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Saturday, May 31, 2014

Hallux Rigidus: Email Advice

Hi, I was diagnosed with hallux rigidus a year ago.

 I'm a 40 year old male that was fairly active doing things like running, triathlon, ultimate frisbee.  I've see 3 different doctors about my toe, all recommended surgery saying it was advanced, but I'm still on the fence. 

 At this point, I'm able to run 3 miles once a week with minimal pain the day after.  I'm using a morton's extensions and very stiff running shoes.  Besides the weekly run, I ride my bike.  I would really like to get back into ultimate frisbee but I'm pretty sure it's what caused the problem as it's much harder on my foot than running.  

 I'd like to come up with a plan on how to get back to playing ultimate frisbee, even it it means having surgery.   Should i just start playing and hope my joint self-fuses?  Or perhaps the hard answer is that my ultimate frisbee days are gone, if I want to still want to walk normally when I'm 70.  

 Any advice you could provide would be appreciated.  I live in the south bay and would be willing to drive up to see you, do you accept blue shield ppo?  Finally, I do have a soft copy of my xrays if you care to take a look.   Thank you

Carl (name changed)

Dr Blake's response, 

     Thanx for the email Carl. Your ultimate frisbee days are over for now (hopefully temporarily), since it is just too hard to control the forces with all the cuts and uneven terrain. Typically, we get you comfortable at cycling first, then running, and then begin to introduce side to side stresses. The pain you have to avoid is the pain that comes on during a workout, that you ignore. And, any pain that begins to effect your gait can mess something else worse. Xrays are less important than MRIs and CT scans so I would progress your diagnostics to include these. Let us get a good 3D image of your big toe joint in 2014, and will be able to use these as baselines. Like any arthritic conditiion, you need to be icing for 10-15 minutes 3 times per day, no matter the workout, but especially as soon as you work out. This alone should enable you to do more. You need to learn spica taping and be great at it. This is for all your workouts. Most patients with Hallux Rigidus (less than 30 degrees of big toe joint dorsiflexion) feel better with dancer's pads, not Morton's Extensions so work on that. You will definitely need an orthotic to shift weight to the center of your foot and off the big toe joint. There are many times that athletes need a little different correction for cycling vs running vs ultimate frisbee so multiple pairs may be in order. Have someone measure the big toe joint, I have a video on that, to see exactly how much motion you have. It is hard, but typically doable to gain 20 degrees with anti-inflammatory, physical therapy, and self mobilization. So, if you are really 50 degrees (Hallux Limitus) not 30 degrees or less (Hallux Rigidus), that may help you. I hope this helps you some. Rich

Friday, May 30, 2014

Complex Regional Pain Syndrome: Email thoughts on possible/present treatments

This is an email I sent a patient, whom I just met, with 14 months of CRPS. The neural prolotherapy from Dr Lee Wolfer as described in my last post is helping greatly. She still has metatarsal pain so I am making soft Hannaford orthotics and sent her some of my other thoughts below. 

First of all Sally (name changed), it was a pleasure to meet you. Here are 2 links from my blog I would like you to see. 

My general thoughts for now and in the future:
  1. Continue with the Wonderful Dr Wolfer and neural prolotherapy
  2. See if Dr Wolfer will look into Calmare Pain Therapy
  3. Consider adding low dose naltrexone 1-4.5mg/day
  4. Have an Rx for sublingual Ketamine for flares if occur
  5. Purchase Neuro-Eze and apply topically 3x/day
  6. Get Hannaford orthotics for protected weight bearing
  7. Continue Gabapentin/Cymbalta/Atavan for nerve stabilization
  8. Start daily Graded Motor Imagery with laterality flashcards and Mirror therapy
  9. Remember PT and exercise are crucial, PT you must start an exercise below pain level, and very gradually increase to restore lost function
  10. May consider 50%DMSO cream (99.9% Pure) with other topicals
  11. Vit C 500mg x 45 days or with flares
  12. 30 min to 1 hour meditation per day
  13. We await reading of the MRI CD
  14. Consider sleeping with Lidoderm patches
  15. Check Vit D3 level, make sure it is at 45-50
  16. Consider Somatic Experiencing (decreases sympathetic response)
  17. Consider gluten free diet, emphasize fresh whole foods, de-emphasize highly processed foods.
  18. Do Neural Flossing 3 times per day
  19. Increase Cardio--stat bike with weight on non painful area (like arch or heel). Exercise decreases glial inflammation. 
Hope this helps. Rich

