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Thursday, October 31, 2013

Lateral Knee Compartment Disease: Varus Wedging seems to be a good aspect of treatment

As a podiatrist, I team up with orthopedists to treat many knee conditions. One of the most gratifying is the treatment of lateral knee compartment disease. In attempt to avoid complete or partial knee replacements, I am asked to varus or medial wedge them to open up the lateral joint line. I can not tell you how successful it is, but I have many very happy patients. The treatments are always teamed with a variety of other treatments, including synthetic cartilage injections, knee braces, knee strengthening, shoes selection, icing, and some cortisone shots. I have enough very happy patients who presently are avoiding surgery, and love their wedges, that I thought I would share this video with you. 

Monday, October 28, 2013

Negative Impression Casting: A Start towards Making Great Orthotic Devices

My true love in podiatry is helping people. Making the best orthotic devices I can do is a vital part of my and most podiatry practices. I hope this esoteric presentation on the nature of taking an impression cast of the foot, called the "negative cast", will give you some insight into the workings of making good orthotic devices. It starts here with me. 

Sunday, October 27, 2013

Hallux Limitus/Rigidus Examination with Self Mobilization Technique

This video below discusses the measurement required to make the diagnosis of Hallux Limitus vs Hallux Rigidus along with the self mobilization techniques to improve your range of motion. Please enjoy!!

Sesamoidectomy: Patient Comments

Dr Blake,

I just wanted to send you a note to say thank you so much for taking the time to write your blog. It has been a huge help to me over the last year as I've gone through the drama of a sesamoid fracture. I thought I'd share my story with you. I'm sure you've heard plenty that are similar, but I hope you don't mind adding one more to the list. 

I fractured my lateral sesamoid (I think - it's the one closest to my 2nd metatarsal) July 2012. I was referred to a podiatrist, and at my first appointment she diagnosed me with a stress fracture of the 2nd metatarsal even though I kept saying that the source of the pain was right around that sesamoid. Nothing was showing up on xrays at this point so she told me that it had to be the 2nd metatarsal and that the pain was just deflecting for some reason. 

I was put in a walking boot for 6 weeks, which I diligently wore until I was told I could start to wean myself out of it. A week after I was finally out of the boot completely the podiatrist told me I could start a walk/run routine and build up slowly, as well as slowly begin swing dancing again (a hobby that my husband and I do together). I danced for a total of 30 minutes in 1 week and my foot ended up swollen and in more pain than before. I couldn't get in to my podiatrist for a week, so I put myself on crutches, ice, and elevation until I could get in to her. By the time we got to do an MRI a week after the swelling, I had managed to get all the inflammation down, but could not get comfortable in the walking boot again. So the podiatrist suggested spica taping and a dancers pad in walking shoes. The MRI also showed a fracture on the sesamoid at this point but nothing wrong with my 2nd metatarsal. So, I started doing my research online and found your blog, watched your videos to learn how to tape, and went from there. I used your taping method and a dancer's pad for 6 months straight while I went through the rest of my story. 
Dr Blake's comment: A bone stimulator would have been great at this point, and some discussion of dietary calcium and Vit D3, and the use of icing and contrast bathing daily (my favorites). 

By January 2013, my husband and I had to move to a new city for work, so my podiatrist sent me on my way with a referral to a PT for 6 weeks to try and get my foot healed completely in our new location. Four weeks into PT, the PT told me she thought I still had a fracture based off of my reaction to ultrasound therapy, and sent me for more xrays/MRI and suggested I go to a new podiatrist. My regular doctor also sent me to an orthopedic surgeon for another opinion. 

These xrays and MRI showed the fracture had not healed, the bone was fragmented, and there was signs of necrosis. 
Dr Blake's comment: Necrosis alone can be treated with bone stimulator, necrosis with bone fragmentation sounds surgical to me. 

The orthopedic wanted me to just stay off of my foot for another 9 months and see what happens. Just taping and a dancer's pad was all he wanted (oh, and he said soft-soled shoes, which I found really bizarre after reading your blog). I wasn't happy with a wait-and-see solution, as I had pretty much done that for 9 months already and couldn't understand how another 9 months would help. The new podiatrist, on the other hand, felt that with the state of my sesamoid it would be wisest to remove it. He said he didn't see much hope in it healing considering the damage he was seeing, and that we were at the stage of last resort. Normally I do not jump on the surgery band wagon quickly, but I didn't see much of an alternative either. Even the orthopedic had given the same diagnosis on my bone, he just wasn't willing to cut it and was hoping for a miracle. I queried e-stem but the podiatrist said I probably had about a 30% chance of that working, and considering I had just found out I was pregnant he didn't think the crutches for 9 months would be a safe idea. 
Dr Blake's comment: Congratulations!!!!!

So we waited until I was in my second trimester, got my midwife and an OB to both approve the surgery (they also felt it was better to take the bone out before baby was born so I had more time to heal before caring for a newborn), and made a plan with an anesthesiologist to do the whole surgery with a block instead of a general anesthetic. I took the brave step and had the sesamoidectomy 2 weeks ago, 13 months after this whole thing started. The good news is that the bone ended up not necrotic or fragmented when they got into my foot. It came out all at once, but either tissue or cartilage (the doctor said he'd have to order a lot of labwork to tell) had grown into the fracture, so the podiatrist said that it never would have healed properly and it was probably good we took it out (I hope this sounds right. It was a little overwhelming to hear right after surgery). 
Dr Blake's comment: I hate MRIs for the read of avascular necrosis. It scares many patients into unnecessary surgery when bone stimulators can help. I am unclear however how the bone fragmentation was not fragmented. I think MRIs show more internal disarray that we read as external disarray (ie. fragmented). But, soft tissue in the fracture would mean it could not heal. So, let's accept that as fact. 

