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Thursday, February 28, 2013

Sesamoid Fracture in Growing Child: Email Advice

Hello Dr. Blake,
I am writing today regarding my daughter, Tonya (name changed). She is 13 1/2 and has a right tibial sesamoid fracture. First let me say, I know our feet are important to all of us....Tonya is extra special because she is a dancer. Five days a week and hours a day. She does almost every kind of dance you can think of from ballet to hip hop.

 She has already been told she can not perform in her upcoming ballet, which is heartbreaking, but we will do whatever it takes to get her at her best. She has another dance recital coming up in May, as well as tryouts for the High School program directly following. She is hoping to be able to participate in both of these things.  She is not getting a great deal of hope from her doctor of healing. She was in a hard cast for 3 weeks and has now been in a soft removable cast (non-weightbearing) for 2 weeks.
Dr Blake's comment: Typically, sesamoid fractures take 3 months of immobilization (casts or removable boots as long as you are creating a pain free environment, following by 2 to 6 weeks of gradually weaning out of the boot, into orthotics and dancer's pads, and icing, with some physical therapy. Then 3 plus months of gradual return to activity. There can not be pressure due to upcoming performances, or the gradual process of healing has a chance to be rushed jeopardizing healing. Typically, 6 to 8 months after the immobilization is started, the dancer/athlete feels comfortable to return to competitive activities. And, this is just average, with some going alittle less time (5 months) and many going longer 12-13 months. I know this sounds like a long time, but complete healing of the fracture with her future ahead of her, has to be carefully guarded.
Her doctor has mentioned that this could be an activity changing injury.
Dr Blake's comment: This is rarely the case. So, why go to that discussion in these early stages? Remember, as tissue heals, there is a lot of swelling that collects in the area. The swelling is painful to walk on. Casts trap the swelling, and non weight bearing also does not allow the fluid to be pumped naturally out of the injured area. So, casts and non weight bearing are necessary evils in our fight, producing both good healing of injured tissue, and bad problems of swelling retention, muscle/tendon weakness, joint stiffness, nerve hyper-sensitivity. This is why the weaning process from the cast to no cast can be long (always too long). 

 We are doing all he suggests for her best chance of healing, but are looking for some more information.
Dr Blake's comment: So, I gauge you have 6-7 more weeks of immobilization. Hopefully, you can process to an removable boot eventually, so you can start the important anti-inflammatory part of icing twice daily and contrast bathing once day. Hopefully her diet is very well balanced with enough calcium. She should be getting 1500 mg Calcium daily in her diet/supplement, and 1000 units of Vit D unless she is out in the sun for a short time every day. I hope she has no history of eating problems, or on any diets. One of our MDs requires one serving of red meat daily with these bone injuries. Once in the removable, ask for advice on what she can strengthen, what to stretch, how to start balancing. I have a lot on my blog on this. But, it has to be pain free, what ever you do in this area. 

 Have you seen a teenager with this injury?
Dr Blake's comment: Yes, and they tend to heal just fine. Children have great bone metabolism and will heal things much quicker in general than an old geeser like me. Yet, children do not have a greatly developed nervous system. Pain can be much higher than it really is for some, and much lower than it really is for some. This makes the process of rehabilitation either slower than it needs (which I think is always okay) or much faster than it should (possibly dangerous). Parents affect the equation for the rehab specialist a lot. They must allow the process to go on without focus of upcoming events, possible scholarships, the emoitional heartbreak the child may have. The parents must be the voice of reason, of common sense. Talking to doctors, therapists, or reading this blog post, it must make sense to you. Your child must be protected and not harmed. There is a lot of weird advice out there. 

 What are her chances of healing?
Dr Blake's comment: 99.5% unless there is something else in the MRI that I do not know. A simple sesamoid fracture in a child, with all the time in the world to heal, good diet, good parental advice, heal these things very well. If they do not heal, something else is going on. 

 Do you have any added suggestions? She is taking calcium and a bone/joint health supplement daily. And of course the power of prayer is our biggest help. Is there anything more we can do? Her doctor has stated that surgery is not an option at her age.
Dr Blake's comment: No doctor wants to do surgery on a young child. Treating ballet dancers, I have done my share of surgeries on these fragile athletes, and it is scarey (if you have anything of a conscience). You are just in the Immobilization Phase of the Injury which will last for probabaly 12 weeks longer. The next phase is the Restrengthening Phase, which you can start somewhat when you are in the removable boot. All doctors use these at different times during these initial 3 months. This Phase goes on for 9-12 months, and is blended with the first phase and the last phase. The third phase, after you have successfully and painlessly weaned out of the removable boot, is the Return To Activity Phase. It should be slow, normally run by a physical therapist, and the pain can not get over 0-2 on a pain scale of 0-10. It will be important to read my post on "Good vs Bad Pain", and familiarize yourself with the pain scale.
Right now, we are scheduled to go back after 3 weeks in the soft cast. The doctor said he will take a look then and decide where to go from there. He did mention that when the day comes that she is "better", she will need 3-4 weeks of physical therapy.
We are looking for some more input and advice. Maybe you will just tell us to keep being patient. If so, we can and will.
Thank you for your time!
Dr Blake's comment: I sure hope you comments have been helpful. Read all my posts on Sesamoid Injuries, so you are aware of padding, taping, MRIs, etc, so you can help your daughter the best. Remember, Complete Healing is the most important, not when that occurs. Please leave that in God's Hands. 

