Post Plantar Fascial Release: Email Correspondence

This is a series of 6 email interactions between David (post op plantar fascial release) and myself over the last several days.


Wow, I really appreciate how freely you communicate with people who write you.  I would certainly come see you if I did not live on the wrong
coast.

      Probably contrary what would have been against your best advice, I had
the partial plantar release surgery performed by a pretty well known
 podiatrist.  I had previously encountered athletes (adventure
 racers, mainly) who had been cut by him and raved about the results.  I
 suffered with PF for nearly three years and tried various (but probably not
 every) conservative measure.  I had the surgery on December 15th, and at
 this juncture the end result is a mixed bag.  Well, the heel doesn't hurt.
 So, that is a positive.  I have not resumed running (or run walking) yet
 (and for other reasons which I will get to..) but I do bike, walk
(distances of up to 8 miles at good pace..) and have done up to 175 floors
 on a Stairmaster (the good / escalator variety..)  Typically, it does not
 hurt while exercising, but sometimes, after a long / intense session, I
 have some lingering pain the next few days along the lateral side of the
 foot and ankle.


Dr Blake's comment: This is extremely common post plantar fascial release since it is the medial band that is cut (big toe side), leaving the lateral band (baby toe side) to do all of the work post op. 


  It is not enough to make me limp (eh, give it a 2 or so..)
but it is disconcerting.  I, for the most part, understand why
 this is happening, but I wonder how much I should be concerned about it, and how
 conservative I should be with it.  All in all, the foot is probably in less
 pain than pre-surgery, but feels a little less...functional, if that makes
 sense.

     Prior to surgery I had pain in the ball of my foot (I was running a fair
bit prior to surgery..)  It was essentially undiagnosed, and after the
 surgery it did not bother me again until about two months post surgery.
 Then it really flared up again, and sesamoiditis was diagnosed.  I got an
 MRI and it showed a bipartate sesamoid (confirmed by x-rays taken years
 earlier..) with "mild edema on the proximal, tibial sesamoid".   Strangely,
my left foot started experiencing what I woudl describe as sesamoid pain a
week or so later, although I did not notice the same degree of swelling.


Dr Blake's comments: Sesamoiditis (pain in the small bones under the big toe joint) is like many other injuries with a strong mechanical cause. And, if it is one of the weak links in the chain on the one foot, it is probably one of the weak links on the other foot. Mechanical problems tend to occur bilaterally (both sides), although can be separated by a time interval. 

 I got custom orthotics with a first ray cut-out for both feet, and
 sometimes wear a soft sesamoid pad / sleeve with it.  I most often feel the
 ball of foot pain not when I am walking or standing, but when I am sitting
 wearing shoes; even if the foot is not weighted at all.  It is usually just
 a dull ache.  Sometimes, if I come down hard while walking or biking, I
 might feel it a bit (more of a sharp pain) but that does not generally
 linger.  I have been conservatively treating it in this fashion for about
 2.5 month now.  I was told that these things are just slow, and it can be a
 good 6 months.  I would say that it is somewhat better, and the swelling is
 substantially down at least as far as I can perceive.

 I was told that my fat-pads there are rather thin; disconcerting for my
age.


Dr Blake's comments: I have found thin fat pads under the ball of the foot and under the heel on many patients presenting with pain in those areas. It is good to call it to their attention, so they are mindful of the padding in that area with stressful activities. 
 Anyway, I am somewhat disheartened.  I really hoped that the PF surgery
 would end an unpleasant chapter in my life, and now I have some brand new
 problem I have to try and heal, along with the post surgery recovery.

Dr Blake's comments: David, athletics equal pain and recovery, followed by participation, followed by more pain and recovery, and the cycle goes on. It will only end when you decide not work out, but instead work on heart disease, diabetes, obesity, and all the other side effects of poor activity. 

 Does it seem like I am doing the right thing?  How slow should I take my
 exercise program in light of BOTH problems?  How worried should I be about
 the lateral pain, and does it, generally, go away?  And why the hell did
 the ball of my left foot start hurting?

 I was previously a rock climber; recreational, not great, but I enjoyed
 it.  I hoped to return to it, but I am beginning to have my doubts.