Although I'm only 2 weeks out, and still non-weight bearing (I go for my 2nd post-op appointment this afternoon to see if I'm ready to start moving into weight bearing), I'm amazed at the difference I already feel. I used to get sesamoid pain even sitting on the couch or lying in bed, and now I don't. I haven't really needed any pain killers except for maybe a couple of times in the last 2 weeks. Normally the pain is staying below a 2 (yay good pain!), and icing the back of my knee (a trick one of the OR nurses taught me in recovery) reduces the swelling enough to lower the pain if it gets any higher. I have a little bit of weird nerve sensation in my big toe, but I see from some others on your blog that this seems to be a fairly common feeling post-surgery. 

Again, I just wanted to thank you for your blog. Your different posts on this issue has been helpful to read and has made it much easier for me to know what to ask and what to expect. I'm hoping that my foot continues to feel as good as it does now, but I'll admit I'm slightly nervous for the weight-bearing stage. 

Fingers crossed! 

Dr Blake's comment: The love this patient is really pouring out to anyone of you with sesamoid problems is easily felt. Thank you for your real time experience and honesty, something I can not give the reader. It is immensely vital. Keep me in the loop and to a gradual but easy healing!!! Rich

Achilles Tendon Flexibility Measurement and Strength Daily Routine

I hope you enjoy my new video on the Achilles Tendon

Post Sesamoid Surgery: Email Advice

I am a Detective and in an office setting most days but of course have to be 'fit for duty' with the ability to run, chase and fight at a moments notice. I had a sesamoid bone removed 072913 (i broke it in two after chasing a bad guy in May 2012 and the doctor let me walk around it until 07/2013) and have been home since.

 I had one post surgery visit and he said "start putting weight on your heel" so I did that. 6 weeks later I went for my second post surgery visit and I cant bend my toes without pain, there is a burning sensation on the top of my big toe and at the bottom of my incision scar is a "lump" that is very painful. I think it is scar tissue and when I touch it, it is very sensitive. I still can not put my weight on this area therefore I am walking on the outside of my foot (according to my tennis shoes) and not putting any weight on the inside ball of my foot because of the pain.

 Last week I was released to "light duty" with restrictions of no more than 15 min walking or standing an hour.... is this normal?
Dr Blake's comment: This sounds like the surgeon's mantra: "To cut is to cure". Surgery is really just the start (normally a good start) towards being well again. This is the hope of every patient when they go to surgery. And with sesamoid surgeries, this is what you should expect. It is hard to know what is going on right now. Are you just more painful than most, or is this a complication? You really have to create a pain free environment with a removable boot, orthotics, dancer's pads, stiff sole shoes, etc. Whatever it takes, and with whatever combination it takes. You are the surgeon's responsibility so have a heart to heart conversation. You should be icing twice daily with 10 minute ice pack, and doing a 20 minute contrast bath each evening. Read my posts on sesamoid fractures which talk about how to protect the sesamoid. 
Should I get a second opinion because I don't feel my surgeon "cares" now that I am back to work and I am in pain still. I have began to take my hydrocodones at evening time again and my foot is so sore on the top (tarsals) I think because I am walking wrong.
Dr Blake's comment: You really need to talk to the surgeon. Say you need advice because you think you have more pain then you should. Find if he/she believes physical therapy would help you. Physical therapists see you typically after the stitches come out, and you are ready to get the joint calmed down, un swollen, and moving again. Ask the surgeon if the Blaine scar kit is appropriate. Ask if an agent like Neuro-Eze would help reduce the pain and allow you to massage the injured area. Pain free self massage is always good to a painful area. Tells the brain to not be so hyper about it. 
What do I do? Should I be home letting this heal properly? Should I anticipate additional surgery to eliminate this pain? Is this amount of pain normal?
Dr Blake's comment: This could be where a second opinion comes in. Not to transfer care, because that would be hard to advise from afar, but just to say yes or no to some of these questions. Second surgeries are rare post sesamoidectomies, but secondary problems because you are not doing a good post operative program are not uncommon. Good luck, and please keep me in the loop. 
Thanks for your reply and assistance.

Hammertoes: Cause and Treatment

Please enjoy my new video on hammertoes and their treatment. Rich

Tuesday, October 22, 2013

Movement: Simple or Extreme: Is a Vital Part of Living

When I treat injured patients, who come in with pain, crutches, limping, boots, etc, the immediate goal we have is to get normal motion back. Because movement is vital to life. When lost, devastating. This is sent by my friend Kenn. Thank you for thrilling with movement. Simple movements, complex movements, and scary movements. Movement defines our health, gives us vitality, gives us a sense of well being. We need to never stop moving when life allows us to keep on going. 

Hang on to your seat, and turn up the sound!
Things I'm sure I can't do, maybe you can't either. 

Although, I might still be able to do the last one!

Ball of the Foot Pain: Email Advice

Hi Dr.Blake,

 I have been diagnosed with sesamoiditis and have had this foot pain for over a year now. It is beginning to develop in my other foot as well.

