Students at the California School of Podiatric Medicine (part of Samuel Merritt University) studying biomechanical techniques

The Podiatry Students at the California School of Podiatric Medicine today learning important biomechanical techniques. 

RED-S. Relative Energy Deficiency--Sport (Syndrome)

     This is a must read for any health care provider treating athletes! Thank you Dr. Karen Langone for pointing it out to me! 

https://www.childrenshospital.org/conditions/red-s

Progressive Collapsing Foot Deformity Classification by Dr Allen Jacobs

https://www.hmpgloballearningnetwork.com/site/podiatry/whats-name-understanding-progressive-collapsing-foot-deformity?hmpid=&utm_medium=email&utm_source=enewsletter&utm_content=1710811546

Patent Leather Shoe Stretching: This Article gives some Tips

   

  I had a patient yesterday with bunion irritation from her beautiful patent leather shoes. We talked about getting the bunion stretched some so this article should help. The difference between patent leather and leather shoes is that patent leather shoes have a plastic coating over the leather to give it its incredible glossy shine. That plastic however makes stretching the leather part harder. 

https://oureverydaylife.com/the-best-way-to-stretch-patent-leather-shoes-12260432.html

Nerve Hypersensitivity: Great Video explaining how the Nervous System gets out of Whack!!

https://youtu.be/oaDyTND7Nts

https://youtu.be/jrzBRHfrxX4

Review Article For Hallux Rigidus sufferers concerning surgery

https://pubmed.ncbi.nlm.nih.gov/32153308/

Yes, You Can Unfuse the Big Toe Joint: Interesting Blog

https://anika.com/blog/can-my-toe-fusion-be-unfused-we-have-answers/?fbclid=IwAR0zgVZJEwE_LWcSvUJ_Cw0jYHfz59cwlBOoA_Xbv3qK2F_BUVdcw_frBdE

I also encourage Hallux Rigidus sufferers to view facebook page on Hallux Rigidus

Great video on some powerful exercises for External Hip Rotator Strength: Much need in Over Pronators

https://youtube.com/watch?v=IrvuERT5U3c&feature=shares

     As Podiatrists we are always treating over pronation linked to a myriad of problems. Here is a simple but powerful video by Dr Clifton Bradeley on some exercises to help. Rich 

How to differentiate between corns and warts

https://www.cwmtafpodiatry.co.uk/blog/seed-corn-vs-plantar-wart

Adding more Support to your Foot Orthotic Device

     So often in clinical practice, we have either designed orthotic devices, or are evaluating previously mad orthotic devices, and we find that the stability could be improved to help the patient. 4 simple improvements are supporting the arch, adding a temporary Kirby skive, changing the shoes to more stable ones, and power lacing those chosen shoes. 

Simple Medial Arch Reinforcement here with 1/4 inch Grinding Rubber

Or, a Temporary Kirby Medial heel skive along to the medial heel cup

     The following is a simple video and discussion on power lacing. 

https://youtu.be/Lj40hKy-uqI

https://www.drblakeshealingsole.com/2010/07/power-lacing-secret-to-excellent-shoe.html

Sesamoid Injury with Vasomotor Skin Changes

https://jamanetwork.com/journals/jamaneurology/fullarticle/796101

     A patient today presented with a sesamoid injury and sympathetic overload signs of vasomotor insufficiency (also called vasomotor dysfunction). This involved his right foot. The sesamoid injury went from mild to totally disabling as the nervous system went wild in an over protective manner. Instead of getting better and better in the last 3 months (the injury is about 5 months old), it is getting worse and worse (only explained by this nervous system issue). He has become less and less active. I opened this post to be a 3-4 month post as I follow his progress. He will be starting Lyrica most likely, and perhaps getting a sympathetic block (which could be done sooner than later). I did not get a photo of his two feet today, but I will ask him to send me one to post. Rich 

Here is the requested photo. This is what the injured right foot and leg look like each afternoon. Most of the time it is better in the morning. Occasionally, if he does too much, he will take 2 days to get back normal. 

Sesamoid, under the first metatarsal, injured 5 months ago is now not the main reason he is having problems. 

Email Advice: 9 months after Sesamoid Injury and AVN diagnosis

Hi Dr. Blake,

Thank you so much for your blog posts over the years on sesamoid pain! They have helped me greatly in my diagnosis with sesamoid AVN.

I'm 19 years old and was diagnosed July 2022, though my pain started February 2022. My affected leg was immobilized in a CAM boot for ~10 weeks before I transitioned to orthotics. I still experience pain occasionally while walking.