Wednesday, May 28, 2014

Neural Prolotherapy: A potential help for chronic pain

Just saw a wonderful new patient who has a 14 month history of developing CRPS (aka RSD). This is a severe disabling nerve condition. She has had wonderful help from a Dr Lee Wolfer in San Francisco utilizing a new technique (to me) known as Neural Prolotherapy. The nerves exhibiting point tenderness to palpation are injected with small amounts of sugar water. I hope those suffering from chronic pain may be helped by reading this. 

Tuesday, May 27, 2014

Sesamoid Surgery: Email Advice

Hi Dr. Blake,
Four months ago I had a sesamoidectomy after 2 years after the onset of my pain.  My post surgery follow-ups were with the orthopedic's assistant who was pretty clueless about the recovery.  He ended up referring me to a physical therapist which has helped reduce the scar tissue and increase my big toe range and strength as well as helping me to stop walking on the outside of my foot as I had for 2 years. 

     But I am now at the end of therapy and I still have stubborn scar tissue which is somewhat tender to walk on. Also as soon as I began the therapy and strengthening and stretching the toe I began getting numbness and tingling in the toe.  It's pretty persistent, but the "toe curls" increase that sensation.  This may sound strange, but that nail seems to have slowed/stopped in its growth.
Dr Blake's comment: Surgery is an incredible event that your body must deal with. All bodies deal alittle differently, but overall the surgical area gets the majority of the blood supply for healing, some being shunted from other areas close by. The nail may be alittle poor on blood supply for a while, but should come back to life within the next year. 

    So I am curious to know what is "normal", how long these symptoms may last, if they may be permanent and what I might still do to promote recovery.   Thanks for any insight or experience you have in this area.  

Regards, Bill (name changed)

Dr Blake's response:
     Thank you so very much for the email Bill. You are on the surgical plateau from 3 months post surgery to 9 months post surgery. It can feel like nothing is happening. This is when you stop PT in general, and do your daily stretching, strengthening, scar mobilization with Blaine Surgical Scar Kit, Hallux Self mobilization (as described on my videos), anti-inflammatory measures like icing and contrast baths, and wear your protective shoe inserts. Continue to honor the pain, keeping between 0-2 pain level. The next big change will be between 9-12 months when scar tissue maturation occurs. You will see during this period that the exterior skin changes from red to white. You will gain some range of motion. Your gait (walk) push off will be better. 
     So, during this next 5 months, when nothing happens quick, be diligent on daily stretching, mobilization, strengthening, scar manipulation, anti-inflammatory, and protection. It is hard to do, but very important, and for some, crucial. Hope this helps some. Rich

Achilles Pain Flow Chart of Treatment

I am just beginning to experiment with various flow chart software to capture the complex nature of treatment of these lower extremity injuries. I apologize for any confusions as it is meant to supplement the information already in the blog on achilles tendon injury treatment. 

Monday, May 26, 2014

Webcam Treatment of Acute Ankle Sprains

I hope you enjoy this Webcam on Treatment of Acute Ankle Sprains. See the attached video below also. 

Sunday, May 18, 2014

Abrupt Severe Heel Pain needs MRI for diagnosis: Email Advice

Hi Dr. Blake,

I found your website while searching for a podiatrist in the bay area. I'm an ultrarunner (multiple trail 50ks, one 50 miler). I developed abrupt severe onset of right heel pain during a 14 mile trail run (running downhill) at 7 miles, finished up the run. This was 12 weeks ago now. 
Dr Blake's comment: Abrupt severe heel pain during a run is either heel stress fracture, plantar fascial tear, plantar heel bursitis, or Baxter's Nerve Entrapment. 