 I have tried almost everything imaginable: two different orthotics, cortisone injection, active release, had a chiropractor tape the joint with kinesio tape and even one of those electric wave machines.

 I really do not know what else to do the pain keeps getting worse. Do you have any other suggestions? I am extremely desperate. - Thanks, Ann (name changed)

Dr Blake's comment: 

     All we know from what you have said is that you have pain under the ball of your foot, that no one feels is broken or arthritic, and the pain is not getting better with people doing things to you. So, I would begin to be more active in your approach (very sports medicine) and begin to see what happens. Take this one month at a time and you can give me a followup 30-40 days from now. So, what can be done:

  1. Attempt some form of better diagnosis (xrays, etc).
  2. Ice pack the area for 15 minutes twice daily.
  3. If swelling or stiffness noted, do contrast bathing once daily or once every other day.
  4. Find a shoe that works best whether it is padding or stiff or flat, etc. Try to decide what is best.
  5. Put your self in the Immobilization Phase I of Injury Rehabilitation by staying in an Anklizer removable boot or Ovation Medical Boot with EvenUp on the other side.
  6. Spica tape your toe daily.
  7. See if your doc will prescribe voltaren gel or flector patches for you (at least for when you sleep).
  8. Figure out if either of the two pairs of orthotics actually do protect the ball of the foot (we need function not number of). 
  9. To specifically deal with the pain, see a pain specialist. Avoid NSAIDs since you could have a bone injury.
  10. See if any other activities you are doing daily is irritating things and make some change. 
  11. Apply Neuro-Eze to the sore area 3 times daily (buy online).
  12. Do Metatarsal Doming and Single Leg Balancing daily to keep some strength in the foot (painlessly). 
I hope this gets you started in a good direction. Rich

Tailor's Bunion Pain or Is it?

This was a comment on my tailor's bunion video on my youtube channel also entitled  drblakeshealingsole. 
To:Richard Blake

I have a question about the tailor bunion...does this seem to come on suddenly and feel as if one is stepping on a rock? I did so much googling on internet for days and could not find anything for the longest time.
The location of my foot problem is in the tailor bunion area. But it seems I have other symptoms that don't match.
About 4 months ago I stepped out of the pool and felt like I had a rock stuck in my foot but nothing was there! Hurt sooo bad. It seemed to be slightly red/ was exactly where I have a mildish callous on the bottom of foot below pinky toe. It went away after a while and I forgot all about it.
Then a couple of days ago..boom out of nowhere it happened again! (walking in my kitchen minding my own biz). I took a closer look with flashlight and the area (on bottom of foot where callous was) was a little red and when I put pressure on it I could see a sort of star shaped white-ish area inside below the skin...did not have that on the other foot. (it's not a plantar's wart). So I pushed on it for a while and took some pics of it. About five hours later it was all bruised up (but maybe that is because I was manipulating it so much). Also when standing only, the bone below the toe on the top of my foot appeared to be protruding more so than the other foot..I really freaked out about that but concluded it was from the area being swollen. I really don't think it is broken. I can move my toes and everything just fine.
Does this sound like tailor bunion? I have pictures...
I'm so bummed because I've been slacking in exercise and was planning to start walking/jogging again.

Dr Blake's comment:

     Tailor's bunions are very gradually changes to the fifth metatarsal which develop over years as the foot spreads out. The pain you are having could be a bone bruise from walking on the cement around and in a pool, or a simple corn that can slowly develop under the tailor's bunion and one day hit critical mass and really hurt. Simple corns can bring big strong people to their knees. Corns are actually just dead skin accumulations and should not hurt to debride them. If they hurt and bleed, you may be dealing with a wart which may just be in the area of the tailor' bunion. The star shaped whitish area is probably the central core of a corn, and this central core dives deep irritating the nerves. I doubt it is broken also. Try the lip stick technique where you mark alittle lipstick on the sore area and place it barefoot in your shoe that has an insert. Walk around alittle and see where the lipstick rubs off. Cut a hole in this area and/or build up the area around it with other pads from old shoes. I hope this helps you. Rich

Sunday, October 20, 2013

Kinesiotaping for Plantar Fasciitis: Patient Recommendation

I typically show my patients with plantar fasciitis some simple and more complex ways to tape their arch. Recently, one of my patients has been using this technique with great results. 

Foot Numbness: Email Advice

I have read some of the posts on your blog, but not seemed to find the correct answer to my problem;

Last winter I walked with Ice Traction Cleats for a long time. 1 hour every day for 4 months at least. After that I one day suddenly felt numbness of the ball of my left foot.  I tried talking to a chiropractor who believed there was a problem with the piriformis because I take B12 shots near to this muscle and the piriformis might have been hit.  
I have tried to stretch this muscle, but no relief.  

I have also talked to my doctor who did not believe in the piriformis theory and found nothing after MR.  

The numbness is still the same after 7-8 months and has also occurred in my right foot, but not as strongly. I feel the numbness all the time, but  sometimes it gets worse.  I am not diabetic.

Looking forward to suggestions.  Thanks!

Dr Blake found a video that may show a similar type cleat. 

Dr Blake's comment: 

     First of all, no matter what the cause start massaging Neuro-Eze into the area 3 times daily. Neuro-Eze is a homeopathic topical that concentrates an amino acid L-Arginine. It works on over 50% of my patients with your symptoms. One bottle will last about one month and it is helps keep going. If it does not help, ask your podiatrist, or primary care, to give you an Rx on a compounding nerve lotion or gel. 