I'm wondering if you could provide some insight on some patterns of pain I've noticed:
1) My sesamoid tends to hurt when I walk after sitting or lying down for long periods of time. After I've walked for a while, the pain disappears.

Dr. Blake's comment: This is called post static dyskinesia, meaning pain after rest. The tissue either tightens from swelling that collects during the rest period, or some neural tension that develops while the tissue is immobile (nerves like motion). Both of these causes hurt at the beginning of activity and then disappear as the nerves relax or the swelling dissipates. Either way, it is consider good pain in that 0-2 pain range. You should try to warm it up before you begin to walk like foot massage, big towel range of motion with your muscles doing the motion. Patients will do both by placing a towel next to their bed. When they wait up, they lassoe the toes and pull gently up and down with the towel, or massage the area like you are drying your foot after a shower motion. Remember, total healing (meaning when your body will stop trying to heal everything) typically takes 2 years with these sesamoid injuries. So, recognizing when it is good pain is crucial. 

2) I used to go on 30-minute bike rides. When I finished the rides and started walking, I felt virtually no pain in my sesamoid.

In both cases, I suspect 1) walking for some period of time and 2) biking increases blood flow to my foot and therefore sesamoid, which temporarily alleviates my pain. Is this the likely explanation? If so, I'm wondering why this relief is only temporary (the pain returns after extended periods of inactivity), and if not, I wonder what alternative explanations could be. I am especially curious about the physiology behind temporarily increased blood flow and temporary sesamoid AVN relief, if there is a relationship between the two at all.

Dr. Blake's comment: Increased blood flow with activity, contrast bathing, after icing when the area warms back up, acupuncture, massage, warmth, all play a role at daily increasing your chances to save a bone that underwent AVN (avascular necrosis). As some may not know, the sesamoid normal blood flow is tiny, and alittle swelling in the bone can cause compression to the bone vessels temporarily shutting them off. No one knows why AVN occurs in one person and not another, but daily use of Exogen bone stimulator and contrast bathes are my go to treatments to make sure that bone gets more normalized blood flow. Temporary is fine and short lived, but it is the utilization of temporary methods of increasing blood flow daily for 9 to 12 months that will produce the best chance for the bone to get healthy, really healthy again.

     The other main component to a healthy bone is weight bearing more and more each month. You will be fine if you live in that 0-2 pain level, or the good pain levels since we also need to gradually re-mineralize the bone. Good luck and I hope this answers your concerns. 

Thank you very much for taking the time to read -- I appreciate your help!

Happy New Year and All the best,

Happy New Year 2023

    All of us will have different dreams for this year. I always love saying goodbye to one year, with its ups and downs, and welcoming a brand new year full of promise. This year will bring the end of my full time practice of Podiatry with the joy, and sadness, that accompanies that decision. It will bring much more time for family with afternoons with my first grader Henry, and trips to Carlsbad to visit my grandson William. We have trips to England, possibly Norway, Hawaii, Palm Springs, and Lake Tahoe already planned, so I won't be bored. I plan on continuing to write (especially my blog), teach at the local Podiatry school, mentor my replacement Dr Ajitha Nair, and enjoy life. Thanks to all the readers who have entrusted their foot problems with me these many years. Hopefully, I have a few more inside of me. Happy New Year!! 

Achilles Tendon Anatomy Review Article and How Strong It Can Be

• Ankle
• Published: 25 February 2010

Functional anatomy of the Achilles tendon

• Mahmut Nedim Doral, 
• Mahbub Alam, 
• Murat Bozkurt, 
• Egemen Turhan, 
• Ozgür Ahmet Atay, 
• Gürhan Dönmez & 
• Nicola Maffulli 

Knee Surgery, Sports Traumatology, Arthroscopy volume 18, pages638–643 (2010)Cite this article