I did lots of icing, stretching, you name it afterward. I am very good about stretching, wearing the correct shoes, etc. I have continued to have heel pain ever since. Initially I took a week off of running, then went back. I run 3-4 times weekly, mileage is never more than 25-35 weekly. I have tried everything under the sun, including MLS laser, Graston/ART, E-stim, rolling, stretching, icing, changing my shoes (was in Pearl Izumi M2, went back to Hokas), heel cups, night splint,  plantar fasciitis cups, superfeet. 
Dr Blake's comment: When patients give me info about past treatment, it is important to know what treatments helped somewhat and what treatments aggravated. You have had treatments in the 3 important areas of heel pain treatment---stretching, biomechanical changes, and anti-inflammatory. However, without a diagnosis, we need the info on how various treatments effect the heel pain for the positive and negative. 

I have stopped running altogether, I'm going on my 2nd week. The symptoms have not gotten better, in fact it is getting worse. I did some research the other night and realize I may have injured my heel fat pad. When I displace the fat over my heel, my pinpoint tenderness, which is in the middle medial of the heel, goes away. I have started taping the heel (for fat pad syndrome). 2 days of that but have not noticed any improvement.
Dr Blake's comment: Typically heel fat pad injuries are chronic, but the lack of heel padding can lead to nerve entrapment, bursitis, or stress fracture/bruise. 

 My heel is swollen, which I believe is unusual for plantar fasciitis.  Prior to this injury, I was in great shape, no aches, pains anywhere. I did have a weird sensation to my 4th and 5th left toes starting about a month prior when I would run; felt like they were squished together, broken.  I have NO achilles pain, no dorsal foot pain or numbness, no arch pain.
Dr Blake's comment: The swelling is typically plantar fascial tear or calcaneal/heel stress fracture. MRI is crucial and definitive for the diagnosis. 

I am completely devastated by this injury. I run on trails, I don't pile on tons of miles, I stretch, get rest, take care of my feet. I am afraid I've done permanently damaged my heel fat pad. I am waiting to get into a UCDavis sports PM&R doc soon and will request an MRI. I did have an xray about 2-3 wks after the injury and no stress fracture was seen, they did see a small bone spur.
Dr Blake's comment: I would not get too excited until the results of the MRI come back. If the the MRI comes back negative, I would be happy to look at the images. If negative for tear or bone edema, which will both heal with cam walkers and time, then the doc soon palpate for a bursitis or neuritis. He/she can compare the fat pad on both sides. Keep me in the loop!!! Rich

I am not interested in cortisone injection as the research doesn't seem to show that helps much and if fat pad syndrome an issue, it could worsen it.

Do you have any recommendations? Would it be helpful to make an appt with you?


Cheilectomy Post Op: Email Advice

Good evening, I had the cheilectomy surgery Nov 6 2013
Dr Blake's comment: A Cheilectomy (also known as an arthroplasty) is basically a joint cleanup of the big toe joint when arthritic spurs and cartilage damage is noted. Like meniscal repairs and cleanups of the knee, it may be the precursor of a partial or complete joint replacement. 

I was making good progress I thought. Recently, I am having a lot of soreness behind the big toe actually the entire toe is sore and nerve sensations are occurring.  I limp because of this soreness. 
Dr Blake's comment: If you read the post on Good vs Bad Pain, you are definitely in the Bad Pain side of things. What can you do to help this? Some common changes you can make are: daily ice pack for 10-15 minutes three times a day, learning spica taping, wearing a removable boot or another stiff sole shoe any time possible for the next several months, trying to make yourself dancer's pads to off weight, and going to PT for advice and anti-inflammatory treatments. 

 I went for my check up 6 months  he said to get some insoles for my sneakers but I  wear a 2 inch heel at work.
Dr Blake's comment: There is some many factors involved in finding a comfortable heel to wear. You definitely want to go shoe shopping. Try 20 different pairs of 2 inch heels and you will find some much more comfortable than others based on stiffness, padding, volume, flexibility, etc. 

  He said I was pushing my toe down causing pressure from wearing this small heel. He is a Orthopaedic surgeon for the foot and ankle.  I don't have much cartilage left by looking at my X-ray.   I am very active with weight lifting and stair stepping everything bothers my foot.  Further Surgery I don't think I want.  It's been 6 months and somewhat worse than 2 months ago for some reason.
Dr Blake's comment: When you are in a flare, which is very common for this and many surgeries during the first year, it is important to figure out how to get out of the flare as soon as possible. If that means a removable boot every weekend and evening after work for several weeks, so be it. If it means icing 5 times daily, and a good dose of oral meds, and shoe changes and physical therapy, so be it. See if you can begin to experiment and find what seems to help at least some, and then take the additive approach of finding multiple things. Hope it helps. Rich