     Piriformis syndrome was a good thought since the motion of telemarking, like a ballerina's turnout, overuses the piriformis and can cause irritation to the sciatic nerve there. I am not sure exactly how you moved, but it probably was differently than you walk normally.  But, you can also irritate the same nerve at the low back, in the spine itself to the neck, in the hamstrings, behind the knee, in the calf, and on the inside of the ankle. There are many choices you have. Typically you seek a physiatrist or neurologist to help you sort out where the nerve is being irritated, while you start treatment on the symptoms. 

     Many would also start you on an evening dose of nerve meds like gabapentin, lyrica, or elavil to help calm the nerve down. The faster you act on an upset nerve the better!!

Border to Border Run: My Past

During my second year of podiatric residency, I joined with 9 other runners and 4 alternates to run from Oregon to Mexico as a Publicity Stunt for the California Podiatry Association. I am right between the R of the first Border and the TO (rather dorky looking) in the first row---always got to be in the spot light. It will always be the most unbelievable endurance event in my life. I ran 125 miles in 7 days!  I ran from Feb to early May building my mileage from 0 to 70 miles per week. My weight went from 236 (Medical Residents eat not exercise!!) to 184 during my training, and then to 174 by the end of the week. 

We started at the Oregon Border with 2 vans--5 runners and 2 alternates in each. The 2 alternates were in charge of every detail besides running. We had 10 hours to run 70 miles, yes averaging 7 minute miles, and then transferred the baton to the next van while we were supposed to drive 70 miles down the course, ate and sleep. We had some much PR work to do (radio, newspaper, and TV interviews) that 8 hours of sleep typically became 5 or 6. We went down the state on 101 then over to Sacramento through Clearlake. After Sacramento, we ran down to San Francisco, and through the peninsula to Pacheco's Pass. We ran day and night, 24/7, with each group sharing some of the most dangerous sections. The entire course was pre-approved by the Highway Patrol. 

We ran on to Fresno for more PR opportunities and then back to San Luis Obispo. I was so sick by then that one of my fellow runners, Matt Fettig, ran 4 of my miles for me!! I was upset since that meant I would only do 121 miles that week. From there we headed now the coast to San Diego, finishing actually 7 days from when we started. From then, I started my podiatry practice one month later. 

I have so many memories of that event, and have had so many inspirations from this group. Closest to me are Dr Jane Denton (female on the lower right) who has her elbows on Dr Chris Yee (Hawaii) and Dr Dave Hannaford (Marin County and famous for the Hannaford Orthotic). Dr Jane Denton has been my podiatric partner now for 30 years, and one of my best friends. Between me and Dr Yee is the true mastermind of this adventure, Dr John Colson. John practiced in San Diego, and was on the committee that agreed with this scheme. John and I were best friends, and with my being at the California College of Podiatric Medicine, called and see if I could round up 8 other runners. They were easy to find in podiatry school. In 1981, Podiatry was truly at the forefront of sports medicine with biomechanics, and students filled the schools (like me) hoping to have a sports medicine practice.

Next to me to the left is Dr Pamela Sisney who practices in Cincinati. Next to her to the far lower left is Dr Kevin Kirby, whom sent me this photo, and is the biomechanics guru of our time in podiatry. Dr Kirby (I refer frequently to the Kirby Skive) practices in Sacramento, California, and lectures around the world on biomechanics. Holding the sign, next to Dr Kirby, and obviously not a runner (but a good friend) is Dr Richard Green who practices in San Diego. Dr David Laha (whom we called Layaway) is in the upper right and practices in Kansas, and in the upper left holding his hands out is Dr Steven Palladino whom practices in Santa Rosa. Dr Robert Eckles and Dr Matt Fettig are next to and under him respectively. Dr Paul Resignato stands in the upper middle with his cool bandana!!

Thanks for letting me relax and remember times that I didn't sit so much!!! 

Preparing for Long Distance Hiking: Email Advice

Hi Dr. Blake,

Thank you for creating and maintaining your blog!  It is a great read and full of incredibly useful information.
Dr Blake's comment: Thank you so very much!!

I recently completed a thru-hike of the John Muir Trail, and my Achilles tendon was very tight and sore for the last five days.  At the time, I did not know how to stretch or tape it so as to reduce pain and the risk of injury.

How do you recommend I prepare my feet prior to long-distance hiking and walking?  And how do you recommend caring for your feet during the hike?  I am doing a 700 mile trek next Spring, and I would like to avoid any complications.


Dr Blake's Response:

     The main areas of concern with events like that are:
  1. Foot and Ankle Strength
  2. Achilles and Plantar Fascial Flexibility
  3. Supportive and Padded Socks
  4. Broken In Boots that are the right style for the terrain you are on
  5. First Aide Kits for Blisters, Cuts, etc
  6. Knowledge (some expertise) in toe, arch, ankle taping
  7. Excellent training with weekend long walks/hikes to rebuild endurance
I have some of this on my blog. You can review the videos on strengthening of the foot and ankle, and flexibility of the achilles and plantar fascia. Go to a store like REI for advice on socks and boots. Prepare a first aid kit with Body Glide for blisters, big and small bandaids, antibiotic ointment, and coban tape. Check the blog also for the videos on toe, arch, ankle, achilles tapings. Check with a PT or Podiatrist if you think you have areas of weakness, like the achilles, that may need some individual advice. Get down to basics and make sure you are cutting your nails correctly (typically straight across). Buy boots at the end of the day when your feet may be slightly swollen, and wear the socks you will be hiking in when the shoes are fit. I hope this helps you. Please email with other questions and I will try to put on this same post. Good luck and happy hiking!!! Rich

Saturday, October 19, 2013

Lower Diabetic Foot Ulcerations with Orthotic Devices: Article

Obamacare: Thoughts from the Prestigious AMA

AMA Insight, No matter which side you are on.

