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Wednesday, July 31, 2013

Foot Sprain: MRI Needed


About 5 weeks ago, I fell and the foot began to swell and turn to a purplish shade within about 5 minutes. I ended up in the E.R, being diagnosed with a bad sprain, and it was put in a splint for a week. 

Although I stayed off of it completely for that time, the swelling, pain, or coloring had not improved at all. In a visit to another orthopedist, he diagnosed it as a chip fracture, caused by tearing a ligament with the bone. He put it in a cam walker originally for 3 weeks. After those weeks, he looked at it again, but the swelling had not gone down very much, and the pain seemed to have increased, if possible. He said to leave it in the boot for 3 more weeks, later transferring it to an air cast, before beginning therapy.

 But now, a week before the follow up, the foot hurts more every time I put pressure on it. The pain is not in the ankle, but in the inside of the foot and the heel. The swelling has gone down a bit, but the bruising has returned, and the pain is becoming more unbearable. Is it possible more than one ligament has been torn and this may require surgery?
Thank you

Dr Blake's comment: 

     Thanks for the email. I hope you can get an MRI to really know what is going on. Typically when you are in the boot, the swelling does not get much better, but the pain does. Something is going on that no one knows yet. Try to experiment to see if crutches help, but push the health care system to get an MRI. I hope this helps. Rich

Bunions Self Care: A Video Discussing Non Surgical Options

I hope you enjoy this short video discussing the common treatments used in avoiding or preventing the need for bunion surgery. There are many posts in this blog discussing all of these points.

Tuesday, July 30, 2013

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I've been following your blog since January, and I see that you have a lot of great advice on how to deal with sesamoid injuries. I've been following the advice you provide to people in their posts, but I'm very frustrated because I have yet been able to heal my injury completely. I believe my situation is somewhat unique so I would be so very grateful if you would consider reading about my situation?? I apologize if its so long!!! (feel free to cut stuff out if you want to post it on your site)

About a year ago I had a job where I was doing a lot of walking, which is what I believe caused my injury. I remember one day coming home and not even being able to put any weight on both my sesamoids. I resorted to just walking on the sides of my feet. However, it went away for the most part after a couple days of rest. And although it continued to bother me intermittently, it seemed as if it was just a temporary condition that would heal with rest. Soon after, I got another job that didn't require much walking, so during daily activities I just remained mindful to wear shoes that were comfortable. 

But then 6 months later (December of 2012) the pain in my feet increased to the point where I was regularly having trouble walking pain free. I finally saw a podiatrist and was diagnosed with sesamoiditis. I resolved to rest, rest, rest. I started doing contrast baths, and I made several versions of dancer's pads which I wore in brook's addiction shoes and wore with custom made orthotics. I found your blog and followed your advice on icing. However after a couple months of resting and contrast baths, I failed to see any improvement. In fact, it felt like it was just getting worse. I finally got an MRI of my right foot since that one was the more painful one. The MRI showed that the sesamoid was inflamed and it was either bipartite or fractured. The thing is that although it was the sesamoid itself that was inflamed on the MRI, I also have just overall pain and stiffness on that whole metatarsal region of the foot and my big toe. The pain sort of moves from one region to the other, and doesn't always remain localized in one spot. Sometimes it feels like its the bone that hurts, other times, a fleshy part and maybe a tendon.  I was previously diagnosed with Reynaud's phenomenon, so my feet are very sensitive to cold and I made sure to soak them in hot water on the regular in order to maintain good circulation.

 However, the condition of my feet began to decline, and in May I decided to quit my job because I felt like the stress from work, and the fast paced life I was living were causing increased stress to my feet. I wanted to make my feet my #1 priority. At that time, my doctor had told me to wear a boot on the right foot for a month, but by the end of the month, my foot didn't feel better. In fact, I was having new pain in different parts of my feet. Especially along the outside edge of my right foot, including the baby toe. Along with this I developed weird tingly sensations all over my foot but especially in these painful parts. By this time I was really fed up, and feeling very hopeless about my situation. I'm only 24 years old and having to deal with this for the rest of my life is not at all something I want.

After I got my boot off in mid June, I went out and bought new shoes by this company called Alegria  These shoes really seemed ideal because of how rigid the sole was. I paired these shoes with some insoles by a company called barefoot science which are supposed to strengthen your feet. I also proceeded to do strengthening activities by balancing and using latex bands. I started walking more and being more active which really helped encourage the circulation throughout my body, and in turn my feet.  I believe that wearing these stiff soled shoes really allowed me to carry out all these activities that were previously very intolerable. With these shoes I've been able to do more than I have in the past 7 months. Earlier this week I was actually able to do bikram (hot) yoga. (What I've noticed about my feet is that they are very temperature sensitive. And being in a warm, or hot environment seems to make them feel better. Especially being able to walk around and be active to encourage the blood flow.)

However, regardless of this improvement I am still struggling with just walking. Something about the movement in my feet while I'm walking causes more discomfort than standing and doing crazy balancing poses in yoga. When walking, I will sometimes still feel pain or stiffness in the Alegria shoes, but when I do, it is not quite as debilitating (like a 1-3). However, if I take these shoes off and try to wear other shoes (Even Brook's Addiction) or walk barefoot, my feet feel just as they did before. Walking barefoot a little doesn't cause immediate pain, but if I do it for longer than a minute, then my feet will hurt more for the next couple of days. I'm conflicted because although these shoes have provided a tremendous amount of relief, I'm starting to think that all they're doing is just covering up an issue that is clearly still a problem. It just seems weird to me that after wearing them for over a month that I still can't even step out of them to walk comfortably. A lot of my improvement has come from me being more active, so I'm starting to wonder that maybe I should ditch the shoes and push through the pain, in order to ultimately strengthen my feet and increase blood flow ( I don't really know how to tell the difference between good pain and bad pain. Its all bad pain for me). I've just already delayed a lot of things in my life because of this injury, and I'm feeling really impatient and eager to get back to doing all the same activities I used to do. Do you think that by continuing to just wear these shoes and avoid being barefoot, I will likely see improvement with my feet? Am I just being impatient, or do you think that resting may not be the best solution? 