Sunday, February 24, 2013

Achilles Tendon Pain + 2 Surgeries: Still Painful

Hi Doctor Blake,

My name is John (name changed). I now live in Valley Springs California. I have been on the internet researching Achilles tendinitis/heel pain and found your blog.

 I have been having Achilles tendon/heel problems since July 2010. I have been dealing with another podiatrist. I was told in July 2010 I had a partial tear of my Achilles tendon and some real large bone spurs.

 Because I am a diabetic they did not want to do surgery at this time. I was placed in a cam walker, but the pain got worst and I was placed in a NWB short leg cast. I was in the cast until October 2010. The pain got better, but as soon as I started rehab, the pain returned.

 I was put back in the SLC walking cast until the 1st of November. At this time an MRI was done. The MRI showed the tear and the bone spurs. The podiatrist wanted me to go back into a cast. Being from the old school of sport medicine, I suggested a long leg cast to completely keep my heel from moving. The podiatrist finally agreed to my request. My foot was plantar flexed for the first 3 weeks, then the foot was raised about 10 degrees for another 3 weeks. The last 3 weeks my foot was at 90 degrees. After that I was put in a SLWC for the next two weeks. Finally I was put back in the cam walker. While in the long leg cast my heel felt much better, but when I when back into the cam walker and started rehab the pain returned just like nothing had been done.

 Finally in March 2011, the podiatrist decided to do surgery. She was to repair the tendon nd remove the spurs and scrape the heel smooth. She decided to use the Topaz procedure on the tendon. Everything felt good until I had my knee scoped to clean up a partial tear of the cartilage. Soon after the scope of the knee the Achilles tendon pain returned. By September 2011 the pain felt like I had just injury my heel. X-ray showed that bone spurs had returned.

 I changed podiatrist and had to start my treatment all over. He place my leg in a SLWC for the next 2 weeks. But it did not help. He suggested the long leg cast again. I was in it for 6 weeks. After that I was placed in a air cam walker. This lasted until April 2012 until a second surgery was done. Again the tendon was removed the spurs removed and the tendon reattached.

 In December 2012 I started a rehab program. Near the end of January 2013 the pain has returned. The podiatrist had earlier tried injecting the heel and putting it in a cast, but it did show any sign of improvement. The podiatrist had order ultrasound treatments but was over ruled.

 I worked for 25 years as an athletic trainer and started my own rehab program. The more I do the exercises the more painful it becomes. The podiatrist asked me to look into calf lengthening surgery. I have very high arches. The podiatrist now feel I have a very bad case of Achilles tendinitis. He feels that because I have very tight calf muscles lengthening the tendon might helps.

 What do you think about calf lengthening surgery?

 Or do you have any other suggestions for treating my Achilles tendinitis?

 What can you tell me about the Topaz procedure and it success or failure in Achilles Tendon repair?

Dr Blake's comment: Let me start out by saying that achilles tendons are very tricky to deal with. You simply look at an achilles the wrong way and it starts to hurt. And, every day you have pain in the achilles you lose up to 1% of your strength, so let us assume you have no strength in that achilles. The weaker and weaker the achilles gets, intensified by prolonged casting, by the time you had the second surgery your achilles is jello!!! And it will hurt if you use it. And you must get it strong again. Stay away from surgery if they are just guessing. If you lengthen the tendon, you will make it weaker. You know about force length curves!!!!  Your tendon must be so weak you can not even walk without straining it. Why was there no mention of tightness issue until now? 

     What do you think is going on now? Are the spurs finally gone? Is the tendon intact? Topaz is fine as a technique to repair, but did they do it correctly is a whole other question? But, if there was concerns, I hope they would have addressed that in the second surgery.

     Without further info, let us assume you have repaired the stuff you needed to have been repaired, and now you have a weak, tight, swollen, strained, fragile achilles on one side of your body and a strong healthy one on the other side. And you begin to rehab without more casts. You get orthotics that center your heel from a good orthotics guy/gal, you limit your activities to pain free as much as possible, you ice 5 to 10 minutes multiple times a day, you stretch and stretch and stretch (see my blog videos), and you find what strengthening you can do for the achilles that does not hurt, and you slowly get stronger, and stronger, and stronger over the next 12 months. 