The American Medical Association has weighed in on Obama's new health care package. The Allergists were in favor of scratching it, but the Dermatologists advised not to make any rash moves. The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the Administration had a lot of nerve. Meanwhile, Obstetricians felt certain everyone was laboring under a misconception, while the Ophthalmologists considered the idea shortsighted.

Pathologists yelled, "Over my dead body!" while the Pediatricians said, "Oh, grow up!" The Psychiatrists thought the whole idea was madness, while the Radiologists could see right through it. Surgeons decided to wash their hands of the whole thing and the Internists claimed it would indeed be a bitter pill to swallow. The Plastic Surgeons opined that this proposal would "put a whole new face on the matter". The Podiatrists thought it was a step forward, but the Urologists were pissed off at the whole idea. Anesthesiologists thought the whole idea was a gas, and those lofty Cardiologists didn't have the heart to say no.

In the end, the Proctologists won out, leaving the entire decision up to the assholes in Washington.

Thursday, October 17, 2013

Navicular Pain: Email Advice

Hello Dr Blake my name is Ron (name changed) and I live in Oregon. 

I have be diagnosed with Posterior Tibial Tendon Dysfunction. 

In 1988 I broke my Left ankle in a fall and and as a result I was left with a slight loss of dorsiflexion but not enough to keep me from running and riding my bicycle. I had a 20 year career of racing bicycles = Cyclocross which is riding and running without any problems. I have always known that I was limited in dorsiflexion but it was never a limitation for me.

In December of 2012 I bought a pair of shoes that have no built up heel so the thickness of the heel and fore foot are the same thickness.  They felt great and seemed to make my feet feel like they were getting stronger. At the same time I was skate skiing every weekend and began to develop a pain in my foot after skiing that would go away during the week and come back after skiing. 
This continued to develop into more pain centering on the navicular bone

My own theory was that the shoes without any heel height made my foot come into dorsiflexion sooner than if you were wearing a heel which pushed my foot into pronation. 
Dr Blake's comment: This was my exact thought when you mentioned the zero drop shoe. Not good if you have limited ankle dorsiflexion, and it is not merely an achilles flexibility problem. 

It took several months to figure out what was going on and now I have some orthotics which have helped quiet the pain in the navicular down some but not completely.  I have new shoes with heels that let my foot not have to go into dorsiflexion so quickly. I am able to ride my bike with stiff cycling shoes and a orthotic. 
I am Icing 2x a day and use my orthotics most of the time. Should I be doing the strengthening exercises daily?
Dr Blake's comment: First of all, all we are sure off is that you have arch pain. Pain at the navicular does not mean you have posterior tibial tendon problems. That being said, pain in any area should be treated with strengthening as much as possible. As you do foot strengthening as in the video below, see what muscles are weak and emphasize them. If it is the posterior tibial tendon, then that may point to PTTD. 

Will this tendon quiet down again now that I am not aggravating it?
Dr Blake's comment: Typically it will. But, you should ice 3 times a day for 10 minutes, gradually strengthen the area, wear supportive shoes/taping/orthotics as you increase activities, gradually stress it with a progression of activities from slight to more stressful on the area.

I would be willing to come see you if you think you can help me. 
Thanks for taking the time to read this. 

Tuesday, October 15, 2013

Foot Injury with Nerve Pain: Email Advice

Dr. Blake,
I found your blog this morning as a started in on two weeks of trying to completely not use my foot.  My email will be long as has been this nightmare Odessa.  I pray you can shed some light on this matter.

On July 29 I slipped on a wet spot in a store while wearing high stiff bottomed heels.   I slid gently into the slip and ended up on one knee with my left foot behind me as though kneeling to ask someone to marry me, plus perhaps a little more stretched out.  I got up and all seemed fine.  I went for my 3 mile walk the next 3 days with no pain.  On the 4th day I woke up with pain in the ball of my foot underneath the big toe and it became slightly swollen.  I could not pull my big toe back without sending a sharp pain down the foot.
Dr Blake's comment: This is the first sign of a small injury. The longer it is between injury and symptoms, the more minor the problem. I am looking for signs of hope for you. 

I went to the podiatrist and she did X-rays to see if the sesamoids were fractured and wrapped the foot.  That night the wrapping made the medial arch cry out in pain.  I took the wrapping off.
Dr Blake's comment: I make this mistake all the time since it is hard to know actually how tight to do in face of swelling that needs room to spread. The pain is not a sign of worse problems. 

The X-rays showed no fracture but a bipartite sesamoid and I only have one in each foot.
Dr Blake's comment: Bipartite Sesamoids are weaker than normal sesamoids, and thus, can get injured easier. It is usually a bad sign if x rays show bipartite sesamoids and point to an injured connection between the two pieces (weakest link in the chain). 