• 8023 Accesses

• 140 Citations

• 6 Altmetric

• Metricsdetails

Abstract

The Achilles tendon is the strongest and thickest tendon in the human body. It is also the commonest tendon to rupture. It begins near the middle of the calf and is the conjoint tendon of the gastrocnemius and soleus muscles. The relative contribution of the two muscles to the tendon varies. Spiralisation of the fibres of the tendon produces an area of concentrated stress and confers a mechanical advantage. The calcaneal insertion is specialised and designed to aid the dissipation of stress from the tendon to the calcaneum. The insertion is crescent shaped and has significant medial and lateral projections. The blood supply of the tendon is from the musculotendinous junction, vessels in surrounding connective tissue and the osteotendinous junction. The vascular territories can be classified simply in three, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. This leaves a relatively hypovascular area in the mid-portion of the tendon where most problems occur. The Achilles tendon derives its innervation from the sural nerve with a smaller supply from the tibial nerve. Tenocytes produce type I collagen and form 90% of the cellular component of the normal tendon. Evidence suggests ruptured or pathological tendon produce more type III collagen, which may affect the tensile strength of the tendon. Direct measurements of forces reveal loading in the Achilles tendon as high as 9 KN during running, which is up to 12.5 times body weight.

Vitamin D deficiency: excellent article

https://www.medscape.com/viewarticle/985973?src=WNL_trdalrt_pos1_221228&uac=399573HX&impID=5042408

In sports medicine I am always getting my athletes tested for Vitamin D levels especially when fracture healing is concerned. I hope this article shows the complex nature of Vitamin D and its importance. Rich

Tailor's Bunion or Bunionette

    

Tailor's Bunions (aka Bunionettes) are a prominence off the lateral side of the foot at the fifth metatarsal head.

 Whereas most treatments of tailor's bunions are wide shoes and orthotic devices, there are so many other conservative treatments available. I have attached a typical article on conservative and surgical treatment, followed by a video on other forms of conservative care. The top 6 treatments are:

1. Gel bunion guard for little toe to be worn in shoes.
2. Ice massage 5 minutes 2-3 times daily when painful.
3. Aloe Vera or other creams/lotions on a daily basis to keep soft tissue healthy and non irritated.
4. Proximal padding with 1/8th inch adhesive felt from www.mooremedical.com
5. Wide shoe box if possible in most shoes.
6. Arch binder worn around the metatarsals to prevent spreading of the forefoot.

https://journals.lww.com/jbjsjournal/Fulltext/2001/07000/Bunionette.16.aspx

https://youtube.com/watch?v=cRxKVUPyQfM&feature=shares

Sesamoid Injury: Email Advice

Hi Dr Blake,

I have been reading your blog for a while and it has been very informative for me.

I have been dealing with sesamoid issues for a year now and I can't seem to move forward, so I'm looking for your advice.

I first started having issues in both big toes in January this year, right side was initially worse. I didn't do any sports at that time as I was recovering from another foot injury. Then, I started walking barefoot around the house (as recommended by my physio), but after about a week of this I started having pain in sesamoid area.

          Dr. Blake's comment: To let you know how my brain works, each word or sentence has a 

                          possible clue. January means we could be dealing with Vitamin D deficiency 

                          from lack of sun exposure. Another foot injury means alternated mechanics 

                          that could have stressed something out. Typically, if it is both sides, you did not

                          break again, and this is backed up by no impact sports at the time.  

In May of that year, an MRI was done on my right foot and it showed a small edema on the medial sesamoid. Then, the left foot started hurting a lot as well.

          Dr Blake's comment: Medial sesamoid bares more weight naturally than the lateral sesamoid

                          and many foot types have prominent first metatarsals (or at least more pressure)

                          including pes cavus (high arches), plantar flexed first metatarsals, hypomobile first

                          rays, and very pronated feet.

Throughout this I have been offloading the sesamoid using zero-drop, wide, stiff shoes with thick metatarsal pads from Dr Jill. During Summer I also did three months in a Darco shoe with a hole cut out where the sesamoid is. After all of this there was some improvement, but the pain is still there all the time especially on the left side. I have also tried orthotics, but I could not tolerate them as they gave me Baxter nerve entrapment. I have also developed pain in my pinky toe from compensation on both sides. I'm doing contrast baths every day as well. I have high arches, but had previously always been very active with little issues, I'm 33.

          Dr. Blake's comment: Well I am very proud of your attempt. Since orthotics can be a game

                          changer, and you could not tolerate the hardest in the heel, have the doctor/lab 

                          make their version of a Hannaford design (all over my blog). This will get you

                          a soft arch to transfer weight off, but a way of off weighting the sesamoid reliably.

                          Many patients need to add a Dr Jill's Gel Regular Dancer's Pad on top of the 

                          orthosis. Other mechanical treatments are spica taping, 4 hour per day of full 

                          immobilization with bike shoes with embedded cleats, cluffy wedges, or carbon plates

                          under your shoes.