     Since, no one bothered to look at the sciatic nerve as a possible cause or aggravating factor for you, definitely have a physiatrist look into this as one of your pain triggers. Why are people saying you hurt this much? Just tendinitis? 

     I hope this points you somehow in some direction that is good. I am sorry for your struggles. Rich Blake

Ball of the Foot Pain: Email Advice

Hi Dr. Blake,

I found your blog on the internet, and was hoping you could shed some light on my rather longstanding foot problem.

Two years ago, after running a bit on the treadmill (no more than 2 miles at a stretch) the ball of my foot starting really hurting.  X rays and an MRI did not show any breaks or stress fracture, and 3 subsequesnt podiatrists diagnosed plantar fasciitis.
Dr Blake's comment: Pain in the ball of the foot is so rarely plantar fasciitis, but you may have a rare case. Normally plantar fasciitis presents with heel pain, and sometimes arch pain, but rarely ball of the foot pain. There is just no tension on the plantar fascia in this area. 

 I tried many treatments for  this including the strassburg sock, a night splint, icing, stretching, even custom orthotics.  The pain would get a bit better, but not go away. The pain seemed to be concentrated just at the base of my big toe, slightly toward the inside of the foot.
Dr Blake's comment: When you try a lot of treatments, try to stick with those that give some, if any, relief, and eliminate those that do not help at all. You may have to go back and add something you have already tried for the next week and see if you are some better. Try one new treatment every week over the next month. Treating plantar fasciitis, or another foot injury, somethings requires 5-6 treatments working in unison all at once. But, who wants to waste time on treatments that either do not help, or possibly aggravate the situation. 

Convinced there was somthing else going on (I never thought I had plantar fasciitis) I went to a physiatrist  (M.D.) specializing in sports injuries and rehabilitation.  He seems to feel the problem is an inflammation of my flexor hallicus brevis muscle and surrounding tissue casused by a weak or compromised hip.  (My gait puts too much pressure coming down on that big toe area.)  So I'm supposed to do hip exercises (which I am doing) and gradually some foot strengthening exercises as well.
He also suggested that instead of orthotics, which were only protecting my arch and doing nothing to protect my forefoot, I needed to wear something that prevented my toe from bending backward too far.  So I'm wearing this sort of half sole steel plate under the existing insole of my asics.  I think these plates are designed for turf toe injuries.  (Initially the injury was only on the left foot, but last year it came on my right foot as well.)
Dr Blake's comments: So, sounds more like Hallux Limitus/Rigidus, or sesamoidits, problems. The orthotic devices for ball of the foot pain must have a lot of work getting the right amount of off weighting, stiffness, and cushion. And the shoes you wear them in, or if you use a plate, must be analyzed and experimented with. It can take alot of work, as you can tell from some of my Hallux Rigidus patients. Definitely sounds like there is movement in the right direction. 

Things seem to be getting better, but very gradually.  My foot doesn't hurt as much while walking.  I can pull my big toes backward without significant pain.  It is only when my big toe is pulled back and there is presssure on it that I get this sharp, stabbing pain down my toe and into my arch.  So, squatting is a problem, I can't stand on my toes, or when walking, I can't really push off too much.  While walking, I try to roll my foot forward instead of pushing off with my toes. Needless to say, I can't walk as fast as I used to.  This injury has been very frustrating to me because I am a very active 52 year old woman.  I can do the stationary bike, but I still can't walk very fast, or do many of the yoga poses I used to do.
Dr Blake's comment: I am assuming that the working diagnosis now is FHB tendinitis. Tendon injuries can be inflammation, a partial tear, or a complete tear. This is an MRI differential, so I recommend getting another one. After the MRI, you will know if it is safe to do PT, aggressive foot strengthening, etc. The MRI will tell us if we have a permanent injury, for you will see if any structures look worse than 2 years ago. 
I think I should start doing the contrast baths.  If it's just inflammation, won't it heal in time?  Is there anything else you might suggest I try?  I feel as if I am getting closer to figuring this thing out, but it seems the pattern is that it gets better for a while, then the slightest thing can aggravate it.  It was doing well last week until, while walking the dog, I mistakenly hurried down the hill with him so he could do his business in the right spot!  Then it took almost a week to be able to walk the way I did before that happened.
Dr Blake's comment: So, assuming that you have found that limiting the toe motion helps you, the three obvious additions without further info are: learn to spica tape (see my videos on the 2 versions), get one of the rocker bottom but stable shoes, like the New Balance 926, and have your orthotics modifed for more rigidity across the metatarsals (some form of extension under the metatarsal heads. You also need to be doing 3 to 5 minutes of foot exercises that do not hurt, like met doming, single leg balancing, etc. I have videos on all of these. It will take you a year from now to get your injured foot very strong, so that you can get back to all your activities. 
Your blog contains some great information, and it is so kind of you to try to help as many people as possible and encourage questions from readers.  I know it's difficult to diagnose problems and suggest treatments without seeing a patient, but I hope I've given you enough information to at least give you a sense of what is going on with me.  Basically, I can't put full weight on my big toe while it is flexed upward.  Can you see a time frame for me to be back to normal?
Dr Blake's comment: You may just have some neural tension in the deep peroneal nerve. This, of course, would be missed on an MRI, and give you some neurological symptoms of numbness, tingling, sharp, burning, etc. Ask the physiatrist if this is a possiblity. Good luck and I hope this helps some. Rich
Thank you for any insight, and may God Bless you.
Leslie (in Virginia)  (name changed)

Nerve Pain: Double Crush, Diabetic, Low Back??