I'd love to hear whatever thoughts you may have. Thank you so much for your time. And sorry again that this email is so long!!!!

Dr Blake's comment: Wow, where do we go from here? Reynaud's Phenomenon surely complicates things since you can not ice, like the rest of ice, so you need medications more to reduce inflammation. Most NSAIDS can slow bone healing, so you want to be cautious. I would still take 2 Advil 3 times daily to reduce inflammation and stay away from the warm water soaks (which may be allowing your body to hold on to the fluid). By my calculations, the MRI was in Feb/March, so any time you can get a repeat MRI to compare with the old one and see if any sign of healing is occurring. I will try to look into this shoe more, which sounds great, and weight bearing pain free is always better than non weight bearing. Sesamoiditis, even complicated with bi partite sesamoids, does not present like this so we are probably dealing with a fractured sesamoid. When a bone fracture seems slow to heal, then we have to think about bone health. What is your bone density? What is your Vit D3? Definitely your doc should be getting a bone stim. I like Exogen's ultrasound unit. 

     You need to create a pain free environment for the next 3 months. If that is with partial weight bearing with crutches, or with full time use of Alegria shoes, do it!! We need some weight bearing or the bones demineralize too much and there is problems. 

     Remember, anyone with a sesamoid fracture (diagnosed with MRI and bone scan) is a candidate for surgery. You do not have to suffer. Surgery is done when conservative treatment fails. Each patient is there own judge when enough is enough of conservative management. Just make sure at this point that your inserts/orthotics truly off weight the sore area, since it is crucial to avoiding surgery, but also crucial if you and your doc decides surgery is necessary. I hope this helps some. Rich

Monday, July 29, 2013

Generalizations in the Treatment of Athletic Injuries

I hope this short video helps you with the basic principles of treatment in athletic injuries.  

Sunday, July 28, 2013

Ankle Sprain: Injury Advice


     About 5 weeks ago, I fell and the foot began to swell and turn to a purplish shade within about 5 minutes. I ended up in the E.R, being diagnosed with a bad sprain, and it was put in a splint for a week. Although I stayed off of it completely for that time, the swelling, pain, or coloring had not improved at all.

     In a visit to another orthopedist, he diagnosed it as a chip fracture, caused by tearing a ligament with the bone. He put it in a cam walker originally for 3 weeks. After those weeks, he looked at it again, but the swelling had not gone down very much, and the pain seemed to have increased, if possible.
Dr Blake's comment: With a 3rd degree sprain with chip fracture, swelling is going to take 4 to 5 months to go down. It never goes down when you are immobilized, as the velcro straps above the ankle will prevent the swelling from going back towards your heart. You can help this with compression within the walker, elevation, massage, PT, acupuncture, contrast baths, and various salves. You will see the first real reduction in swelling when you can walk normal with the cam walker for 2 straight weeks. The second reduction in swelling occurs when you have been able to wean successfully out of the walker and are in the Aircast brace full time. 

   He said to leave it in the boot for 3 more weeks, later transferring it to an air cast, before beginning therapy. But now, a week before the follow up, the foot hurts more every time I put pressure on it. The pain is not in the ankle, but in the inside of the foot and the heel. The swelling has gone down a bit, but the bruising has returned, and the pain is becoming more unbearable. Is it possible more than one ligament has been torn and this may require surgery?
Dr Blake's comment: 30 years ago, in the infancy of sports medicine as a discipline, doctors and physical therapists were encouraging mobilization for ankle sprains, not immobilization. I definitely feel this needs to be tailored to each individual, but immobilization can lead to all your symptoms. When you sprain an ankle, you may have an obvious injury, and several less obvious injuries (minor or severe). Since you are having more pain, the obvious thing to do this next month is to get some other test your doc feels appropriate (MRI, bone scan, other xrays, etc) and to re-create a pain free environment (different boot, out of the boot, crutches more, or some obvious change in your activity). Typically with your injury I would have you in PT within the first week. The PT can successfully work on the swelling, find sources of pain, re-create a pain free environment, and give great feedback to the doc treating. Surgeries for torn ligaments, even with chip fractures, are done 9 to 12 months after the injury when the PTs can not find a way to get you functionally stable (where you feel a small crack in the road will cause a sprain). I sure hope this helps you some. Rich

Saturday, July 27, 2013

Achilles Stretching: What if it hurts?

YouTube Viewer Asked:
What if your achilles gets irritated ?

Dr Blake's comment:

If you are doing achilles stretching exercises, and you feel that the tendon is getting irritated, you must back off. There are many ways to do this. You can try spending less time (say 20 seconds not 30 seconds). You can try going a little less deep into the stretch. You can use heat before (or massage) stretching. You can ice for 5 minutes after the stretch. Once you find the appropriate stretch that does not irritate, gradually increase the stretch over the next few months. Hope helps. Rich

Another YouTube Viewer Wrote:
I read that these stretches can be done with pain and can improve the pain.

Dr Blake's comment:

See my comment above. Pain is so subjective. Yes, pain between 0-2 on a scale of 10 is probably okay since you are stressing the tissue. However, your level 2 may be my level 5 and someone else a 0. We all have different pain levels. That being said it really boils down to you listening to your body and feeling what is good pain and what is bad pain. 25% of people are natural at this, the other 75% really do not get the idea so online advice has to be somewhat conservative. Hope this helps Rich

Thursday, July 25, 2013

Sesamoid Injury: Email Advice

Hi Dr. Blake,

Your blog is the best resource I've found for sesamoid injuries. Thank you for giving me hope.

This has been a frustrating injury. I am a female runner, 29 years old, and I went to a podiatrist after feeling some pain in my left foot during plank and downward dog in Pilates.  After an initial mis-diagnosis, via an x-ray he found that I'd fractured one of my sesamoid bones. I went a month without running, but the pain didn't go away. I was even beginning to feel it when I walked up the stairs at work.

I decided to seek a second opinion, and went to see an orthopedic surgeon who specialized in feet and ankles.  He did more x-rays, and advised me that my fracture was worse. He then gave me an air cast (walking boot), and advised me to see him in 4 weeks.