About a month ago, another MRI was done on the left foot, and it shows again mild edema in the medial (bipartite) sesamoid. The toe hurts if I bend it up or when I press on the sesamoid.

          Dr. Blake's comment: If it hurts to bend up, definitely start using spica taping to see how that

                          helps. The nerves could be protecting or the soft tissue tightening up due to pain or 

                          prolonged immobilization. Make sure you are painlessly moving the top up and down 

                          10-20 times 3-4 times a day. Make sure you are doing some foot massage, but not 

                          pressing in, just to relax the soft tissues around and especially into the arch.  

I have now tried significant offloading and also more recently trying to work with the pain (so only doing things which do not make the pain worse for more than 24h), but still I'm very limited in my activities of daily living. I can't quite understand why a minor injury to the bone won't heal in over a year and also produce so much pain. Is this normal? Or do you think there is also nerve involvement? Do you have suggestions of things I can do?

         Dr. Blake's comment: Unfortunately, minor foot injuries, especially under your foot, that you 

                         have to continue to walk on, can spin out of control. After 3 months, all of these

                         injuries do have some nerve hypersensitivity issues. Between the massage, and topical

                         Neuro Eze or Neuro One gels, and add some warmth for 5 minutes before you 

                         massage. Check your Vitamin D, if you have an history of poor diet, then check your

                         Bone Density. Edema is a sign of both stress and healing. If you have been taking

                         off the stress corrcctly, and the bone is healing, a new MRI would show  great 

                        improvement. I like to wait 6 months between MRIs for their maximum change. So, 

                        you could definitely repeat the right side now. The bone may be healed completely, 

                        and your pain is all nerve now. It would be good to know. I am happy to look at any

                        MRI CDs that you mail to me. 

I have signed up for shock wave sessions now (ESWT), I hope this will clear up the edema. I'm also making sure I get all the nutrients for the bones and my bone density test came back normal. If this doesn't work, I don't know what more I could try, all this offloading has caused other issues for me. My doctor also doesn't know what to do, but told me I'm not a candidate for surgery despite only having very little success with conservative treatment.

          Dr. Blake's comment: One of my blog patients just had shockwave for chronic sesamoiditis 

                         with good results, so good luck. Glad bone density good. I am not sure why he

                         said surgery is not an option. Has be mentioned anything about your foot structure?

                        Please keep me in the loop, and always attach the URL for this post so I can refer

                        to it. Rich  

Thank you for reading this. If you want, I can also send you the MRI images, would be curious to hear what your conclusion would be.

          Dr. Blake's comment: Definitely. Dr Richard Blake 900 Hyde Street San Francisco CA 94109 

Best Regards,

To My Podiatry Family: Thank You

     What do I mean by Podiatry Family? The longer you practice, the more your patients become part of your family. They are my friends, and family, teachers, and much more. They make me laugh, cry, stress out, work hard, and be truly human. They have simple problems, and incredibly difficult ones. They come in all forms, and some relate to me and others not. I have so much loved to treat my patients that keep coming back, then the ones that come once or twice. I guess I love the relationships that need time to simmer. I succeed in helping most (I think), and am saddened when I can not. I have performed miracles (in the patient's eyes), and given such painful advice or injections that make patients run! I typically mean well by my patients, and hope that they feel my concern. 

     I have told all of my patients that I am retiring from full time practice in January. Since the patients I am treating are family, what sin am I doing? It is time for me, but my heart sinks at the thought. Each kind word from a patient about how I may have helped them, in one sense means I am deserted them, turning my back. Wow!! It will take me months or years to find some peace. For, you see, I love my Podiatry Family. They are my life, I have tried to take care of them, help them, and they in turn have helped me grow. I have suffered with them, I have rejoiced with them, and they know that they have been able. to count on me. I am sorry and sad to say good bye. I love you and you have enriched my life. I thank you from the deepest part of my being. Medicine is a business, but medicine is an incredible journey of souls towards health affecting both physician and patient alike. Thank you. Rich 

Creating a Healing Environment

Creating a Healing Environment for a Patient Requires Maintaining a 0-2 (no pain to mild pain or discomfort) for an extended period of pain. The goal with our patients is to get their pain down and keep it there through the entire Rehabilitation Process. 