I have had severe sharp stabbing and burning left foot pain for some time now. I was tested twice for neuropathy and found I am showing signs of it. A slight increase shown in the last test from the first which was three years apart. I am a Diabetic, not on insulin but taking 1500 mg of Metformin/day. I also have sciatic problems but mostly in my right foot. I blew out my l5-s1 in 1991 and had surgery to fix it. 6 moths later I was at the GYM working out on a machine and felt my right foot go numb. I put up with it ever since. I have been to three different Doctors about my pain. One claims it’s my neuropathy, another says it’s my back injury, and the last doctor (and current one) says it is Tarsitis. He gave my a shot in my ankle which took the pain away. BUT, it came back after two weeks. He gave me another shot but it only lasted four days. The pain is getting worse, keeping me from sleeping. Ice dose not work anymore. The pain is on top of my foot and on it’s left side looking down at it. It is also into my small toes. Seems to travel from in front of my ankle to my toes and wraps around the left of the foot.

No body has done an x-ray or a MRI. I am taking Lyrica which at first I thought it was helping but now the pain is worse.

Any suggestions?

John in PA  (name changed)

Dr Blake's response:

    Thank you so very much for the email. I am sure that there are some versions of Diabetic neuropathy that present like this, but it is an unlikely presentation and therefore not my top pick. However, it is a perfect time to make sure that your diabetes is under control. What is your HbA1c? Make sure it is below 6. You need to get a handle on what your neurological exam tells us. Please review the videos next.

So, from your description, and the 2 videos you can be dealing with a localized nerve (superficial peroneal or sural) or the L5 and S1 nerve roots, or both called the double crush syndrome. See the link below.

The injection you got was very diagnostic in identifying what nerve was involved, but it still does not tell you if all or some of the pain is coming from your back. Please follow these steps.

  1. Develop quickly a pain free environment, since nerve pain can get out of control. I personally had to get both an epidural and a sympathetic block since I could not calm mine down in 2004. I am presently nursing another back injury, and trying to be much better. 
  2. Get to a back doctor to do back xrays, MRI, and NCS/EMG. You deserve all these things because of the severity of your problem.
  3. Typically with nerve pain you are on some topical medication and oral like Lyrica. So, for right now ask about a topical and build the Lyrica gradually to 150 mg twice daily. 
  4. Work on your diabetes by getting the HbA1c and fasting blood glucose. 
  5. Use crutches, removable boots, activity modification, etc to get out of pain ASAP. 
 I hope this helps your direction. Feel free to comment. Rich Blake

Saturday, February 23, 2013

Sesamoiditis and Hallux Limitus: Email Advice

Hi Doctor,
I've been following your blog closely and I greatly appreciate your helpful optimism and passion to tackle people's ailing foot problems.  I was hoping that you could enlighten me with your opinion on the "Cluffy Wedge". I've pasted a link here I am struggling with sesamoiditis and hallux limitus, and so far I have found some relief with custom made orthotics from my podiatrist and a handmade, felt version of a dancer's pad which I wear with sturdy soled Dansko shoes. I tried the spica taping from your video with the kinesio tape, but I am unable to have it hold my feet in a sturdy and still position. It seems like despite bringing my toe down and taping it securely, it starts to come lose when I walk because of the necessary flexing motion of my feet that occurs. I stumbled on these cluffy wedges at the Good Feet store here in San Francisco and I thought I might as well try them. However I tried doing some research, and aside from their own site, I can't find many critical evaluations of the product. Are you familiar with them? And in your opinion, could it help with my sesamoiditis and hallux limitus? 

Thanks so much,
Sharon (name changed)

Dear Sharon:

     Thanks for sharing about the Cluffy wedge. Dr Jim Clough was one of my students, and I remember him well. How fun!! There are 3 or 4 very positive effects of his wedge that I put occasionally on my orthotics, but one big negative. The negative, based on how you use your big toe, the Cluffy Wedge may put too much back pressure on the sesamoids and increase the motion across the big toe joint when it should be lessened. These are normal aspects of working on the delicate biomechanics of the orthotic and shoe interface. I have routinely needed to have 3 different orthotic and padding combinations for the 3 main shoes a patient uses. Some made need the cluffy and dancer's, some Morton's extension, some greater arch support, etc. Now that you have written, since I have never actually called the padding I use a Cluffy Wedge, I will begin giving credit where credit is due. Also, try 3M Nexcare Waterproof tape, usually sold at Walgreens, for better stability when taping than Kinesiotape. Hope this helps. Rich

Thursday, February 21, 2013

Sesamoid Pain: Email Advice

Dr. Blake,

Thank you for being available through your website. Any help is appreciated more than you can imagine.