After 4 weeks in the walking boot, I went back to the doctor, and he advised me to try walking without the boot.  After 3 days I was limping, and was in pain.  This was so frustrating because the entire time I was in the boot, I was pain free.
Dr Blake's comment: With sesamoid fractures, you need 3 months in a removable cast, followed by a 2-6 week gradual wean out process keeping the pain level between 0-2. There is normally no skipping corners with this tricky injury. 

I put the boot back on, and called the doctor.  His assistant advised me to leave the boot on for another 4 weeks, and to then see him again.

It was durning the second 4 weeks in the boot that I found your blog.  I was concerned that we couldn't really see the bones in the x-ray, and couldn't tell how I was actually doing. On the follow-up appointment with the doctor, I requested an MRI as you'd suggested in your blog, and had an MRI the following week.

On another follow-up appointment the next week, upon reading the MRI, the doctor advised me that the bone had healed, but that it had then necrotized.  Looking at the bone on the MRI, it was darker than the other bones.  What didn't make sense to me was that the bone would heal, and then just die.
Dr Blake's comment: That is typically a mis-read. The bone is inflamed for months and months even after healing, which makes it look darker on T1 images (bone is white), and whiter on T2 images (bone is dark). 

I read in another part of your blog that bone growth can be misdiagnosed as necrosis on an MRI.  Do you think this could be the case?   Should I have a CT scan done?  What is the difference between an MRI and a CT scan?
Dr Blake's comment: CT scan shows only bone anatomy in 3D, and MRI is great for showing soft tissue and fluid within the bone. I would just wait a minimum of 3 months for a followup MRI to see if these bone changes look better. MRI changes are much more predictable for this injury. 
I've been in the boot for 2 1/2 months now, and still feel tenderness and some pain if I land wrong on my foot. 
Dr Blake's comment: The key line is "if I land wrong". The sesamoid is going to be tender, especially if you land wrong, for months and months. This is not a sign of poor healing. This is the time to be designing a shoe insert that you are going to be wearing to off weight the sesamoid post cast. It is essential to weaning successfully off the cast. You place that insert in the boot also while you continue to wear the boot. 

 The doctor is suggesting surgery to remove the bone, but that makes me very nervous.
Dr Blake's comment: Average sesamoid surgery, which is done rarely BTW, is over 1 year after injury. Fight hard to save the sesamoid. It is important.

  I have a copy of my MRI, and am seeking a second opinion before considering going under the knife. My mom had a sesamoid removed, and said that she still has pain from the surgery after many years.  I'm not ruling surgey out, but I don't believe it will only have a 2 month recovery time that the doctor is suggesting.  If the bone is actually dead, I want to make the best decision that will lead to a pain free and active life.
Dr Blake's comment: I would be happy to look at the MRI, but any elective surgery should get a 2nd opinion. Look at the AAPSM website for a fellow or member near you. These are sports minded podiatrists that typically share my anti-surgery zeal unless proven it is needed. Email me with your city and perhaps I can narrow your search. I hope this helps. Thanks for all your kind words. I think you you need to investigate icing, contrast bathing, orthotics, taping, bone stimulators, dancer's pads, etc. Rich

Thanks for all your help.  Your blog is wonderful, and has really helped me understand what is happening with my foot.

Take care,

Wednesday, July 24, 2013

Severe Foot Injury with CRPS and Possible Injections: Email Advice

 I received this email today 7/24/13. This patient is in very capable hands, with only some of the facts coming to my attention. My answers are only with great concern for the patient since it is impossible to really know what direction to answer some of the questions. Patients who develop CRPS truly suffer and need to trust their doctors. In my answer I give general guidelines, but they are only guidelines. Every guideline has exceptions, and individual situations sometimes demand taking risks. This patient is in an extreme situation where sometimes risks are worth it. So, in my answer I have many questions. I agonize over what is right.  

 I suffered a severely crushed foot one year ago today. All five metatarsal joints were fractured into many many pieces and soft tissue damage was severe. Surgery to repair them resulted in an external fixator for 8 weeks, hard cast for 2 weeks, boot for another 4 weeks ( non-weight bearing for close to 4 months). Temporary pin was removed 4 months later resulting in confirmed diagnosis of RSD/CRPS which I've been under pain management care, the surgeon's care and continuous PT.

     Foot developed severe arthritis almost immediately with osteoporosis now confirmed this week with MRI. The reason they finally did an MRI last week was because of the continued anterior ankle pain and stiffness that wasn't responding to PT and Massage therapy. I've complained about it repeatedly since I started weight-bearing last November, but no one paid any attention until last week when my foot surgeon ordered the MRI on foot plus one on the ankle. MRI confirmed a "partial thickness longitudinal split tear within the infra malleolar peroneus brevis tendon"..
Dr Blake's comment: This is tough since the peroneal tendon is along the outside of your ankle, and you describe the pain being in the front of your ankle. Also, get an ultrasound imaging of the peroneus brevis, since MRIs miscall this all the time. Let us make sure this is really a major source of your pain. 

     Surgeon immediately wanted to schedule operation to fix the tear then almost immediately remembered I was an active RSD patient. So absolutely "no surgeries" while RSD is active (which clearly could be forever). Even if RSD goes into remission and he could do surgery, it most likely would bring another attack of RSD (which is a horrible horrible disease). I still do not understand how or why the original MRI done when injured didn't mention this tear and the exact pain I have has been the same since first day of weight-bearing, so It didn't happen "latter on". I am also not convinced that this particular injury "may" be the main culprit of my RSD.
Dr Blake's comment: Unfortunately, CRPS can just develop with this scenario of severe injury and immobilization. And definitely you want to have more than one person say with certainity that your symptoms are related with this possible tear. And, if you need surgery, there are pre and post surgery protocols to limit the risk of another attack for RSD patients. 