I continued to walk on it, limping and landing on the foot flat not really bending the joint under the ball.  A week later after Ice and Motrin I went back to the Dr and the swelling was down and the Doc said I was getting better and gave me hard orthotics with a high arch.  They made the foot hurt like heck again in the medial arch.  I still could not walk right.  My big toe did not work on push off and I could not make the foot walk. 

Dr Blake's comment: Orthotics should change function, off weight areas, feel borderline obnoxious, but never hurt. It is imperative to get them fixed by analyzing what is wrong and fix that (for example lower the arch in your case). 

 She did an MRI that only showed some mild edema by flexor abductor.  They could not visualize the sesamoids which kind of defeated the whole purpose.
Dr Blake's comment: This is impossible. Did you see the MRI? Can you look at the CD and send me images of the views that I normally show on my sesamoid posts. Something is rotten in Denmark!!

  She was flustered that I could not walk and threw me in a cam walker and thought maybe I tweaked a nerve and offered a cortisone shot.  I refused as she seemed to be guessing ( she would have put it in the tarsal tunnel).  Once again I only wore the boot one day and that night I had the worst deep aching pain in the center of my arch.
Dr Blake's comment: An injury causes pain. But, living with that injury, causes secondary pains from nerve protection, muscle/tendon favoring/splinting, inflammation not being controlled right. You need to do what you can to create a pain free environment while you are working on a specific diagnosis. Without a diagnosis, your treatment is too much guess work. You may need 2nd opinions, other tests, etc. 

Next I went to an orthopedic foot and ankle doc at the HSS.  He thought the nerve was getting trapped or irritated under the Knot of Henry. 
Dr Blake's comment: The Knot is back in the arch. The original injury is the ball of the foot. Do not lose focus on the ball of the foot, for the other pain is secondary. I like the idea of PT to reduce inflammation only. What about a repeat MRI to find those sesamoids, or a nerve conduction test if the nerve are being suspected. The same doc that does nerve tests are typically the best at calming nerves down with topicals and oral meds. 

 He wanted to do a diagnostic lidocaine shot but I refused.  He said PT with only modalities to bring down inflammation- come back in two weeks if not better and get a cortisone shot. The most tender point was right at the knot of Henry and that night after he palpitated  it I had the worst deep nerve pain.  When I got up I had pins and needles(. Which is the only time I have had this). They gave me a compound cream for nerve pain and with that and PT it started to feel better.  
Dr Blake's comment: Now, it is sounding better. The PT and topicals are probably working solely on the compensatory pain. But, the original problem goes undiagnosed. Have you found a shoe or boot/walker that allows you to walk comfortably. Sometimes, online purchase of a short leg walker from Ovation Medical and 1/4 inch adhesive felt from you can fashion a custom made boot and padding to off weight the area. 

But I still could not walk right.  I saw another Foot Doc from Hss for a second opinion and he said a nerve traction injury and it could take  2 years to calm down and to find good shoes.    He was against the cortisone shot as he said he saw idiosyncratic reactions that caused flare ups of nerve pain .  At this point I could walk around the house and short distances but was still not pushing off with the big toe or really stretching the arch at all when walking. 
Dr Blake's comment: It was a good decision to avoid the shot which can irritate an already irritable nerve!!! And, you were getting better. 

 The nerve pain seemed to be under control so I stopped using the cream.  2 days later the ball of the foot opened up and started to work.  My PT felt all my problems were with the FHL tendon as it was stretched and strained by the injury and this was where the tenderness and pain was.  The PT started me with very mild walk thru exercises to get my big toe to grab. 
Dr Blake's comment: I get very scared with this. The nerve is still irritable, and the system still too delicate. Weight bearing exercises are potentially too aggressive at this stage with so many wonderful less aggressive, non weight bearing exercises to chose from. 

 He did some massage to get the foot moving.  It helped somewhat but the more I could now make the foot move right( using the arch). The nerve pain came back. 
Dr Blake's comment: The art of medicine is in the timing of things. This was predictable. Your system still too irritable. Nerve pain, even when gone, needs a long time of respect before it allows a lot of stimulation. I love to keep patients on those creams for months after the nerve pain is gone. 

 It would burn at night and after a good day when I was able to walk barefoot around the house without a limp and felt the big toe start to grab that night it burned and hurt to just rest my heel on the bed.  At this point I still could not go down stairs although I could go up.  I could walk 2 aisles in the grocery store and then it would hurt in the arch.  Not able also is that once the nerve pain started I could not use ice it made it hurt more.
Dr Blake's comment: Angry nerves love pain free massage, heat over ice, gentle stretching. The nerve pain is secondary to your original injury, but now a major player. See if Low Dye taping is tolerated to support, but not press up. You course of events is very common, and some of it predictable, so cures can be found. Read all I have on the blog on nerve pain and tarsal tunnel, and CRPS. Many tips will be there.

 Also my first PT gave me exercises to do that had me lifting the forefoot off the ground while keeping the heal on the ground.  These made the foot hurt so much and my PT now said that was stressing the inflamed FHL.
Dr Blake's comment: It was just not the time to do weight bearing exercises. You were in the Immobilization Phase when some very simple exercises are needed, the diagnosis needs to be confirmed, anti-inflammatory measures rule and the creation of a pain free environment is paramount. 

