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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…

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.