    So -- he suggested cortisone shot which would not fix tear but "perhaps" would allow for asymtomatic pain relief until such time I could have surgical repair. I immediately said that I "thought" cortisone was harmful to tendons and ligments and he said "only if injected directly into the tendon or ligament -- he is injecting into the tendon "sheath" and that won't cause a problem he says.
Dr Blake's comment: If there is a tear, the cortisone will go into the tendon from the fluid around the tendon where it is injected into. I would be very nervous. Does cortisone going into your tendon cause a rupture all the time, definitely not. I am not sure the odds. 5% or 10%. Please ask the surgeon. You weigh those odds, with the odds of the shot helping you. Only your surgeon would have some idea. I can really only raise the questions, give generalizations, etc. Not a cop out, just reality from where I sit. 

    I am assuming it will be a long-acting cortisone. Also ice can not be used due to the RSD, so your "icing" after injection would not be possible for me. You also say I should be immobilized for 3 days - how??? Put in a brace or something? I saw your blog page where you say "never" inject long-lasting cortisone into a tendon or into it's sheath so now I am extremely confused/ worried/ and scared of more permanent damage as I already live with large level of disability with the RSD, the crushed foot, (and also my back was broken and I had a kyphroplasty to repair two crushed vertebraes).
Dr Blake's comment: Yes, do no harm. One idea is to inject long acting local anesthetic into the sheath, after 30 minutes of Synera Patch, and use an ankle brace to protect the ankle for the next 6 hours. This will tell you diagnostically if the peroneal tendon is the source of your pain. Be prepared for a 4 day flare of RSD which can be eased by the understanding that it will past, meditating, see if you can get sublingual Ketamine for the flare, and getting off your foot for several days. Definitely talk to the pain specialist and surgeon about how you will handle a flare post shot so you all have a plan. 

    Since my surgeon is actually "internationally" well-known as one of the best in the business today, I worry about constantly questioning him or telling him I read this or that that contradicts what he says to me, etc.
Dr Blake's comment: You have to feel that what you are getting done is the best. There are so many conflicting bits of information, that I constantly doubt my decisions, but at some point my patients and I have to make them. There is many rights and many wrongs. And, we all get tunnel vision in one approach. What does the pain specialist say? Does he understand about RSD pre and post surgical protocols? What are all the treatments for CRPS you are undergoing? Are you going to consider Ketamine Infusions? If you can get the CRPS calmed down, I would feel a lot better talking about injections, etc.

   " Short-acting shots normally are beneficial for 3 days and are used to quickly reduce inflammation. They are commonly betamethasone (6mg/ml) or dexamethasone (4mg/ml) formulas. Since even short-acting cortisone can cause damage/weakness to tendons, if given into tendon sheaths the body part should be immobilized for the 3 days. It is the long-acting shots that are the true healers when the inflammation is out of control, and normally what people are talking about when it comes to a cortisone shot. Long-acting cortisone shots should never be given into tendon or tendon sheaths (the covering of the tendon) since they are associated with tendon ruptures. It is important to keep the cortisone as far away from the neighboring tendons as possible." (excerpt from Dr Blake's blog).

    Since your "blog" page is from May of 2010, I am wondering if the cortisone issue has more recently been rethought and would appreciate any updated thoughts you may have. I really have encountered so much conflicting information, I feel like just giving up any hope of returning to how I was before the accident.
Dr Blake's comment: This is still my thoughts, and there has been no change in cortisone makeup or tendon anatomy. I would focus right now on getting a possible local anesthetic shot first as mentioned above, if your pain specialist feels that a shot can be safely given with perhaps sublingual Ketamine, to prove you may be a candidate for peroneal injection. Only then, should be again weigh the odds of cortisone into a tendon sheath. I hope this helps you some. Answering an email like this always makes me feel small, humble, somewhat stupid, and unbelievably touched with a sacredness. Thank you. Rich

Posterior Tibial Tendinitis: Brief Video Discussion on Treatment

Tuesday, July 23, 2013

Morton's Neuroma: Email Advice

Hello Dr. Blake,

      I recently came across your blog while trying to better understand my diagnosis of Morton's neuroma in my left foot. I noticed you are in San Francisco and was hoping to set up an appointment with you, since nothing I've done seems to help the pain.

      I began noticing a strange sensation in my foot last September, but didn't take any measures to treat it until December 2012, when it began to feel significantly worse. In summary, I had 3 cortisone shots but still experience a lot of pain and would like to find out if I am a candidate for surgery, as much as I'd like to avoid it.

      For a very detailed account, here are the steps I've taken so far:

 1. I went to see a chiropractor first, since my mom thought it might be similar to her foot pain, which he treated by working on her back. With minimal observation, he thought perhaps I had a metatarsal sprain or pulled tendon and suggested daily ice an massage.

 2. One month later when the pain got worse, I set up an appointment with a podiatrist and got an x-ray to rule out a stress fracture. When I saw her she confirmed that it was actually Morton's neuroma, and suggested 3 cortisone shots over the course of 3 months in addition to wearing only shoes with orthotics.

 3. My first cortisone shot was on Feb 13th 2013, and after about 48 hours I estimate that it felt about 30% better. Actually, she injected two shots - one between the 3rd and 4th metatarsal and one between the 2nd and 3rd. She said the injection included Marcaine (0.25% plain), Kenalog 40, and Dexamethasone 4 mg/ml.

 4. On March 20th, I had my second round. Again, I noticed a 30-40% improvement, so I really felt like I was on my way to recovery.

 5. On April 22nd, I went back for my third round, but she decided not to give me the third shot, suggesting that it would go away on it's own.

 6. A month later, when I still felt some slight discomfort, I made another appointment because I was afraid to resume my normal activities or wear other shoes without orthotics. On May 21st, she gave me a third round of shots. However this time, it seemed like the injection made it worse and it seemed like almost a week before I could put equal pressure on both feet.

 7. When I told my podiatrist that I was still in pain, she ordered an MRI, but I declined because I have very minimal health coverage, not to mention that I was very frustrated with how casual she was about the treatment. She said it was very common and very easy to treat.