  I decided to go back and see my foot and ankle dr prepared to get the cortisone shot to calm the inflammation.  He still said the next step would be to do the diagnostic lidocaine so he could be sure to know where to put cortisone. So I did it and it was a Hugh mistake.  The shot was placed in the tendon sheath by the knot of Henry.  The foot became numb from mid foot down and I had no pain for12 hours.  When it wore off my foot exploded in pain.  All the nerve pain was back and now it hurt to just gently run my finger along the FHL tendon and in that spot in the arch in the middle of the foot. 
Dr Blake's comment: I have only done this once to a patient, but it will live in my memory until I die. Injecting even local anesthetic into an unstable nerve is risky. I understand the principle of what he was trying to accomplish, but I am sorry that you had to experience it. Nerves like this can be unpredictable for several years. The symptoms can last for 4 days to 3 weeks. You must calm the nerve down with icing, or heat, or just rest. No compression at all. See a pain management specialist for oral medications (typically neurologists or physiatrists). Start using the nerve cream again if possible. Lidoderm patches are wonderful for this and you primary may be able to write for. 

 I talked to the Dr and the Dr who gave me the shot ( ultrasound guided at Hss). They had never seen a reaction like this and were confounded.
Dr Blake's comment: I am probably not as good a doctor as them, between me and my colleagues, we have seen this a lot. 

  I was left on my own.  The ortho said go to a neurologist.  It's been two weeks since the shot.  The foot is better but has been sent back beyond the beginning.  My PT did some massage and I had a good day and thought perhaps it was passing.  Then he massaged the FHL tendon deeply ( I don't think either one of us realized how re inflamed it was) and since then (last Wednesday) the foot is burning and I can' walk between rooms without burning pain in the arch of my foot.   And now the ball of the foot is re inflamed and swollen!  Back to the beginning!  On Friday
Dr Blake's comment: Please get this calmed down, and do not do anything until you email me. See if your area has a physical therapist that specializes in neuro-based PT, totally different then typical musculo-skeletal based PT. You should read the post on Checklist for treating CRPS, and begin understanding how to treat nerve pain. What ever your original injury, you now have a nerve injury that needs to be honored. 

 I went to the neurologist who was no help.  I did refuse Emg test since the foot is  so inflamed and had such a reaction to the lidocaine shot I did not trust that it would not further inflame the foot. 
Dr Blake's comment: Thank you for so much common sense!!!!! It is all in the timing. It is not the right time with the nerve so grumpy!!

 He sent me across the street to some bigwig podiatrist who heard my story hardly examined the foot and said RSD.  He sent me for an ultrasound and X-rays which I will get back at weeks end.  Both my ortho dr's PA and my PT do not agree with RSD .
Dr Blake's comment: All bad nerve pain is not RSD, although some of the same concepts of treating RSD or CRPS will/do apply to you. One of my posts goes over the Harden classification for CRPS (modern day RSD). Our job my friend is to not develop it with repeated flares over and over again. 

  I have no color or temperature changes and my pain is still pretty much contained to original area of injury.  My PT has treated a lot of RSD and said its simply not presenting that way.  He can massage it and it only hurts after.   He is at a loss.  After that shot just simple stretching of the FHL inflames it.  He will continue with ultrasound and TENS and he and the PA said just stay off of it for a few weeks ( something I' ve never done). So here I sit on the couch 21/2 months later unable to walk with a bunch of baffled pros.
Dr Blake's comment: Believe me, I give tons of second opinions, and you are catching this cycle so early. You have to stop thinking of time right now, and focus on healing, which may take a long time. But, it will be as logical and all your flareups have been once we realized you had a bad nerve reaction. It brought you from an orthopedic/podiatrist/physical therapist injury into the world of nerve pain. 

Dr. Blake I am not doing well with this.  I could face a definitive illness with a path and plan for recovery but this no knowing what it is or how to treat it and all the missteps by pros (HSS for goodness sake) has given me terrible anxiety.  I can't sleep or eat and feel out here on my own.
Dr Blake's comment: This is the realm of nerve pain. It causes suffering, where orthopedic injuries to the musculo-skeletal system cause inconveniences. I think you understand what I am saying. You need to create a pain free environment while you find docs/PTs that understand what I have just said, and can treat it. I will help as much as I can, but locally you will find your best options. 

  Even my GP of many years who I love says he just does not know what to do.   What are your thoughts?  What should be my next move?  My PT suggested going to a physiatrist he trusts that could coordinate things.  Should I go to yet another ortho?  What do you think happened with that shot?  Have you seen this before?
Dr Blake's comment: Yes, the physiatrist is a great choice. Right now stay away from the orthos or pods, unless you hear of one that has a knack for nerve pain. Also, find a neuro PT, even if the PT you are seeing does not like me for suggesting. Unless, I hear a better rationale for treating your nerve pain, I do not want any one but you massaging your foot. 

  I know the one ortho frowned upon the cortisone injection and said its always risky for a shot near a nerve.  At the time I thought he meant a cortisone shot but maybe he meant Any shot could irritated the nerve?  Do you know any great podiatrists in the NYC area.  Any help would be so appreciated. I am lost.
Dr Blake's comment: I only know 3 great sports podiatrists in New York State: Dr Karen Langone, Dr David Davidson, and Dr Robert Conenello, but maybe they could point you in the right direction. Believe me, there is nothing in what you said that does not make sense, that podiatrists have not seen, that treatments do not exist. Hang in there, and I hope this helps you some. Rich

Thank you, S

Patient's Response:

Dr. Blake,
Thank you so much.  I've been completely resting the foot and the pain goes down to almost 0 if I don't move it or walk on it.  Is that a good sign against RSD?  The PT did deep massage on the FHL tendon right under the big toe and gentle stretching ( pushing the foot back from the ball of the foot) now the ball of the foot is painful and swollen again-could that have been the reason?
Also, the nerve cream stings when I first put it on which it did not do originally- is that ok?  And lastly- Dr Conenello- is he great?  He is right by me -  would he be a great choice to guide me thru the rest of this rather than the physiatrist? 