Exogen Bone Stimulator: Dramatic Help for my Patients

     If you read my blog you know I love the Exogen bone stimulator since it strengthens bone. I have hundreds of patients benefit with healing at a faster pace then expected, or healing when no improvement was expected. It is not a cure all. But when you want to try to give a bone injury a chance to heal, especially in my sesamoid injury patients, Exogen is my go to Bone Stimulator. Most sesamoid injuries are within the bone and there is not definite fracture line or gap. The goal is to get bone stronger, which is all I care about, and symptom relief seems to follow. 

https://fda.report/GUDID/M937710344001

Posterior Tibial Tendon Injuries: Conservative Management

https://pubmed.ncbi.nlm.nih.gov/22938638/

Whereas there are too many articles implying surgery even in Stage 1 Posterior Tibial Tendon injuries, I hope this blog post will help direct you into more conservative management first. 

The following is an excerpt from Chapter 13 of "Secrets to Keep Moving" on Posterior Tibial Tendon Problems. It is an important tendon to protect. Yet, surgery in Stages 1, 2, and 3 can still be delayed or prevented if the doctors skill level can increase in conservative treatments. At least, you can have better informed conversations with your doctor after reading this. 

7. Posterior Tibial Tendinitis/Dysfunction/Tear

    The posterior tibial tendon is the major tendon to support the main arch of your foot. Damage to the tendon causes arch collapse to a major degree. Any sign that this tendon is have problems must therefore be over treated to avoid long term issues. It is one of the most common surgeries on my patients because of the disability. I work long and hard on each one of these patients both trying to avoid surgery (usually), or post surgical rehabilitation.    

https://youtube.com/watch?v=YPyC0ze2gO4&feature=shares

The top 10 treatments for tibial tendinitis/dysfunction/tear are:

1.  Understand the biomechanics of the posterior tibial tendon to support the medial longitudinal arch and begin to support the arch as part of all phases of the rehabilitation: Immobilization, Re-Strengthening, and Return to Activity.

https://youtube.com/watch?v=7ilOVqF0aPc&feature=shares

2.  Start with OTC and advance to custom orthotic devices with maximal support (this is not an injury to have less than optimal support).

3.  Learn several different taping techniques: posterior tibial and circumferential arch.

https://youtube.com/watch?v=AcSSyBfFocE&feature=shares

4.  Ice the area 3 times daily for 15 minutes each.

5.  If possible, get a baseline MRI (may be an important comparison 6 months later), or baseline ultrasound imaging.

6.  Most ankle braces hold the ankle pronated which is bad for this injury, consider an Aircast Airlift PTTD brace for times you are not using orthotic devices.

7.  Create an initial pain free environment with below knee removable boot/cam walker, and perhaps a Roll aBout knee scooter.

8.  If the injury is substantial (Grade 3-4 typically), have a rigid AFO custom made at a brace shop right at the start of the injury (it can take awhile to get fitted)

9.  Begin strengthening the posterior tibial tendon as quickly as possible with at least active range of motion exercises. The Posterior Tibial tendon is strengthened by pointing the ankle first and then moving the foot towards the other foot. See Chapters 2 (general strengthening principles) and 6 (tendinitis principles).

https://youtube.com/watch?v=w3FXx4OFqec&feature=shares

10. Definitely have a surgeon as part of the treatment, or the help of a regenerative specialist.

Email Correspondence 

Patient: Hey Doc!!

I found your blog and I am so grateful! I have already learned a great deal. I really need your advice and help. Last fall I started to play tennis again. I played daily and began to have foot pain.

Dr Blake's comment: When have taken time off from exercise, it is important to start every other day so that you can access the toll on your body correctly, and give yourself the 48 hours to regain your strength in your muscles. 

Patient: The inside of my ankle and the bottom of my foot were sore. In November I saw the ortho and he said I had PTTD.

Impression Casts taken of a left sided PTTD showing the collapse inward of the heel and arch more than the right.

Dr. Blake's comment: Posterior Tibial Tendon Dysfunction diagnosis can be like shin splints, you really do not know what is wrong by the name. The Posterior Tibial Tendon is the most important tendon to support your arch. The Dysfunction part implies that the tendon is not doing it's job, and patients have seen complete collapses of the arch in severe cases requiring surgery. Since I do not know the severity, but Melanie is implying that it seems difficult to treat, therefore, to protect her, some immobilization must be recommended until more info is obtained.

Patient:  He put me in a walking boot and that did not help.