 8. Since June 4th, (this email was received July 21st) I have been going to regular acupuncture appointments twice a week. I definitely seems to help with pain management, but it does not feel like a solution. The pain now seems to vary day to day, depending on what activities I am doing. All this to say, I feel pretty desperate for your help because I don't know what else to do besides surgery, and I would like to avoid it at all costs! If possible, please let me know if I can set up an appointment with you. Many thanks, Susan (name changed)

Dear Susan,
     Thank you so very much for your email. With your health insurance issues, I will try to minimize visits. You can call the office any day at 415-353-6400. But first, here are my thoughts for your to think about. 
1. You have definitely had adequate cortisone, which each last for 9 months, so are in there working right now. 
2. What does cortisone do? It controls swelling around the nerve that is all. So, even though the cortisone is working, you can still have nerve pain which is not inflammatory. 
3. Continue to work on any remaining inflammation however by putting your foot on an ice pack for 10 minutes 3 times daily.
4. What can be the cause of the residual nerve pain? Typically it is mechanical pressure and nerve irritation from above the foot. 
5. How do we work on the mechanical pressure part of the nerve pain? You change the weight bearing on that part of the foot. Here we are only limited by our imagination. We have so many choices, and you need to find out what excites the nerve and what does not.
6. Part of the mechanical fix is always inserts/orthotics which are carefully designed to take pressure away from the sore area. This insert is the staple of the treatment. But, staying away from tight shoes, too high heels, shoes with poor padding, and shoes with too much flexiblity should be done. 
7. Many times I will use a removable boot for awhile, with an EvenUp on the other foot, to rest the area while allowing the patient to walk. You can get the Anklizer at relatively cheap. 
8. Avoid barefoot for sure, find a clog or sandal or slipper that does not irritate you at home. 
9. Check my blog and online for Hapad Adhesive Felt Longitudinal Medial Arch Pads. I use the Small size on most patients, and there is an art to applying and adjusting. However, if you are not afraid of making mistakes, you can move them around, thin them, cut them shorter or narrower, to individualize the design for each shoe. I love these. They can be put in any shoe that orthotics do not go into, even heels and sandals, and may even be better than the orthotic you have.
10. I do love Acupuncture for this syndrome. Acupuncture works at the nerve layer of this injury, and can be very helpful. 
11. For your money, I would see a neurologist/physiatrist next. You really need to get their advice on whether this nerve pain is coming off your back (even if you have no back pain), and if they recommend nerve drugs (oral or topical) to help you. I would at least understand the concept of double crush--type into the search engine on this blog. 
12. Definitely get a bottle of Neuro-Eze. For $30/bottle, you rub a small amount into the area on top and bottom of your foot for 1 month, along with everything else. It is homeopathic, a concentration of L-Arginine, a natural amino acid. 
13. Take this one month at a time. So few patients need surgery that you are not close to that right now. I hope this gives you some focus for the next month or so. Rich

Monday, July 22, 2013

Plyometrics for the Distance Runner: Fitness Tips from Personal Trainer Lisa Tonra

PLYOMETRICS for the Distance Runner - JUMP for Faster Race Times and More Energizing Runs!

5K, 10K and half-marathon runners! Looking for faster race times, a greater sense of 'ease' with your run and greater running efficiency? It's time to step (or hop) it up with plyometric training!

Plyometric training helps runners recruit muscle fibers in the most efficient way. Plyometrics are based on the principle that a muscle's Stretch-Shortening Cycle (defined as an active stretch, or eccentric contraction of a muscle, followed by an immediate shortening, or concentric contraction of that same muscle) can create much more power than a normal muscle contraction. This is because the muscles are able to store the tension from a stretch for a short period of time - causing the muscle to react like a rubber band. The better your muscles are at producing force against the ground quickly, the less time you spend on the ground. Plyometrics help the hip and lower extremity muscles transition from their eccentric to concentric contraction more quickly, thus producing more force against the ground. Now we're moving fast!
As a rule, distance runners tend to recruit and use more Type I (aerobic, slow twitch) fibers. But when speed work is incorporated into your routines, more of the anaerobic, Type II fast-twitch fibers are recruited. Part of improving your ability to run is maximizing muscle recruitment. The more muscles recruited, the more ability you have to produce force against the ground and the faster you’ll go! However, the goal is ALSO to recruit as few muscle fibers for the task as possible. It sounds contradictory, but the more muscles you recruit, the more oxygen they require, and this can lead to decreased running economy. So we have to be picky with our fiber selection! Running economy is all about using oxygen efficiently. Our goal is thus greater recruitment of those explosive fast-twitch fibers, which use less oxygen. More bang for the buck from a muscle perspective!

NOTE! In addition to good overall strength in the major muscles of the hips (gluteals and hamstrings) and thighs (quadriceps), it is CRITICAL that you have adequate strength in your calf muscles and flexibility in your ankles for the plyometric drills. The biggest calf muscle (gastrocnemius) usually contains a larger proportion of Type II fast-twitch muscle fibers, and responds well to traditional strength training. 

Beginners should start with calf training basics: 

1. Heel raises: holding onto a counter top, squat rack or other sturdy surface, raise and slowly lower your heels until you reach fatigue. Use a weight amount such that you are completely fatigued by 10-15 repetitions. This weight can be simply your body weight, or you may hold small dumbbells of equal weight in each hand. You may also try lifting one heel at a time, with or without added weight. More advanced exercisers may use the same exercise but increase the weight amount used, such that fatigue is reached by 6-10 repetitions. Everyone should complete 2-3 sets with a 1-minute rest interval between sets.

This basic exercise is well worth the time invested: more Type II fiber recruitment  in your calves equals better ground force reaction time, less overall body fatigue and a better race time!

Once you've achieved good basic strength in the calves, it'll be time to move on to some basic Plyometric drills.

Beginning runners can start with stair climbing (two stairs at a time if you're able), two-footed hopping in place, or short bursts of running uphill. Each activity should be performed for 45-60 seconds per bout.