Fibular Sesamoid Fracture: Email Advice

     I just found your blog trying to research sesamoid treatments and I wish I had found it sooner! I have been in a walking boot for four months to treat a fibial sesamoid fracture and I'm starting to get frustrated. Every visit to the podiatrist shows improvement on my x-rays, but I'm confused by the questions he asks about pain. He says that if it hurts the bone is moving, but how can it be moving when I wake up in the morning and it's been up and elevated all night long- and still hurt.
Dr Blake's comment: There are so many causes of pain after you hurt a body part, that blaming it on one specific thing may not be correct. The pain is most likely due to the swelling that collects in the area, that is a totally normal part of healing, but loves to sit there and interfere with movement and compromise the circulation and nerves. 

    I've been reading some of the posts and concerned about all the information that I haven't seen before, literally the only treatment has been this boot that I was told was to avoid having to do surgery- but not to remove, but to pin?
Dr Blake's comment: Unfortunately I have no experience with treating sesamoid fractures that have been pinned. It has always seem too small a bone to do something like that, but new technology is being introduced almost daily. I have only seen one unsuccessful surgery where the surgeon removed one half of the two bipartite bones. 

 The more I'm reading the worse this is sounding.
Dr Blake's comment: If you have been in the removable boot for 4 months, you have done everything right up to now. But, it is time to move from the Immobilization Phase to the Restrengthening Phase of Injury Healing. The Restrengthening Phase should continue your 3 times per day icing/contrast bathing, your Calcium and Vit D intake considerations, your protected weight bearing with orthotics and/or dancer pads and/or stiff soled shoes, a gradual strengthening program from the core down, and a gradual return to full weight bearing with no barefoot. 

 In the past month I swear it's been getting worse and the boot itself is driving me nuts and starting to hurt the other parts of my leg. Any advice?
Dr Blake's comment: Typically after 3 months in a removable boot, the negative effects of immobilization start to take their toll and pain syndromes develop. How to begin protected weight bearing without the boot is the next goal and many of your new soreness will abate. 

 My next appointment is in the first week of May and I'd like to sound like I know my options. 
Dr Blake's comment: Sorry, I just had some personal family problems that needed me so I am late with this response. 

My podiatrist is a nice guy, but this is getting really frustrating, according to him I should have been healed by now.
Dr Blake's comment: You can ask any athlete if they continued to have pain when their injury was healed and the majority would say affirmative. You need to respect pain levels over 0-2 and increasing as you work out. You need to gradually stress the injured area to prevent flares. Working with a good physical therapist on lower extremity strength and flexibility at this time on a weekly basis will also get their regular feedback on activity levels permissable.

Dr Blake's comment:
     Thanks for the email. When you see him, ask the following questions.

  1. Can an orthotic device be designed to off weight the sore sesamoid?
  2. Can you go to PT to learn joint mobilization, spica taping, dancer's pads, foot strengthening, and anti-inflammatory techniques?
  3. Can you get a baseline MRI to see where you are at, or CT Scan? There are many reasons to get a MRI other than healing of sesamoid for it can show if other structures are involved.
  4. If he thinks you are slow at healing, can you get a bone stimulator?
  5. What shoes, like hiking boots, can you wear to begin to wean off the cam boot?
  6. Has he had cases like this that heal without surgery? This is check if he has a bias. 
  7. Does he feel you can heal without surgery? If not, who should you see for a second opinion?
Typically, the next 3 months should be geared towards gradually getting out of the cast, developing a good orthotic, gradually increasing activity, gradually understanding good vs bad pain, and daily continuing to ice and contrast bath. Good luck. Rich

Sunday, May 11, 2014

Peroneal Tendonitis: Email Advice

Hello Dr. Blake,

     I have had severe peroneal tendonitis in my left foot for over a year now. MRIs and Xrays were normal. After failing conservative treatment, we chalked it up to psoriatic arthritis and I've used a walking boot and crutches to get around in. Started meds for arthritis that have helped joint pain everywhere else, but foot pain still bad.
Dr Blake's comment: With negative MRI, and negative response to anti-inflammatory meds, you need to think nerve injury or mechanical (over pronation or over supination). 

