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Thursday, April 25, 2013

Peroneal Tendon Surgery Rehab: Email Advice and The Role of Over Supination

Hello Dr Blake,

I am writing to you for I failed rehab after peroneal tendon repair (approx 20 mos ago)

I finally got fitted for custom orthotics at Davis shoes after an unsuccessful attempt at another orthotic place the last two months
  Arnie n Michael fix up my presurgical orthotic so that I have something while they work on my real one which will be ready in several weeks.
My problem is not just fallen arches; now I understand why I struggled everyday after returning to work  post surgery in superfeet

My question is what is a bad pain? My first day with this  orthotics; I am better than I have been since 1/2012.
Dr Blake's comment: See my post on Good vs Bad Pain

Tonight, my legs are achy (deep) after rolling
The temporary orthotic seem to help my surgical ankle -no burning up laterally to my butt; just stings in ankle joint, but I have pain in nonsurgical inner ankle which I started to experience back in 4/2012; post tibial tendinitis

They tell me to ease into this but I am a Neonatal ICU nurse who is on her feet 8 hours (duration of my shift)

I need some help in making better choices to heal my body

Thank you in advance

Amanda (name changed)

And here was another early email

Good Morning Dr Blake,

I am writing to ask about gait training ...
I had peroneal tendon surgery 7/1/11(slipped in water n fell onto my ankle bone on 12/20/09; didn't know about torn tendon til 8/10)
5  mos (12/1/11) after surgery I returned to my job as a neonatal ICU nurse/12 hrs shift; I had problems almost immediately; I decreased my hours to 8 hrs shift at end of 1/2012 and I continue to struggle all of 2012.  My surgeon recommended superfeet before n after surgery
I used superfeet n presurgical custom orthotic through out my journey. I did not realize that my problem was more than just fallen arches n  lack of strength

I was at my worst by winter of 2012.  I could not bear weight on my L side.  My surgical ankle showed it's problem by sending burning pain up to lateral calf as well as to hip n butt
I now have a temporary orthotic from Davis shoes  n can see that I don't push off with my big toe; burning to hip only happens at 6-8 hours

My podiatrist thinks it's time for EMG
I don't have auto immune disorders; just chronic pain from shoulder injuries a decade ago
I don't believe I need Lyrica
I started a PT program for core strength ( Pilate on reformer) in Jan 2013; has help me some
I think that I am doing something very wrong
So, this am I am thinking gait retraining is important

Dr Blake's comment:

Amanda (name changed),

      Since you are in a painful state, you really should be in some form of brace for standing/walking, and then gradually restrengthen your peroneals. You probably have some nerve pain, but does icing at least temporarily calm down the pain? Watching you walk and then prescribing the right shoe inserts is crucial. But, you will still need to get very strong. Do you have alot of scar tissue? What does the PTs say is the reason you hurt? What do your doctors say? Any information is appreciated. Rich

Thank you so much for writing back and your advice on bracing/getting the peroneal stronger

Some how that did not cross my mind.  I will go back to using the figure 8 brace.  I have reviewed your blog for the exercises. I don't think I was ever doing them like your video. I was using yellow and red for point n flex.  PT had me doing lots of point n flex; towel pulling n activating quads; soleus on weight machine; two calf stretches. I had about 15 PT Postop. I  work on balance  very minimally ( after my 3th 12 hours shift my right foot got caught in a wrinkle of a carpet as I was exiting the hospital. I didn't react I just fell onto my knees n hands
Last w/e i found out I still don't like to react with the right side
I have been told that my R hip is tighter but I feel more pain in my left 
I stopped the therabands when I started to have more and more problems  as I returned to work
Dr Blake's comment: Therabands are a very difficult exercise to do correctly and can take a skilled podiatrist and/or physical therapist to help you do it correctly and safely. Here is the link most likely to help.

I also have the donjoy brace but it got too uncomfortable the last time I used it (about 10 days ago)
My podiatrist continues to just say my R ankle is structurally  sound.
  He is planning for me to get EMG testing even though the burning pain goes away the next day or after contrast bath.  I knew about flashing (contrast bathing) from previous dequevain injury
But I have been doing them differently from your blog; works quickly n well all the way up to the thigh.
I will do the warm n cold then elevate after as well as writing the alphabets

He asked me to see a rhumatologist last year and I did and to get Pilate txs for my core.  
He wrote for acupuncture txs when I told him that I was not going to take lyrica;  it has helped some
He finally wrote for more PT to treat my lower exts as well as hips; I am to use my own insurance for Work comp has denied all tx as of 10/2011 so I have not seen s PT til this Jan.
After 20 sessions she did say I am using my hip more n not my shoulders; she did work on my incision at my last visit

My AME said I don't need any PT for I had too many and I just need myofascial therapy for my symptoms have spread all over ---laterally up 
So, my myofascial therapist has elbow massaged from ankle up to the butt because I was sore in my  thigh after a shift
I have some scar tissues 
I am working on it as much as I can
I can now balance on single leg for 2mins; I could bearly do 1 min last October
L Post tib tendinitis is better; I just massage the soleus trigger points 
My L side really suffers qoday unless I stay off my feet
R side pain was gone for about 7 days after I begged another doc to inject my peroneal trigger points because I don't want cortisone injection from my podiatrist

I am seriously looking for a new rehab plan;  rehab was what I was worried about before committing to surgery n I somehow got derailed.  At the time I  spend so much time in the pool because I was worried about my core n spine ...
now I am stiff all over but glad that Gail and Carol have given me your name and have found your blog

Thanks again 

Good Morning Dr Blake,

I spent  Sunday reading your blog, contrast bathing and trying the peroneal L/B Thera band exercises, stretching my Achilles w excercise band for 45 mins, compression sleeves and staying off my feet,  etc

Is it normal/ok to have this slight pain at the end range of exercise behind ankle bone?
Dr Blake's comment: Yes, and it is totally fine. You should avoid the end range of motion in either direction as you do the therabands. It is where the internal tissue is either too stretched (in one direction) or too compressed (in the other direction). 

Is it okay to kick in the pool by swimming or be in water exercise class if I am having pain?
Dr Blake's comment: Again, the article on Good vs Bad Pain should be memorized. You must know the difference to rehab correctly.

I had no/minimal symptoms on R (surgical foot) when I wake this am
Burning pain left me during class  but left side  flared after deep water exercise class/ after my 8 hour shift on Sat; from ankle to ribs. Inner ankle to outer ankle  like where perineal would be  contrast help some but too uncomfortable for compression after so i just try to roll; stretching the Achilles for 45 mins at midday on Sun did help all the symptoms from my mid back/ribs/ inner thigh/knee pain
Does tight Achilles cause you pain straight down around your ankle  bone?
Dr Blake's comment: Yes
I don't feel much stretch when I try this prolong stretch to my surgical ankle
I think that I am not getting it deep into or behind that bone
I have always had that problem
I also did not tell you about my bunions; R worst than L
Only had pain in that joint when I wear high heels which was very rare

Thanks again


Dr Blake's comment:

     I had the absolute pleasure on seeing Amanda as a patient, since she lives locally. Amanda has what 10% of the population has, over supination. This motion was not really helped by her orthotics, so I adjusted them. Excessive supination as shown in the links below is devastating on peroneal injuries since the peroneal tendons must stabilize the ankle and resist the over supination. By controlling the excessive supination, the peroneal tendons should not have to over work and her symptoms should improve. I was able to see that she had Peroneus longus weakness, no achilles tightness, no scar tissue issues, and stable shoes. She should do just fine.

Another Hawaiian Sunset

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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.