More advanced runners can try the following:

2. Ankle hopsWith feet hip-width apart and heels elevated, balance on the balls of your feet. Bend your knees, place hands on hips, and repeatedly hop forward, pushing off and landing only on the balls of both feet. Stay on the ground as little time as possible between hops and never let your heels touch the ground. For variety, you can try hopping backward. Reps: Start by hopping 10 yards, building up to 20 yards. When you're ready add a second and third bout of 20-yard hops with 1-minute rests between them. This drill will strengthen EVERYTHING below the knee, but especially the Achilles Tendon, shin muscles, calves (see above), and the flexor muscles that support the ankles.

2. Squat Jumps: Stand with both feet hip-width apart and place your hands on your hips. Tilt your hips back and bend your knees, leaping straight up as high as possible. Land softly with both feet  in the same spot. Bend your knees to absorb the impact. Reps: Begin with one set of 10 jumps in rapid succession. As you get stronger, build up to three sets, each set separated by a 1-minute rest. This drill will strengthen all of the muscles, tendons, and ligaments from the waist down. Efficient!
In a nutshell: plyometrics work primarily because they strengthen everything related to your feet and ankles. They make all of the muscles, tendons and ligaments acting on your ankles stronger and more powerful, helping you to become "stiffer" (a good thing!)
How tired should you feel with this type of workout? In general you should finish any plyometric workout just as fresh as when you started. If you feel unduly fatigued you likely did too much. Keep the repetitions low enough so that each rep is a quality rep. With regard to rest intervals, rest at LEAST one minute or long enough to be at 100% for your next attempt. 
As with ANY athletic program, make sure you check with Dr. Blake about proper footwear and the need for corrective orthotics. Bring any new (or existing) foot and ankle injuries, or muscle/joint pain to his immediate attention.
Best of luck! And here's to your next personal BEST race time!

About Lisa: 

Lisa Tonra, a twenty-year veteran of the fitness/wellness business, holds credentials from ACSM, NASM, and BASI Pilates and is currently a Physical Therapy graduate student. She specializes in injury 'pre-habilitation,' prevention and recovery for all sports-related and overuse conditions. Lisa can also design, implement, coach and monitor fitness routines for all recreational athletes, fitness enthusiasts and beginning exercisers. Her philosophy is a simple one: "There is a (sometimes hidden) fitness enthusiast in all of us! It’s good to set a short-term fitness, health or lifestyle goal to get yourself up and moving, but challenge yourself to take the longer view of 'training for life.' What are Your Body Goals? I can help you achieve and maintain them, and do it injury-free!" 

Visit Lisa's personal website here:

Sunday, July 21, 2013

Greetings from Maui, and Aloha!

Since my readers become my friends, and I am an open book, I hope you enjoy some of my photos as I travel with my wife Pat to wonderful Maui. I am celebrating 59 and 1/2 years of age. My life of the last 30+ years is changing, and I am excited to continue my journey with God's blessing. I understand each day is a gift, and I will try to be even more in the present. Greetings from Hawaii!!!!  Aloha!! and Mahalo!!! We had a blast, and I thank my friends Kenn and Lois for making their gift!! Rich

Big Toe Joint Injury and Severe Pain: Email Advice

Dear Dr. Blake,

I am 51 years old and recently found your terrific blog.  It’s my hope you can help provide me with insight and guidance on an injury I sustained to my left first metatarsal and sesamoid bones on July 17, 2011 while trail running.  I apologize in advance for the length of the email, but my history is extensive and symptoms chronic.

A month or two before the July 17th injury, I had stubbed my left big toe walking down stairs at my house.  To my surprise it did not swell or hurt and I continued to run approximately 10 to 12 miles per week.  The day before my injury I experienced a uniform pain throughout my left big toe after finishing a run.  It completely resolved about an hour or two later.

The next morning, during a five mile run I felt an explosion of pain under the ball of my left toe.  My foot was swollen and painful after the run.  A day or two later I had plain x-rays ordered by my podiatrist.  They were normal.  Initially I was placed in a surgical shoe for walking.  After a few days with no improvement in pain or swelling I went into a walking boot, which I wore for the next eight weeks without significant improvement in pain or swelling.  During the eight weeks I also was examined by a foot and ankle orthopedist who felt the walking boot was the proper treatment.

Dr Blake's comment: Symptoms like this are stress fractures until proven otherwise by MRI or Bone Scans. Many times stress fractures start as stress reactions which have mild transitory symptoms before the final straw is drawn. 
After eight weeks in a walking boot, I was given a cortisone injection in the ball of the foot and placed on crutches for four weeks.  There was no improvement in pain or swelling.  I then went to a well regarded foot and ankle orthopedist in Philadelphia.  He suspected CRPS.  He casted me for two weeks.  There was improvement in temperature and color of the foot and some reduction in the pain.  He casted me for another three weeks.  My pain and swelling improved, but continued at about a 4 or 5.

Dr Blake's comment: CRPS is made much worse typically with immobilization. So, by your improvement with this modality, you may just have an orthopedic injury with some sympathetic overload. If the cortisone shot was into the big toe joint where the sesamoids are, and there is no improvement of symptoms, it points more to the flexor tendons or another structure outside the joint. 
Between July, 2011 and October, 2011 I had three MRI studies.  The first was on 07/22/11.  It showed a bone bruise pattern of the undersurface of the distal first metatarsal across from the tibial sesamoid.  The sesamoid showed no fracture.  Synovitis of the first metatarso-phalangeal joint and flexor tendinopathy between the sesamoids and just distal to them without tendon tear.

Dr Blake's comment: Now we are getting somewhere. Bone contusion sub first metatarsal head with resultant tendinitis and synovitis makes sense from how you did this. However these bone contusions can take several years to get better and have to be followed by serial MRIs. The sudden onset of pain from the bone contusion probably meant it was a stress fracture of the first metatarsal head. Stress fractures occur in the first metatarsal head if the sesamoid is stronger. Ground reaction force pushes the sesamoid up into the first metatarsal head. Normally, everything is fine. However, if one of those two bones is weak, it may break. 