Dr Blake's response:

S, Glad Rob is close, he is kind and smart. You need someone to manage your foot while a physiatrist works on the pain. No shots for now, in your foot at least. Rob may know where to send you, or if he is qualified to help. A good new start!!! You need a team however. With nerve pain, there are times to Honor the Pain (now), and times to Push Through the Pain (someday). You definitely need some weight bearing, some massage, some ankle rotations, some achilles stretching, etc, but start slow. Take it 2 weeks at a time with the next 2 weeks to get new direction, not irritate your foot at all, experiment with ice and heat, continue with nerve cream but gently, get into someone who can put you on Neurontin or Lyrica, and keep me in the loop. Rich

Sunday, October 13, 2013

Bursitis: Email Advice

Hi Dr. Blake,

I have what seems to be a stubborn adventitious bursa under and around my fifth metatarsal that developed because my foot was very supinated. 

Dr Blake's comment: A bursae is a fluid filled sac that develops between the bone and soft tissue, deeper than a blister, in response to abnormal pressure. One can see from the video below that over supination will cause excessive pressure on the outside of the foot.

 I've been able to stretch and ease the peroneal tendons that seemed to be causing the supination.
Dr Blake's comment: As the foot supinates, or rolls to the outside, the peroneal tendons must be strong to stabilize. Focus you attention on strengthening the peroneal tendons. The video below emphasizes the peroneus longus exercise with the ankle in neutral. If you do the same exercise with the foot pointed downward, you will also get the peroneus brevis tendon. 

  The burae comes back with any type of pressure, even stretching.  
Dr Blake's comment: Once the bursae forms, even normal pressure can keep it irritated. I love deep ice massage three times daily to try to break it down, physical therapy with ultrasound and deep friction massage if self treatment is not successful, and injections or surgery if those are unsuccessful. You must off weight the area on a daily basis. You need a dancer's pad not for the first metatarsal, but for the fifth metatarsal. See my video from yesterday on using 1/8th inch adhesive felt from to create an off weighting system in all your shoes (great if you can attach this to your orthotic device). 

I'm wondering if cold laser therapy or some other treatment might help.  The bursa doesn't respond to cortisone, and it won't let me bicycle, even with orthotics.  Because it's on the bottom of my foot and is connected to other tissue, surgery probably wouldn't be a good idea.  Thanks in advance for your advice,


Dr Blake's comment: I like the old beating up of these bursae, and I have no experience with cold laser. I like, and have good results with cortisone shots when the icing and PT not help. The surgery is rare, so I would not go there right now. Get an MRI if it is stubborn to make sure you are really dealing with a bursae and not another cause of a soft tissue mass. Good luck!!

Saturday, October 12, 2013

Nerve Pain Around Big Toe Joint: Email Advice


I have nerve pain that presents around the 1st MTJ pad, but is centered between the 1st and 2nd MTJ pad has stopped me running and severely effects my ability to walk normally. 
Dr Blake's comment: This is either a local problem with the deep peroneal nerve, or an L4/L5 Disc Issue. 

 My GP took an xray to rule out fracture.  He thinks it is a neuroma and has referred me to a podiatrist, but I won't be able to get in for another month.  As you know that's a long time for a runner, and I hate to be doing anything that would make it worse for a month.  So my question is, is contrast bathing good for nerve pain? 
Dr Blake's comment: Patients with nerve pain love contrast bathing in general since it soothes the nerve by removing inflammation from around the nerve. 

 That seems like something fairly benign that I could start doing right away.  In my desperation, I also grapped some Dr. Scholls metatarsal pads and am experimenting to see if I can find the right spot for placement to see if it addresses the pain.
Dr Blake's comment: Go to and order a roll of 1/8th adhesive felt. You will have more flexibility in where you put padding. Be creative!!!

Which leads me to my deeper question. I have heard a podiatrist say that a neuroma is a symptom of some underlying issue that caused the nerve to fire off in the first place, and that the underlying cause should be found and addressed in addition to treating the actual neuroma.  Is that the way you approach it?
Dr Blake's comment: Nerves fire bad for many reasons. It can be the nerve itself locally, it can be just a symptom that the nerve is stressed somewhere above (double crush syndrome), and it can be from an outside irritant from poor mechanics, bone spur, swelling in the area from a broken bone, etc. You have to treat the nerve, but not have tunnel vision and also look for other reasons the nerve is unhappy. 

Thanks for this blog! It has been very informative.
Michael (name changed)

Supination: Orthotic Designs for Preventing Excessive Supination

This video discusses the common orthotic mold corrections utilized by labs for correcting supination problems. 

Big Toe (Hallux) Soreness: A Method of Padding and Taping

Below is a video describing padding and taping for a painful big toe under the joint closest to the toe. This joint can get over stressed for several reasons--especially related to limitation of big toe joint motion and the presence of an accessory ossicle or sesamoid. Recently, a patient emailed me regarding pain in this area. I wanted to do this video for her especially, but I have many patients with this problem.