Dr. Blake's comment: This requires further information Melanie. The boot, like the photo above, should have calmed the tendon down. Did  it hurt just as much, 50% as much, hard to tell? There are so many factors that come into play with your injury. Normally, the below the knee boots are better than the mid calf or ankle high ones. They distribute the force of stability over a larger area. Also, with PTTD, normally wearing an arch support in the boot is crucial. If you do not have a comfortable custom one, get the heat moldable Sole supports soft athletic version. These are sold at sporting good chains like DIck's, REI, etc. 

 

Patient: He also told me that I have an accessory navicular bone. 

This CT Scan shows an Accessory Navicular, aka Extra Ankle Bone, aka Os Tibial Externum. Typically starts forming around 9 years old, and completely formed by 16. It can begin to give problems in young children in their early teens, or later in life. 

This extra bone occurs in a small percentage of people and normally weakens the attachment of the posterior tibial tendon into the arch making it less effective in supporting the arch and stabilizing the inside of the foot and ankle. 

Patient: It seemed to get worse. ( no arch or foot support in the boot). So  off I went to the podiatrist. He gave me an a shoe insert. It didn't help.

Dr Blake's comment: One of the very crucial points I need to make to all orthotic wearers is why are you wearing them, and are they successfully fulfilling the purpose they were prescribed? Why did you get the orthotics? Pain relief, or better function? Orthotics if done well should make the posterior tibial tendon work better, but maybe, just maybe, you are in the Immobilization Phase of Rehabilitation, not the Re-strengthening Phase. So, a great orthotic device for PTTD can make you hurt a lot more just because it is being used to stabilize and re-strengthen at a time you should be immobilizing and using anti-inflammatory methods. You are definitely in the removable boot with some sort of orthotic and arch taping period.

Kinesiotape used for Circumferential Arch Immobilization

Patient:  About a month ago, I slipped in the kitchen and twisted the ankle on the same foot with the PTTD. Since the initial fall I have rolled it two more times!

Dr Blake's comment: Once you hurt a major tendon, you body naturally protects itself. You can roll your foot to the outside which makes you more prone to sprains, or if a step will produce pain, you can just let the foot collapse/shut off and you fall to the ground. These scenarios are quite common. And, if they are happening to you, I can see why you emailed. It is very very frustrating.

Patient:  I look like someone beat me up!  I keep spending money on shoes, inserts and I need some advice.  I started the tennis to lose weight, and I was.  Do I need a PTTD brace?  I purchased some Orthaheel shoes but my foot for some reason gets to a weird angle in them. I am doing the exercise you recommend for strengthening my ankles. I know losing weight will help me, but I need to know what to do so I can get back to tennis!

Thank you so much!!

Melanie (name changed due to witness protection)

Dr. Blake's response: 

Dear Melanie,

    Thank you very much for writing. I hope some of my initial comments were helpful. Please feel free to comment on this post and I will try to respond in a timely fashion. To summarize:

#1     You are probably in Phase 1 of Rehabilitation: Immobilization and Anti-Inflammatory where you try to create a Pain Free Environment to let the tissue heal.  We need to get you to that 0-2 pain level range for 2 weeks straight.

#2     You can try combining the boot and orthotic, but may have to get another boot or a different orthotic. You need to put out the time and effort in creating this pain free environment.

#3     You should consider crutches, and even a Knee Scooter, for a short time, if that is what it takes.

#4     For the Anti-Inflammatory part, definitely start ice packing for 10 minutes three times daily. The ice pack can be placed in the boot and you walk around (multi-task). Consider anti-inflammatory meds, flector patches, and physical therapy for anti-inflammatory only (although you can send me a video of you bouncing on the trampoline). LOL

#5     Normally, if the accessory navicular is the source of pain, the pain will localize there as the symptoms die down.

#6     You should get (if possible) a baseline MRI or Ultrasound of the ankle. It will show the rearfoot also, and may give clues to what is broken. Hopefully, you strained but not tore the tendon.

#7    Since tennis is out of the question right now, consider elliptical or stationary bike, even some pool workouts will not irritate, as long as whatever you do does not irritate the tendon.

#8     One important bit of information I need to further advise regards pain. What produces it? How is it in the morning? See if you can write up and email the pain questionnaire from Chapter 3. Also, go through the various foot and ankle exercises described in my blog, at least the ones not requiring equipment, and tell me which ones are painful and which ones are symptom free. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist.