 I'm 44, 6'5", and weigh about 205.  I wear a 14-narrow shoe.  Prior to
 injuries three years ago I ran around 15-20 miles a week.  I am a moderate
 pronator, and did not start wearing orthotics until I was diagnosed with PF
 in April 2009.


Dr Blake's comment: If you are a moderate pronator, and you get orthotic devices, make sure that you feel you are running at push off through the center of your foot and not the first metatarsal (cut out or no cut out). If not the orthotic needs to be corrected in the arch more to get you off the sesamoid. 
 Well, thanks for reading this.  You really do a great service.  My
 podiatrist who I went to for the surgery is a few hours away, so it is hard
 to make recovery / check-up / management type appointments.

David
Dr Blake's initial response:


 David, I am just back from vacation, so I will probably tackle your
 wonderful email this week some time. But, that being said, you should spend
 the next year strengthening your feet. Release of the plantar fascia puts
 alot of strain on the muscles to support the arch. Look at the blog and
 start doing 2 exercise each evening for your feet, no more than 5 -7
 minutes total. Since you released the medial 2/3 of the PF, the lateral 1/3
 is taking on too much pressure. Are you stretching it out 3-4 times daily,
 and do your orthotics support the lateral side of your foot well (do you
feel centered with them?). Sorry to be brief. Ice pack 2-3 times a day for
 5 minutes to the bottom of both feet is mandatory. Rich





Dear Dr Blake, 
I truly appreciate your time and reply, and hope to not strain your
 patience with my response.  First, I hope you enjoyed your vacation.  I am
 preparing to go backpacking in Wyoming this summer, and hope that I will be
 able to do so.  If you asked me in April I would have said that I would
 have been fine for this summer, but man, that was a bit of a set-back this
 past weekend.  My previous number of floors was 80, but I was feeling so
 good that I more than doubled it.  I know, 10% more per week / workout,
 right?  Lesson learned...  It does feel somewhat better today.

Dr Blake's comment: Golden Rule of Foot: If healthy, increase your exercise level no more than 15% per week, if recovering from an injury, only increase 10% per week. 

 I will resume icing as you advise; I have two of those blue-ice gel packs
 which are conveniently foot-sized, so that is pretty easily accomplished.
 I was, perhaps, over icing previously (I had stopped for a few weeks until
 resuming this morning..) and it almost seemed that my sesamoid on my right
 foot was worse with the icing than without.  It would often have a blue
 discoloration, roughly oval shaped, right at the ball of the foot where the
 pain was.

Dr Blake's comment: Forget the blue ice--often too cold and produce ice burns. Get a reusable gel ice pack or two that will easily mold to foot even when frozen.

 Exercise: things like towel scrunches, balancing on one foot, picking up
 marbles, etc?  I can do that.  You have quite a few on your blog.  Any the
 you want to specifically recommend?  I am stretching both feet using a
Pro-Stretch rocker 2-3 times per day, and have been doing that for some
 time, and will adhere to further advice.

 Interesting that you asked about how my foot feels / felt.   This is very
difficult to put into words, and I tried to explain it to my surgeon as
 well as a sports medicine doctor I was seeing; and they both looked at me
like I had two heads or something.  If anything, the first two to three
 months after surgery, my foot felt "twisted" within the shoe.  It felt like
 the lateral edge was pressing down and was not lying flat in the shoe, and
 the entire foot was turned and twisting inside the shoe.  Indeed, my foot
 was not sitting straight within the shoe and I occasionally had to knock
 the edge of the shoe to get it all straight.  It became more pronounced
when I spent as much time off my feet as I could from February 15th through
 to the beginning of March when the sesamoid first flared up.  I eventually
 started walking (3ish mile walks a few times a week..) and whether
 coincidence or not, it seemed to even that feeling out to the point where
 it is almost gone.  I thought it completely gone last month, but the recent
 lateral pain caused at least that sensation again, but not as extreme.  I
 did mention that this was hard to put into words?