I am a highly elite competitive runner and I am experience issues with the medial sesamoid bone in my left foot. I had what was diagnosed as sesamoiditis back in 2010 and wasn't able to run for around 4 months. It was much worse in 2010 than it is right now.  To fix the problem I switched from a neutral shoe to a stability shoe and also got general superfeet insoles to help with over pronating. It worked well and I had no problems for over 2 years even running a ton of high mileage weeks, but it came back again here while I was only running very low mileage recently. I am desperate to get something figured out and I have a very exclusive high level team looking to add me to their roster but nobody wants to take on an injured runner..

Typically I run anywhere from 80-120 miles per week but I am barely able to run at all right now. I was running off and on to manage it but it wasn't getting better so I took 12 days completely off, then started back up but the pain returned by my 5th day of running. I have since took another 10 days off and began to run again yesterday. Only 2-3 miles.
Dr Blake's comment: You definitely want to establish a baseline of pain free running. For right now, run every other day, with cycling on the off days, and never run through pain. The initial soreness is fine. Ice for 20 minutes right after running, and several more times that day. Ice 15 minutes twice a day on your off running days.

There is still minor pain in the area but I am having a hard time figuring out whether I should be doing any running right now. There is minimal pain when running and Spica taping the toe to immobilize it while running seems to help reduce the pain. It does however hurt a bit when walking around, and there is always a 'feeling' there, no so much pain but just a feeling of it not being 'right', if you know what I mean? The problem is when I had sesamoiditis in 2010 it was still painful when I first started running again and I simply had to work through some residual pain during my first few weeks back. 
Dr Blake's comment: A runner needs to run in their rehab, even if it is one second!! The pain that injures or aggravates is not mysterious. Find what is bad pain, pain that does not allow you to run comfortably the next day, and modify your workouts until you stay below the threshold of injury (the Good Pain Zone). 

Right now I am doing spica taping daily, ice massaging with an ice cup 4-5 times per day, ibuprofen, theraband inversion eversion, etc, drills, toe pickups, wearing a metatarsal sleeve (this one -, and staying off of it as much as possible.  I have an appointment with a Podiatrist in Portland, OR who is a former high level runner but he didn't have any openings until late March so I am stuck waiting until then. I am almost certain it isn't a fracture because it feels just like 2010, only not as bad.
Dr Blake's comment: Use the ibuprofen very cautiously, since it can slow down bone healing, if there is a bone injury. Let me know if the sleeve works so I can recommend it. Do you feel that the inserts you are wearing is adequately protecting you? The insert should be shifting your weight on to the center of your foot and somewhat off weighting the sore area. Check the American Academy of Podiatric Sports Medicine website for a podiatrist in Portland, if you want to at least get started with a sports minded podiatrist. 

Is there anything else that you could possibly recommend to me to help speed up the healing process? 
Dr Blake's comment: You need an MRI to help sort out this problem, but you may not like the findings!

What about a cortisone shot, is that something I should look into with another podiatrist who can get me in sooner? Are they helpful in clearing up sesamoiditis? Is that something you recommend to patients ever? 
Dr Blake's comment: Cortisone shot only with a negative MRI and only with several months of no running, so basically "bad idea" in this situation. 

I really can't afford to take another 4 months off as I've been trying to get on one of these teams for years and the offer has finally came up and likely won't be available to me ever again as I'm already 29 years old.
Dr Blake's comment: You are so young, but I hope you can fulfill your dream. That is way too much running--over 70 miles per week. I thought runners were doing less distance and more quality now a days. When i was young, over 70 miles per week was normal, but boy did we get beat up! I am a wimp, however.

Thank you so much for you're time

Dr. Blake

In my previous email I forgot to ask..

Will doing theraband drills that cause bending of the first met/big toe cause harm? I al doings in bending the toes forward and backward against the resistance of a therband...
Dr Blake's comment: It is not mysterious, listen to what your body is telling you. Sounds like it is fine. 

Also, what about rolling out the area with a golf ball? I have been doing that as well to break up the tightness. Is that bad for it?
Dr Blake's comment: Listen to your body, and if there is soreness back off, even physical therapists have a hard time knowing at times what is good pain and what is bad pain. Hope all this helps you. Rich

Monday, February 18, 2013

Hallux Limitus/Rigidus: Getting a Good Plan Together to drive the Pain Down

Dear Dr. Blake,

It was so nice seeing you again today!
Thank you very much for the time and direction that you gave my husband and I in your office.