 Further Email Correspondences

 

Dear Yvonne, Thanks for the email. I hope the video (go to YouTube and type drblakeshealingsole posterior tibial strengthening exercises) helps you understand the 4 basic forms of strengthening exercises used in the treatment of posterior tibial tendon dysfunction. Gradually the patient is progressed from Active Range of Motion to Isometric to Progressive Resistance to Functional. Heat (in the form of warm water soaks, heat liniments, or heating pads) is used often to loosen up the tendon before exercise for 10 minutes. If walking is not painful, 5 minutes of walking can get the blood pumping. Ice should be used after for 10 minutes, normally an ice pack over the sore area. NO Pain can be experienced during the exercise. If you are still having trouble strengthening without pain, try the numbing effects of ice. Ice the area for 5 minutes, then let the tissue unthaw for 20 minutes, and then try the exercise. Should work unless the tendon is significantly damaged. Then ice 10 minutes afterwards. I sure hope this helps.

Rich

Further Email Answer

Patient: Dear Dr. Blake,

I have searched your informative blog after not finding much on PTTD. I really enjoyed reading your tailored approach to each patient in your blog comments, and I am hoping you can give me some useful insights. I do like and trust my podiatrist, but I am in a quandary and want to explore every avenue before entering into surgery.

Dr. Blake's comment: PTTD stands for Posterior Tibial Tendon Dysfunction. This is the most important tendon for supporting the arch. Complete tearing of that tendon always leads to complete arch collapse. So this is a very serious problem.

Patient: I am a 40 year woman in excellent shape, trying to avoid surgery for PTTD.  I found you in reference to your use of inverted orthoses and I am wondering if the consistent use of them might help me. I have consulted with two podiatrists and both have agreed on the PTTD diagnosis, now I just need to figure out my plan.

Dr. Blake's comment: The Inverted Orthotic Technique is the most sophisticated foot orthotic for arch support and is always used for PTTD. There are only a handful of orthotic labs in the US that make them, but a relatively easy technique to learn. Many labs now have versions of varus or inverted methods that can help greatly like the Mueller PTTD orthotic device. Before you try to find a lab with the Inverted, have the lab make the best possible orthotic device that they make for PTTD. Posterior tibial tendon acts across the foot and the ankle. A foot orthotic will help the foot component, but at times, the ankle also must be initially immobilized. In that case, you need a rigid AFO.

Patient: History and background:

I sprained both ankles in my early 20's, the left ankle was a more severe sprain.

Dr. Blake's Comment: this probably left her with some weakness in her arch.

 Patient: I have had pain in the arch ankle area of my feet for the past six or seven years, always when wearing improper footwear (heels). The pain always stopped when I went back to supportive/comfortable shoes.

Dr. Blake's Comment: this is the classic presentation of PTTD where the symptoms begin gradually in the arch and/or ankle areas.

Patient: I work-out in the gym four times a week (weights, elliptical, stair climbing machine) and have always hiked for exercise (usually once a week). My problem became severe when, on a two-week trip in SE Asia in the Nov. '09, I wore flip-flops almost exclusively. We did tons of walking, and at for the first time I noticed my feet burning and tingling in the evenings. I did not connect this sensation to my other painful flare-ups, because I had always assumed it was my high heels causing it. It did not occur to me that I could hurt my feet wearing flip-flops.

Dr. Blake's comment: Again, the symptoms of PTTD gradually begin to change affecting other activities, although one day of aggressive walking in flip-flops if you have a predisposition can cause symptoms.

Patient: Over the next six months I experienced increasing pain in both feet upon getting out of bed and standing up first thing in the morning. My left ankle and arch started to look slightly swollen, but I did not see a doctor.

Dr. Blake's comment: This is probably the first mistake, if you see swelling, the body is actively trying to heal something, and may need some help and guidance.

Patient: I finally sought treatment when, after a run last summer (August '10) , I was in so much pain in both feet that I had trouble walking. I experienced shooting pains up the calves up both legs at night and my left ankle and arch was red and painfully swollen.

Dr. Blake's comment: Here she is in the Immobilization/Anti-inflammatory Phase of Rehabilitation. You must create a pain-free environment and allow the tendon time to heal. You normally need a removable boot, followed by brace or AFO, followed by orthotic device. You normally need to combine immobilization with ice and contrast bathing to reduce swelling in the tendon. You normally begin strengthening the tendon pain-free from the first visit. Emphasis on the pain-free.

https://youtube.com/watch?v=rRt5hC24Afg&feature=shares

Patient: First podiatrist diagnosed stage 1 PTTD and prescribed orthotics. Second podiatrist concurred and added ice/anti-inflammatory therapy and in addition put me in a walking boot until my inflammation subsided. After six weeks in boot I went to just wearing the orthotics and sometimes Dansko shoes. My right foot felt 98% better, and my left foot was improved to the point where I could often walk with no pain (always wearing orthotics).

