painful areas or limiting the pull of the fascia by less pronation, less big toe joint dorsiflexion, or less impact stress to the arch). Most cases of plantar fasciitis need simple solutions like daily icing (anti-inflammatory), plantar fascial and achilles stretching 3 times daily (flexibility), and arch support (either custom orthotics or store-bought arch supports). Some more stubborn cases of plantar fasciitis need the above along with physical therapy to improve flexibility and anti-inflammatory measures, custom-made orthotics if not already manufactured, night splints to gentle stretch out the plantar fascia, and many other options. Cortisone shots are actually never given for plantar fasciitis, since you do not want to inject and weaken the plantar fascia. Cortisone is given to the area under the heel (typically a bursitis which develops secondary to the chronic inflammation) and away from the fascial bone attachment. 

In resistant cases, 3 months in a removable cast can help calm down the inflammation and strengthen the plantar fascia which may have some micro tearing not well visualized on MRI or felt by the patient. The moral of the story with plantar fasciitis is never give up. Keep trying to find the right combination of anti-inflammatory, flexibility, and mechanical support. Also remember that 25 to 30% of all cases I see for plantar fasciitis for a second opinion, have something else. Neuritis, bursitis, stress fractures, plantar fascial tears all head the list in the differential diagnosis that may need completely other forms of treatment. 

The above was an excerpt from my book “Secrets to Keep Moving”. 

Saturday, January 9, 2021

Avoid Negative Heel Stretching

Achilles StretchIng: One Stretch to Avoid (when you have achilles tendinitits or plantar fasciitis)




     A vital part of the treatment of achilles tendinitis and plantar fasciitis is stretching these structures. The photo above shows a very powerful achilles and plantar fascial stretch. The position is normally used in an eccentric achilles strengthening program. It normally feels great as you lower one or both heels off the edge of a stair or curb. But this stretch, called Negative Heel Stretching, or Negative Heel Position, can be damaging to your tendon and/or plantar fascia. I do not recommend it at all, but I mainly emphasize it with my achilles and plantar fasciitis patients to avoid with a passion. With the heel in a vulnerable, non-protected, position, the heel is lowered into a position it is just not used to being. If you think about heel position in life activities (functional activities), our heels are either at the same height as the front of the foot, or elevated above the front of the foot as in a normal heeled shoe. Negative Heel Stretching places our heels in a position that life has not accustomed them to being. Almost our full body weight goes into the achilles attachment in the back of the heel and into the attachment of the plantar fascia into the bottom of the heel. Golden Rule of FootAvoid Negative Heel Stretching. Do not take a chance that this stretch is overloading the weakened areas leading to greater damage of the tissues. There are too many other ways to stretch these areas. Whereas you should not do with achilles or plantar fascial pain, you have to be very cautious even when you have no prior pain history in these areas. Eccentric achilles training can go from you heel off the ground as much as possible to a stable level ground position (it is still eccentric). 

The following is an excerpt from my book “Secrets to Keep Moving”. 

Friday, January 8, 2021

Metatarsal Doming or Arcing: One of the Best Foot Intrinsic Muscle Exercises

Just had a patient come in with a possible plantar plate problems. I started him taping or wearing a budin splint, and also keeping the small muscles under the metatarsal strong with metatarsal doming or arcing exercises. It is important to look at your toes when doing them so they have minimal to no curl. I do not recommend toe curls like picking up marbles or towels when there can be a possible plantar plate tear.

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Thursday, January 7, 2021

Ankle Sprain Advice: General Treatment Rules

The top 10 treatments for ankle sprains are:

1.  Understand that the more severe the disability is right after the sprain typically correlates to the damage produced

2.  Create a pain free environment (0-2 pain level) as soon as possible with whatever is  needed (crutches, boot, brace, etc)

3.  If you see black and blue over the first 4 days, you have torn something

4.  Just because you have negative x rays does not mean something is not broken (you may need an MRI)

5.  Use all aspects of PRICE (protection, rest, ice, compression, elevation) for a minimum of 6 weeks.

6.  Begin strengthening the ankle as soon as you injure it with pain free strengthening exercises

7.  Ice only for the first 4 days, then start once daily contrast bathing, with more icing with aggravations

8.  See a specialist when you think it will take longer than 2 weeks to completely heal, when you need crutches initially, when you can not bear weight, when you have sharp pain with each step, when you heard a loud pop with immediate swelling, and if the ankle looks deformed.

9.  Do not begin to exercise without a brace until minimum of 6 weeks and you have done some balancing exercises

10. After 2 weeks, if your disability is marked (limited walking or can not think about running) consider an MRI.


This is an excerpt from my book “Secrets to Keep Moving”.