Below, please find the outline that you requested. 
***One quick question:  the dancer’s pad on my left shoe insert has two layers and the one on my right insert only has one layer.  Was this intentional or should I add another layer?***

Please let me know if you’ve thought of anything else that I should be doing.

I will communicate with you on or about February 14 with a progress report.

Many thanks again!

Phase 1:
·         Begin icing 3 times / day for 5 – 10 minutes each time.
·         Take Prednisone as directed for 8 days.
·         Ask Pharmacist if drug interaction with Prednisone and Ambien.
·         Use “dancer’s” pad (
·         Tape foot as discussed (Kenesio)
·         Begin Egoscue menu(s).
·         Investigate additional shoes =  New balance 928 / Muzano Wave Creation
·         Investigate carbon like insoles.

Phase 2: (after Prednisone program finished)
·         Begin taking Advil – 2 pills 4 times / day Monday thru Friday; no pills on Saturday and Sunday
·         Continue icing 3 times / day for 5 – 10 minutes each time.
·         Continue Egoscue
·         Continue taping
·         Continue dancer’s pad
·         Start walking (as a test)
·         Feb 14th – check in with Dr. Blake

Phase 3: -- to be determined
·         Series of steroid shots?
·         Iontophoresis patch 80 (Patterson Medical)

Dr Blake's comments: program looks great!! Okay to have slight unevenness between the sides, but make sure it feels okay to you. If not, even the pads totally, or slightly. 

Hi Dr. Blake,

I sure hope that your back is feeling better now!

As we talked about in your office  when I saw you on January 30th:

I am to follow up with you right about now on the results of taking the Prednisone  and then switching to the Advil. 
(Phase 1 as shown below in the e-mail to you following our visit)

Day 1     pain level 9
Day 2     pain level 8         a little better!
Day 3     pain level 7         better – especially in the pm
Day 4     pain level 3         walking well and used glute muscles that have not been used in a bit – gait more even- butt sore from using muscles!
Day 5     pain level 3         felt like I could walk on the treadmill = did not want to push it so did not
Day 6     pain level 4         a little worse
Day 7     pain level 5         inching away from a comfort level = worse
Day 8     pain level 7         continuing to get worse

Advil  (2 Advil 4 X day)
Day 1     pain level 7/8    
Day 2     pain level 7/8
Day 3     pain level 7/8
Day 4     pain level 7/8
Day 5     pain level 7/8

Icing (the entire time)
2 -3 X day for 5 – 8 minutes

Voltaren = patch & gel (started using after I stopped the Prednisone)

Taping = I feel I am not applying the tape correctly = it tends to aggravate the situation.  (I believe that I need to review how far down to pull my toe)

Dancer’s pads = feels great

Shoes = in order to control the pain & be mobile - I must wear Nike sports shoes at all times
I would like to figure out how to utilize some of the “props” that are available so that I can wear other (flat) shoes

Exercise = able to ride the exercise bike and the elliptical machine

Carbon insoles = still trying to find some that are reasonably priced (the ones in your sports shop are $99 each)

Rheumatologist = (upon your suggestion = possible other oral anti-inflammatory avenues)
I have an appointment with the Rheumatologist on February 22nd

My observations:
Felt so good on the days when my pain level decreased while on the Prednisone
Now feeling “lousy” and down about the situation = hate to say it but a little crippled…not happy!
I feel I need to really utilize all “props” available to try and avoid surgery (with your help and other ideas from you)

1.  Your comments on my response during the mid cycle of the Prednisone blast that allowed for a few “good” days and pain that was tolerable.   
      Was that a good response and the type that you were looking for?
2.  Do you feel that I  would benefit from  iontophoresis patch 80 ( a possibility that  we discussed in  your office)
3.  Would I benefit from Acupuncture?
4.  The current pain level is too bad to have to live with on a daily basis  ( I could tolerate the level 3 when I was on the Prednisone)
5.   I have a high tolerance for pain but not the direction it is going in right now
6.  Other ideas?

After reviewing:  Please let me know your comments and next step

Do I need to make an appointment with you for follow up?

As you can tell, I continue to need help with this situation.

Thanks so much

Dr Blake's comment:
 Hey, Hope you and your valentine are doing well.

      Glad the Prednisone did knock the pain down at least temporarily, but once you got to more normal doses--10 to 20 mg the inflammation came right back. Unsure why all of the great anti-inflammatory you are doing is not causing some dent in the pain levels. Typically, before we get the pain consistently to levels 2-3 we start seeing fluctuations in the pain level--one day 8 then next 6 then 8 then 4 then 5 then 8 etc. So, how do we accomplish that. 