Dr. Blake's comment: Stage 1 the tendon is inflamed, but fully functional. Stage 2 the tendon has some tearing, and begins to not support the arch well. Stage 3 the tendon tears enough to not be functional, and the arch begins to collapse. Stage 4 the tendon completely tears and the arch completely collapses

Patient: Which brings me to my present situation; I am in pain a lot of the time once again, as sometimes want to be barefoot (live at the beach, have a six-year old daughter), wear an attractive (flat) sandal with support, but find that I cannot do so without incurring a lot of pain in my left foot. As I write this I am back in my walking boot as left inside ankle/heel area is throbbing with a dull pain. I wore shoes without orthotic devices yesterday and I'm now paying the price!

Dr. Blake's comment: Golden Rule of Foot: Create a Pain-free Environment or else the problem will not heal. This is especially true with PTTD. You need to create a pain-free environment. You must stay in that boot until the pain goes away, and then add another 2 weeks for good measure. I think one of the big treatments you have not mentioned is progressive posterior tibial strengthening. We need to make you strong!! 

Patient: Upon hearing all of this from me, my podiatrist has finally recommended surgery. He is of the opinion that that is the only solution for my particular situation. I tend to agree, but I feel overwhelmed when I hear the reality of the recovery. Is there any chance he is wrong? Could I religiously wear the inverted orthoses and "heal" my left foot the way my right foot was improved? Or should I just "suck it up" and do the surgery so I can have a chance for a real recovery and a lifestyle that will resemble "normal" again?

Dr. Blake's Comment: yes, yes, maybe

And Further Response to same patient: 

            Thanks for the email. When patients present to my office with this scenario, I just try to start over. Pretend the injury just happened. Try to put a healing environment together for them to hopefully end with a successful rehabilitation. Sometimes the decisions are hard to make, but we make them and stand by them.

            So, what must you do now? What will allow you to heal? First of all, surgery is only needed at times for Stage 3 and 4. Does not sound like you are there. Your focus must be immobilization, anti-inflammatory, and re-strengthening. Nothing from this point on should hurt. The activities should not hurt, the strengthening exercises should not hurt, and the physical therapy should not hurt. Definitely read Chapter 2 on Good vs Bad Pain and live by it.

            Since the posterior tibial is the strongest arch support tendon, help it out as much as you can to do it's job. This is accomplished with taping techniques, the Inverted Orthotic or similar protective orthotic device offered by labs, stable shoes, wedging of shoes, power lacing, and bracing. Your podiatrist/therapist and you need to create a stable environment, whether it is pre or post surgery. So if a surgeon does not know how to create a stable environment for your tendon, if he/she does surgery, they most likely will not know how to rehab it after.

Here are so many strengthening exercises for the posterior tibial tendon that it is normally easy to gradually build up the strength. Remember, if you try to strengthen a muscle/tendon, and you produce a pain response, the tendon in the end gets weaker. Since the posterior tibial tendon is next to the posterior tibial nerve, there may be some 0-2 pain that the therapist feels is acceptable, but it should have no increased pain afterwards. 

https://www.drblakeshealingsole.com/2010/06/quick-tip-9-begin-strengthening.html

            What helps control inflammation? Icing (if there is no swelling or just after activity), contrast bathing if there is swelling, physical therapy, acupuncture, many topical creams (some by Rx and some OTC), and oral medications. I like to stay away from months and months of oral medications, but short courses when the inflammation is flared is fine.

 So Joann, my recommendations for you right now:

1. Stay in the Removable boot for the left side until you can walk without pain for 2 weeks.
2. Purchase an Even-up for the right side to protect your back.
3. Begin icing 3 times daily for 10 minutes both sides. The left should have evening contrast baths starting at one minute hot and one minute cold alternating for 20 minutes due to the throbbing.
4. Get an Inverted Orthotic Device for both sides, or similar PTTD device per the podiatry lab, which is some type of orthotic that does not allow your foot to pronate at all. You will need this to gradually wean off the cast.
5. Begin some posterior tibial tendon strengthening each evening followed by 10 minute ice bath.
6. Get bilateral ankle MRI’s to document June 2011 status of both your tendons.
7. Find out the stage of your posterior tibial tendon disease. 

I sure hope this helps.

Rich