The second was on 10/06/11 with contrast.  It showed mild edema of the intrinsic musculature of the foot as well as the dorsal subcutaneous soft tissues….mild edema of the soft tissues of the second and third tarsal phalangeal regions, flexor and extensor tendon intact.  There was a small focus of subcortical cyst formation involving the plantar margin of the lateral cuneiform…no drainable fluid collections…first metatarsal-phalangeal arthropathy with sub chondral cyst formation of the metatarsal head and a mild bunion deformity…no evidence of fracture….Intrinsic muscle edema of the foot appears slightly more prominent than on prior examination.

Dr Blake's comment: Most of this is probably secondary to the pain and swelling and length of time and immobilization. The first metatarsal phalangeal joint arthropathy (joint problem) is probably what you have as the actual injury. With the month of injury July 2011, you would expect gradual response to treatment progressively until July 2013 (now!!).

The third MRI was on 11/30/11.  Impression was hallux valgus with first metatarsophalangeal and hallux-sesamoid osteoarthirits and low grade strain of flexor hallucis brevis and third dorsal interosseous muscles.

On December 6, 2011, my orthopedist said he couldn’t do anything more for me after reading the third MRI and discharged me to physical therapy and pain management for CRPS.

On the same day I was able to obtain a diagnostic ultrasound.  It revealed a non displaced fracture of the head of the left first metatarsal and mild tenosynovitis of the flexor hallucis brevis.
I began using an Exogen bone stimulator 1x per day and physical therapy.  Over the next six weeks I strengthened my foot and ankle and the pain subsided.  I transferred to sneakers and shoes and resumed normal activities.

For all of 2012 I functioned with no pain, but the forefoot did appear swollen and the toes were stiff.  I did not return to running, but walked five miles or more per week without pain.

Dr Blake's comment: This makes total sense. The stress fracture was healed enough to walk, but probably not run. Hopefully, you had or are getting inserts that protect the first metatarsal head area with dancer's pads and arch support. When you break a bone, you must also look into your diet. Are you getting enough Vit D3 and Calcium? What is your overall bone density? Is your diet solid? Also, a side note, you never had CRPS during this early part of your problem--July 2011 to April 2013. But, your initial injury may have not been completely healed. 

In March/April 2013 there was increased swelling across the forefoot and tenderness to palpation over the tibial sesamoid.  I went to a podiatrist who gave me a cortisone injection in the big toe and the side of my foot.  On May 3, 2013, four days after the cortisone injection I was wearing snug shoes and on my feet most of the day.  At the end of the day my left foot swelled up like a balloon and the pain was between and 8 and 9.  I have been living with persistent pain, at times 10 plus, and swelling since May 3, 2013.

Dr Blake's comment: The writing for everyone else of this email is July 2013. So, 2 + months of increase pain is now present. We do not know if the original injury is healed, and this is a new injury, or if the original injury was partially non healed, and you did something to wake it up. I suppose you were naturally gradually like all of us would increasing your activities. 
I wore a walking boot the last three weeks of May and iced two or three times a day.  There was no change in my pain or swelling.  Since the beginning of June I have been on crutches and non-weight bearing.  Again, I experienced no change in pain, although swelling varies in intensity.

Dr Blake's comment: Typically when you go non weight bearing for a bottom of the foot injury, the swelling gets worse, since it can just pool there. I always try to get at least some partial weight bearing, even if it is only on the arch or heel. 
On May 8, 2013 a diagnostic ultrasound showed irregularity of the tibial sesamoid (there was none in December, 2011) and a healed nondisplaced fracture of the head of the left first metatarsal.

On July 12, 2013 I had another MRI.  It showed progressive lateral rotation of the hallux sesamoid complex and hallux sesamoid osteoarthritis when compared to prior study.  There is now extensive osseous stress response throughout both sesamoids, with a first MTP effusion and synovitis, but no findings for osteomyelitis.  There is extensive subchondral cyst formation and at the crista of the plantar hallux.

Dr Blake's comment: The most likely scenario, without actually seeing all the images, etc, is that you injured the bottom of the first metatarsal head, and some degenerative changes (arthritic) are taking place within the joint. These changes can be progressive, but could also reflex the demineralization from non weight bearing over the last 2 months, and if you are still using the bone stimulator the bones may light up due to good bone activity. Are you still using the stimulator? If so, stop, and re MRI in 3 months. 

I have been taking Tramadol for pain, which ranges between a 5 and 10.  It does takes the edge off, but does not resolve the pain.  I have not been able to obtain any pain free environment since May 3rd and am at loss for what to do to settle my symptoms down and move forward.

The physicians I have seen are at a loss for what is happening, why it is happening and what to do about it.

I am quite desperate and don’t know where to turn.  I would appreciate your thoughts and recommendations?

With much appreciation,

John (name changed)

Dr Blake's comment: First of all, I apologize for my ramblings above, but I try to think out loud as I read these emails. The pain you are presently having is out of control. What can cause this? Stand A Lone Orthopedic Injuries do not cause this level of pain? The big 3 are Infection (may need to have the joint aspirated), Gout (what is your recent uric acid?/also joint aspiration with crystal analysis can help), and CRPS (add a pain specialist to your team who can rule in/out and also place you on a program to get your pain under control). I always worry about infection if the flareup happens after a cortisone shot--cortisone is like candy to these little bugs. Have an infectious disease specialist review your case. Please keep me in the loop, and I am hope this helps point you in the right direction. Rich

Accessory Navicular: Email Advice

This is an email from a reader recently received.

Accessory Navicular - always had these bones. Didn't know not everyone else did. I did notice that my left one seems bigger. How do I AVOID having it get bigger?? I have just begun working out 2 weeks ago. Do you think the leg press machine did it?


Saturday, July 20, 2013

Bunion Surgery Problems: Email Advice

Dr. Blake,

     I am one and a half year post bunion surgery of my right foot, and am having a very difficult time.  As soon as I was able to walk after surgery, I felt a tiny rub on the bottom of the foot, but just assumed it's normal after surgery, six month after, resumed normal activities, doing Zumba, Spinning, hiking, which may have contributed to the problem I am having now.  There was always a tingle, an ache, big toe area always stiff and frozen. I mentioned it at checkups, but the surgeon didn't seem to be concerned about it.