Dr Blake's comment: After foot surgery of a structure that has an important role, many sensations of distortion, malfunction, instability can be described by patients. Patients often need surgery, but the surgeons often are not experts at foot function and rehabilitation. I am happy to say about podiatrists: 95% of the surgery I see is done well. I am unhappy to say that the rehabilitation post surgery should improve, or the patient's expectations should be lowered. 
As said above, the foot is feeling a bit better today.  And let me be
 honest here.  While it hurt, I did spend all day Saturday doing lawn work
 which included cutting down trees and clearing brush, and I went mountain
biking Sunday followed by a round of golf.  Maybe my expectations are high,
 but my surgeon (like me) is a go-go-go kind of guy, so I they are
 justifiably high.  If this is just the roller coaster that is recovery (my
 sports Doc, who is a friend, always says "healing is a process..") I guess
 I can accept that, and will certainly take the steps needed to make is more
 manageable!

 Again, thanks,
David








Dr Blake's comment:


David, The flatfooted balancing and metatarsal doming are the best. Do at the end of each day. Use a wine bottle with warm water to gently massage the lateral part of the plantar fascia 5 minutes twice daily. Ice other areas inflammed twice daily also. Change your orthotics for better sesamoid protection, or at least ask if this is possible. Rich

Dear Dr Blake, 
Thank you again for the reply.  Last night I did 5 "sets" of towel pulls and 3X30 second one leg stand while barefoot.  Neither were terribly problematic.  I will try the metatarsal doming.  Quick question: I watched the video, and is this done from a seated or standing position? 




 I'll need to empty a wine bottle with a screw on cap to get to the warm bottle massage, and will start on that immediately.  ;)

I'm not sure what to do about further relieving pressure off the sesamoids.  Maybe build up the bottom of the orthotic more so the cut-out can be deeper?   I don't feel them too frequently when walking, standing, etc, but they are touching a surface, at least to a limited degree.  As it is now I have a depression / cut-out on the first ray and wear a sesamoid sleeve which has a thin dancer pad built into it.

I was biking yesterday and passed a fellow jogging along nicely with a mid-tibial blade style prosthesis.  While he probably has his own problems to deal with, sadly,  I felt jealous..


Dr Blake's comment: Only when an athlete is addicted to his/her sport would they understand that comment. Surgeons, doing surgery on athletes, need to understand how David's comment affects the nature of the patient/doctor relationship, and the outcome. A lot of dynamics play here!!

Dr Blake's response:
David, 

Met Doming is done from a sitting position only. Yes, deeper hole will help if the arch is supported enough so that you do not just fall into the hole (sometimes a careful balance). Rich



Dear Dr Blake:
Thank you again for your replies.  The lateral pain was gone by the middle of the week, and that aspect of the foot, the surgery recovery, has really felt better.  Today it felt quite close to pre-surgery normal, but without the pain.  I will be diligent about exercise daily, per your advice, to help prevent future injury and foot fatigue.

While I hope it never comes to it, is sesamoid surgery further complicated by a prior plantar fascia surgery?  I am in no hurry to get cut on again, but I would likewise like to know my options.  The sesamoid seemed to be getting better, but has become a bit more painful and puffy the last day or two.


Dr Blake's response:
David, 
 I will put this correspondence on my blog, removing you name. I am glad I was helpful. The effect on a future sesamoid injury depends on the overall effect of the plantar fascial surgery. Did it ultimately cause your foot to flatten some, putting more pressure on the sesamoids, or did it weaken your foot too much. I would be diligent this next year on your foot strengthening exercises and wearing your orthotics. Rich
 Feel free to email further questions as they come up. 


Dear Dr Blake,


That phrasing above was awkward on my part.  Ever since the lateral flare up calmed down, the right foot has felt pretty good and near normal.  I guess I meant to say it has "never felt better" but even that lacks clarity.  I have not pushed it like I did on the stairmaster that one day.  I will be working on that more incrementally.  The sesamoid has been bugging me more the last few days and I guess that remains my main concern.  I don't =think= it flattened my arch terribly much if at all.  I wear orthotics, although I was not wearing them when the sesamoid problem started (frankly, they hurt and put pressure on the incision site).  That is no longer the case.  I'm seeing a more local podiatrist Monday who can work with me more directly on perfecting my inserts / orthotics to protect the sesamoids.  I met with him before for the heel pain, and he seems like a hands-on kind of guy.


Dr Blake's comment: David, good luck. Please place comments on this blog post if you would like in the future. Please use your witness protection name of David (which is not your real name of course). Rich Your great descriptions will help many.