     The carbon plates may immobilize it better. The Rheumatologist may have better anti-inflammatories to try. One or two shots of short acting cortisone into the joint may help. The ionto patch 80 may work. Acupuncture is a definite yes to try for 6 sessions. We need something to act like the prednisone to tip the scales in our favor. Since you are seeing the rheumatologist, let her try another anti-inflammatory. You can either do 6 accupuncture or 6 ionto patches, I have no strong feeling which would be better since I have had good responses and no responses with either. Rich I love these!!

Hi Dr. Blake,

I LOVE your hearts!  And….Happy Valentine’s to you and your wife too!

Thank you so much for getting back to me.

Interesting enough – the pain level today is down a tick…possibly the flector patch & gel are now starting to kick in.! I am keeping a running schedule of the pain level and activity and will share that with you in a week or two if I see marked improvement one way or the other that would help either way…

·         I will let you know what the rheumatologist has to say regarding another anti-inflammatory after I see her on the 22nd.

·         Do you know a good acupuncturist that you favor – I would be happy to drive into the city for someone that knows what they are doing and can follow your direction.  Do I need a prescription from you?

·         How do I order and administer the ionto patches?  Do I need a prescription from you?

·         I will purchase the carbon plates and monitor that as well and also try a little less aggressive taping on both toes

·         I think it would be a good idea for me to make another appointment with you in a couple of weeks so that we can talk after trying several of the options above and see which direction is best suited for my situation.  Possibly the injections if all else fails.  Do you agree?

So many thank you’s to you again!

Dr Blake's comment:
  Yes, schedule in 3 weeks. I am sorry, but I have no acupuncturist to recommend. I will try to send you in the next few days an Rx for the Ionto Patches 80. Once you get them, I will have you get the cortisone and make an appt with a PT to show you how it is done. Happy Valentines. Rich
 Thank you Dr. Blake!

I’ll be on the lookout for the Rx for the Ionto Patches 80 and where to order.

In the meantime, I‘ll find a good acupuncturist and start with that and then move to the Ionto patches upon receipt of instructions from you.

I will call your office today for a follow up appointment in 3 weeks.

I am confident that we together will find the correct formula that will help these toes of mine!

Hope your back is behaving…

Women's Shoe Recommendations with Foot Pain: Sesamoiditis

Hi Dr. Blake, I have job interviews coming up where I will be wearing suits, and I'm trying to figure out what dress shoes I can wear even though I have sesamoiditis in both feet. I saw that you have recommendations for men's shoes, but do you have any recommendations for women's shoes? Thank you! Oh! And do you mind not using my name in your blog?

Thank you!

      Dear Anonymous: Here the list we post for our patients. There of course has to be individualization due to width and volume issues. With sesamoiditis, under the big toe joint, you have to be concerned with too much heel height, although the exact amount can vary from shoe to shoe that would cause irritation. The amount of cushion in the insole or outersole is another help, too thin in this area can limit your protection. The volume in the toe box and overall width can be deal breakers, along with the softness of the toe box upper. For some shoes, like danskos the rocker bottom sole is vital, other shoes will feel great if the shoe is flexible in some instances, and stiff/rigid in other instances. If the shoe has a removable insole, alot can be accomplished with cushion, dancer's pads, etc. When the shoe has good arch support that can transfer the weight off the ball of the foot and into the arch and 2/3 mets.

 So, my patients are always evaluating these factors: heel height, cushion, rocker bottom, flexibility/rigidity, upper softness, width, arch support, removable insole, and toe box area/volume. I will try to recommend some individual shoes for each manufacturer. They are:
 1. Aetrex---Berries line of shoes
 2. Aravon Tess
 3. Ariat Safety Clog ST
 4. Beautifeel Rima or Ingrid
 5. Birkenstock Maine
 6. Clark May Poppy
 7. Cole-Hahn Air Tali Wedge
 8. Dansko Kitty or Abby
 9. Ecco Sculptured Lace
 10. Finn Comfort Soft Hanoi
 11. Sanita Coronado Wave
 12. Mephisto Figura or Niza
 13. Merrell Evera Pure
 14. Munro Derby
 15. Naot Nau Mai or Jasper
 16. Rockport Juliet
 17. SAS Maria
 18. Josef Seibel Belinda
 19. Stonefly Infinity Lady and Paseo Nappa
 20. Wolky Argentina and Namibia
 21. Ziera Lottie

Sunday, February 17, 2013

Ankle Strengthening Video: YouTube Viewer's Comment

YouTube Viewer's comment:
Why did you ask her to stop when she started to substitute?

Dr Blake's response:

When isolating a muscle/tendon while strengthening, it is important to strengthen that one muscle and not allow for substitution. Substitution means that the patient will use another group of stronger muscles to do the activity, and not use the weaker muscle (it will go along for the ride). By isolating a muscle/tendon, you can increase its strength rather quickly and correct muscle imbalances produced by strong vs weak muscles. Dr Rich Blake

Saturday, February 16, 2013

Short Leg Syndrome: Heel Lifts vs Full Length Lifts

Here are some of the comments on my You Tube channel on the Negative Impact of Heel Lifts Alone for treating a short leg. Make sure you are stable and feeling better functionally and symptomatically in whatever the type of lift you have. The goal of this post is to not have you blindly put a lift in if the provider tells you, but listen to how your body reacts to it. 