Dr Blake's comment: I am not sure if I would have told you anything different at this stage as long as your function seemed fine. Post surgery, bunion or any other surgery, surgeons expect 20% of the symptoms to just gradually work themselves out, as long as the pain level stays between 0-2. This is how you are presenting this at least. 

     Begining of June (6 weeks from the day of this email), the foot started feeling numb, and shooting pain along the big toe area. 

Dr Blake's comment: Now you are having nerve pain and this is quite disabling. Surgical joints are always the weakest link in the chain. They are the one most picked on. The present day does not have to have anything to do with the surgery, other than that this area is a weak spot for you. 

     Went to the Dr, ordered custom orthotics, not even x-ray, endured stabbing pain, was told to adjust the orthotics, still waiting for the appointment to see him.
Dr Blake's comment: So, what should of happened then and now? Creating a pain free environment needs to be accomplished with shoes, orthotics, removable boot, crutches, etc, and anti-inflammatory measures (minimum of 3 times daily 10 minute ice pack). During this time, the sometimes slow process of figuring out what is wrong with diagnostic injections, xrays, nerve conduction tests, low back evaluations, etc should be started. 

     I went to another surgeon, who took the time to watch me walk, x-rays, and said I have sesamoiditis. Pain and discomfort is nonstop, I can barely walk... my question is, what is the relation between bunion and sesamoiditis?
Dr Blake's comment: Your big toe joint, which was remolded to remove a bunion, has 2 bones called sesamoids under neath. You big toe joint is a weak link in your bio mechanics. There are so many scenarios of what is happening to you I could write a book chapter at least. The most obvious, because this is a fairly common problem, is that the bunion joint following surgery is continuing to get weaker. Perhaps some arthritic changes are occurring in the joint which is very common. Perhaps the surgery weakened that side of your foot enough that you are pronating more now and overloading the sesamoids. If there was a surgical complication, you would have been in pain a year ago as you went into normal activities. Perhaps this has nothing to do with the surgery (very common), and it just a new injury due to your activities. The reason you got the bunion is that your mechanics are weak in that area, and unless the surgeon did bone fusions to stabilize (highly unlikely), you are still weak there and could have just irritated the sesamoids.

The fact that something is rubbing right after surgery made me feel something went wrong with the surgery, but the second surgeon I saw said the surgery was fine from what he saw in the x-ray. I never felt the foot went back to normal, and now, I cannot even handle daily routines.

Dr Blake's comment: We tell our patients who have bunion surgery that we are not giving them a normal joint. But, we can hope we are giving them a better joint. You may indeed have a surgical complication that can not be seen on xray. Even seemingly minor collections of scar tissue in the wrong place, can give symptoms. My best guess, based on what you have told me, is that you have a predictably weaker big toe joint area that is susceptible to injury. I can not presently tie it to a problem with your surgery, so my recommendation is to work with the PT on creating that pain free environment, treat inflammation when found, definitely treat the part of your pain that is nerve related with treatments that help that. Get an MRI or neurological workup for possible nerve entrapment, or a diagnostic injection series to find out exactly what structure is painful. As you progress through those steps, you should predictably feel better and better. I hope this helps you some. Rich

Your blog is the best information I can find online, and I just don't know what to do. The new Dr. did send me to Physical Therapy.

Thank you so much for your time, I do hope to find answers from you.

Hallux Sesamoids: Email Advice

Thanks so much for this blog with many useful bits of info.

      I am 61 yr old active woman who noted a "callous" under my mid big toe with tenderness when in hiking boots for prolonged periods about 6 months ago. I was walking and doing pilates barefoot without pain.

     I saw a podiatrist last week  who did xray and showed a rare sesamoid under the  first joint (hallux inter phalangeal) in addition to the 2 sesamoids expected at the lower joint (big toe joint). Unfortunately it was fractured into 15 pieces by his count. He fitted me for orthotics which are due in 3 weeks. However, since then i have had a major flare up with pain and swelling not previously experienced. It is so bad that I cannot bear weight, and awake with throbbing pain in am. I suspect I aggravated something by squatting barefoot on counters while I painted kitchen cabs....

     My question is with this new onset sx should I be concerned about injury to tendons or joint now caused by the bony fragments? Since this sesamoid is rare, looking for info on what can go wrong and if treatment  is much different from other sesamoid fx. I read NSAIDs can interfere with bone healing, but wondered about a tendinitis as the culprit. Is the treatment of extra sesamoid fx pretty much the same as described in previous posts re non wt bearing? thanks.


Dr Blake's response: 

     First of all, you have co-existed for 50+ years with these sesamoid flakes/fragments, without any problem so I think you will co-exist another 50 years or so (God willing!!) with them. When squatting you placed too much pressure on the area, and something (sesamoids, joint, tendons, nerves, ligaments)  got angry at you. Even though these sesamoid bones are there, who knows if they are the problem. Since it would be rare to have to remove these, they are probably not your problem. This is an educated guess, that any one has a right to change with my blessing at any time. 

     So, first thing you have to do is create a pain free environment to allow whatever to heal. If this takes crutches, shoes, orthotics, and/or removable boot, you have to start treating the pain. Then, you work on the inflammation with icing, contrasts, PT, oral meds (okay in this case), accupuncture, topical meds, etc. Once you get your orthotics, make sure they are modified to completely protect the area as you walk, even if you have to go to a shoe size bigger for a while. 

     In terms of diagnostic tests that I do, MRI and local anesthetic injection into the joint. The injection is easy, you place 1-2 ml of local anesthetic into the joint from the top and see if all your pain is gone. If so, you know that pain comes from inside the joint. If not, the pain is not coming from the sesamoids, but the external ligaments, tendon, or nerves. 

     MRIs are not perfect for toes, so I would only get if I needed more information because I did not have a game plan I was convinced of. The reason they are not great is the slices are 3.5 mm and you can miss the area of pain. Also, all parts of the soft tissue are near the skin, and the skin can allow in too much light (artifact). 

     So, for the next few weeks, create your pain free environment, use various forms of anti-inflammatory, create an orthotic base that protects the spot, and then gradually increase your activity. I sure hope this helps. Rich