     Now, recently (in January 2014), I started getting the exact same type of pain, this time in the right foot. This time around, the pain is accompanied by a loud snapping sound behind the outer ankle.
Dr Blake's comment: This definitely sounds like mechanical inflammation of the peroneal tendons. The peroneal tendons are easily irritated by limping. If you are favoring your left foot, you typically place more weight on your right foot on the outside, with only the peroneal tendons to protect and stabilize you. 

    The pain gets worse and worse each day when I try to walk and snaps almost constantly. Went to ortho doc and was diagnosed with intrasheath peroneal subluxation. He said the tendons are snapping over each other. He wants me to do physical therapy. 
Dr Blake's comment: Physical therapy sounds great. The therapist should focus on your mechanics---use an EvenUp on the right when you wear a boot/walker on the left, correct for any over pronation or over supination tendencies, and work to avoid over stressing your right foot. The PT will also help you with peroneal strengthening and anti-inflammatory measures. 

     I'm 25 and have officially lost my ability to walk, as it is too painful. I don't leave my house. I was a straight A nursing student and very athletic a year ago, I don't understand how a person can lose the ability to walk that fast. I don't understand how physical therapy will make the tendons stop snapping over one another? It hasn't worked so far.
Dr Blake's comment: I am sorry for problem. And, you should definitely get an MRI to get a baseline on what the area looks like. There can always be surprises. So, why do the peroneal tendons sublux? Typically, they hypertrophy from the overuse of limping and the tighter tendons snap on each other as they move across. If they dislocate anteriorly out of their normal groove behind the outside ankle bone, then we are talking surgery. But, typically then stay in their place. Hopefully you are experimenting with braces to stabilize the ankle. A back doc should also evaluate you for possible low disc central disc bulge which can cause bilatteral peroneal spasms/pain/snapping.

    Neither have custom orthotics helped me due to the fact that I also have type two accessory naviculars and taking pressure off peroneal tendons puts pressure on the tibial tendons and has been causing arch pain. 
Dr Blake's comment: In biomechanics, we call this Medial/Lateral Instability. It requires orthotics/shoes/braces that carefully help both tendencies---pronation tendencies and supination tendencies. You need someone skilled at addressing both in the same person!! The Fettig Modication of the Inverted Orthotic Technique is one version of an orthotic device that tries to address both motions.

    I went to another ortho person to see if he could do a groove deepening procedure that I've heard about, and he feels that it's "too aggressive."
Dr Blake's comment: Thank you to God that that doctor cared about you. You do not have surgery for subluxation. It can be fixed conservatively. I know when you are in pain, disabled, surgery can seem like a way out, but I would not do any procedure on you unless 2 doctors said you needed it, and a top notch physical therapist (with no financial ties to the surgery). 

    I've gotten so depressed from not being able to leave my house that I've considered suicide as an option, as I've lost my ability to walk and don't know what else to do anymore. I don't know why they wouldn't want to do surgery to fix a problem that's obviously not responding to conservative treatment.
Dr Blake's comment: Wow!! Please listen to yourself, this has only been going on since January (4 months). Check the AAPSM website for local sports medicine podiatrists in your area. Have your low back evaluated. Consider a brace for your better left side and a boot/walker for your right side now. See one or two physical therapists and see if they can point you in the right direction. Definitely see a psychologist to help you focus correctly. Nothing you have said waves red flags suggesting permanent disability. This is run of the mill stuff in a sports medicine practice, although there are many things I have no clue of regarding your case. 

    I'm also curious as to whether or not the subluxation in the right could have caused the pain in the left side as well, although the left side never made a snapping sound. Any advice would be greatly appreciated. I don't need both feet to work again-I just want the right one to stop snapping so I can go some places in crutches again or with an aircast. I've never been this worried before in my life :( Why wouldn't they want to do surgery to fix the subluxation when nothing else is working?
Dr Blake's comment: I hope my comments above have been helpful. Get the MRI, go to PT, back doc, consider a RollaBout for getting a round little. Email me when you have more info. See if a Flector Patch can be prescribed since you can wear 24/7 for a few weeks. We need someone to give you an old fashion muscle test to rule out peroneal spasm and grade your overall peroneal strengthen. You need to constantly work on the orthotic devices to get them right. Good luck. Rich