Comment #1

Never ever take advice off the Internet,such as this.
See an expert and get advice.
Heel lifts worked like s miracle for my short leg and the pain it caused,one leg was only a tiny fraction shorter,does that mean it isn't reason enough to be considered a rare case?
Always seek a good expert.

Comment #2

I have to agree with the other post about not being an expert in their field. Heel lifts WHEN used properly have reduced chronic pain. 1) That heel lift is way too much for that person. 2) If you bend your knee to offset the heel lift........IT'S THE WRONG SIZE This is some of the misinformation that is out careful and do your homework folks. 3) Plus she has Morton's toe from the looks of her feet...that's why she's unstable when trying to stand.

Comment #3

mine was 5mm and it almost killed me.

Comment #4

I've worn a lift in my left shoe for nearly 30 years. Personally, I prefer the full-foot lift as opposed to the heel-only lift. The heel-only lift causes additional pressure on my toes and the ball of my foot. I still use heel-only lifts when a full-foot lift isn't available for the specific shoe that I'm wearing.

2nd Metatarsal Help: Email Advice

Hi Dr Blake

     I am a 52 year old male and have been a practicing martial artist for 40 years. Over the past two years I have had a number of problems with my feet after suffering from Gout (hopefully now under control with diet modification) and having had hallux rigidus in my left big toe for as long as I can remember. 

     Of late the biggest problem has been with the second metatarsal on both feet which has made me question whether I would be able to continue my martial arts practice (which combines bare foot and shoe covered activity). After months of despair I came across your YouTube film on Spica taping and have today, with both feet taped, walked without pain for the first time In ages.

I wanted to say thank you for posting the film as it has given me great hope. One question I was unsure of was how long I could keep the tape on for? In the film your assistant said it would last a couple of days and that's fine I just wondered if there is a need to have a 'tape free' period on a regular basis?
Dr Blake's comment: The taping should be used when needed only after you have had 2 weeks of pain relief. Golden Rule of Foot: Tape or Brace for 2 weeks longer than you think you need to if the tape/brace provided a pain free or pain reduced environment. If you have been out of pain for 2 weeks, begin to experiment when you need it and when not. It usually is quite evident with increase pain during or just after an activity. With taping for the 2nd toe/metatarsal area, you should be icing 3 times per day for 10 minutes. A reusuable ice pack on the bottom of your foot while you multi-task is great. Consider some form of metatarsal support like the Hapads commonly demonstrated on my blog. Good luck and I am glad you are getting some good relief. 

Once again my sincere thanks for your help.

Take care.

Saturday, February 9, 2013

Night Cramping: Food, Nerve, or Blood Vessel?

Dear Dr. Blake,

I have a chronic problem with severe toe and foot cramping in my left foot primarily that occurs nights in bed.

It becomes so severe that I have to get out of bed and put weight on the balls of my feet and my toes to force them to bend in the opposite direction of the cramp.

This has gone on for many years intermittently.

I have read online that this can occur due to low potassium, or calcium, or magnesium.

I do take calcium supplements. For awhile I was trying to take potassium and magnesium supplements, but with no effect.

Many years ago an accupuncturist/herbalist recommended a book to me called "Food and Healing" by Annemarie Colbin that described the alkaloids in the nightshade family of plants (a large group, consisting of potatoes, tomatoes, eggplants, and peppers) leaching (her term) calcium and potassium from the bones.

Since reading this, I have always tried to think about what I may have eaten on the days that I get these attacks and invariably I find that I have indeed eaten some amount of one of these vegetables.

The amount needed to cause the effect really varies. I can eat tomatoes in a normal salad without problem, although once got a relatively mild attack after eating an entire bowl of tomatoes. On the other hand, I recently had a few grilled bell pepper slices in a couple of fajitas and had very painful, long-lasting cramps that night. On the other hand, other peppers, used as condiments primarily don't seem to cause the same problem. Eggplant also appears to have a strong effect.

Have you ever treated anyone with this issue?

So far, I've simply either avoided the food or lived with the results since the foods are pretty delicious going down.

Dr Blake's comment:

Thanks for the email.

      No, I am not wise on foods, other than what you already know. The 2 most common causes of this type of cramping I look into is a pinched nerve in the back (and you do not need to have back pain) and some form of blood clot (although if there you would not have a complete block). Both of these conditions occur normally when you stop for the day and lay down for a while. So, while you work on the food angle, I would also look into a low back specialist and a vascular specialist to rule out nerve or blood vessel issues. I hope this helps you. Rich