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Thursday, March 26, 2015

Heel Pain/Plantar Fasciitis: Email Advice

I came across your website trying to find any other options for the heel pain / fasciitis that I may have. I am from Tennessee. My problems have been going on for 2 years. Both feet.

 About 3 months ago the right heel pain resolved. The left has not. I am seeing my second podiatrist. I have the custom hard inserts I keep in my shoes.
Dr Blake's comment: This is the time to critically evaluate each treatment avenue/modality and possibly make changes. The orthotic goal for patients with heel pain is to transfer the weight into the arch and cushion/float the heel. Do you feel this is being accomplished? If not, see if they can be altered or remade. This is called protective weight bearing and every step you take can be used to make the heel better if done right. 

 I have had my heel injection 3 times by the second podiatrist this year. Helps some but seems to "wear" off and return to pain. 2 times the year before with absolutely no relief which is why it took me a year to finally go again. 
Dr Blake's comment: Cortisone shots can be crucial if there is heel bursitis, but it is a mixed bag with plantar fasciitis. You really do not want to inject the plantar fascia itself, so you have to inject under it (and gravity actually pulls the cortisone away from the fascia) limiting its effectiveness. 

Wears a night splint but not all time because I didn't feel like it was making a difference.
Dr Blake's comment: If you have the classic morning soreness from from plantar fasciitis, the night splints should do wonders if the plantar fascia is tight. When there is minimal results with the night splint, you either do not have plantar fasciitis, your fascia is just not tight, or it is the wrong type of splint (I like the ones where the heel is enclosed and the toes are not bent up). 

 Can't take antiinflammatory long. They hurt my stomach.
Dr Blake's comment: You can use celebrex which is milder on the stomach with or without cytotec. Or, you can use topical Voltaren 1.3% gel or flector patches. Any anti-inflammatory drug, no matter the application, should be done on a 5 day on 2 day off routine, or 10 day on 4 day off routine, to rest the body and prevent some of the side-effects. You typically have to ice more on the days you are not using the medication. 

 Oral steroids may help a little but I know I cant always take them.
Dr Blake's comment: I love an 8 day Prednisone burst to knock out inflammation. See my blog post on that. It is especially good in chronic situations, or acute flares. But, it can also be very diagnostic when it works or does not work. It is for inflammation, but does not help the mechanical or neuropathic aspects of the pain. 

 Have been in a walking boot for 6 weeks. That didn't help any.
Dr Blake's comment: This is where I would need more info. When you were in the boot, were you 100% pain free. Plantar fasciitis feels great in the boot, plantar heel bursitis may hurt more in the boot. The problem with boots and heel pain is that your heel stays down longer than normal walking, thus increasing the normal pressure on the heel. But, the boots allow you to roll through, not bending the toes at push off, and thus not irritating the plantar fascia. I guess you can see that success or failure with any of these treatments can help us fine tune what is going on and how to fix it. 

 Have used heel cups. Good shoes that are known for stability. Have heel Spurs to both feet. But as a nurse practitioner I understand it is not the spur itself causing the pain. I have wore straps around my ankles that allowed me to strap my foot.
Dr Blake's comment: Does the strapping help? Typically works well with plantar fasciitis. And yes, the spur does not cause pain!!! 

  I do work 6 days a week for the most part with one to two of those days 12 hours.
Dr Blake's comment: I do not have to tell you that working that much can decrease your immune system's ability to heal. Have you had a workup on your ability to heal? Are there other problems that have been slow at healing? Are you always fatigued or have other systemic signs/symptoms?

 I am so frustrated that I cannot make this resolve and wondered if you might have any suggestions on what to do. I would love to be able to walk from the time that I get up til bedtime with no pain. I want to be able to walk run and I cannot. My feet get so sore and it is difficult to walk. Once I get walking it will settle some but will be even worse when I sit or sleep. I am suppose to visit the podiatrist again Monday to consider a 4th injection. Thank you again for any comments you may can give
Dr Blake's comment: I would suggest no more shots until you get an MRI. You could have a slight tear in the plantar fascia that cortisone can make worse. Even if you have to self pay for a Rearfoot MRI without contrast, it would be worth it. Hope this helps you in some way. 

Helen (name changed)

Wednesday, March 25, 2015

Sesamoid Pain with Compensatory Symptoms: Email Advice

Dear Dr. Blake,

I’ve been reading your blog over the past month- thanks so much for all the information!  

I wanted to ask you some questions about my foot pain, because there are a few things I am confused about.  I apologize in advance for the length of the explanation.

In mid-February(it is now mid March), I started feeling a vague pain on the ball of my foot under my big toe on my right foot.  It came and went and I was still able to wear high heels to work, workout, and walk around normally. About 10 days later, I was no longer able to wear heels and switched to flats.  A few days later, I could not walk flat on my right foot and started to walk on the outside of that foot.  A few days after that, I was limping and went to see a doctor. 
Dr Blake's comment: Sounds like a sesamoid injury. The swelling within the bone builds up over the first 4 to 14 days after the injury making the symptoms more and more painful and limiting.

I visited an orthopaedic surgeon (the type of doctor covered under my insurance plan).  He bent my toe up and down and pressed on my bones- I didn’t feel any pain.  He took an x-ray to be sure and confirmed that there was no fracture.  He told me to take it easy to reduce possible inflammation of the tendons in that area.   I started icing, elevating, and minimized walking as much as possible. 
Dr Blake's comment: For sesamoid injuries, x-rays are typically a poor indicator of the problem because they may not show stress fractures or bone contusions. 

A week later, the pain became intense and I went for a second opinion with another orthopaedic surgeon.  The pain was now in both feet, in the exact same area with the exact same symptoms.  My feet were tingling and there was a constant sensation of pins and needles and electric shocks.  Additionally, my feet were getting very cold to the touch, even when I wasn’t icing.  There was a stretching/pulling pain in the web of my first two toes. 
Dr Blake's comment: When you injure the area, there can be the mechanical (orthopedic) cause of pain, the resultant inflammatory aspect of pain, and then secondary neuropathic pain for the body protecting itself. You sound like you have all 3.  

The second surgeon did more x-rays on my right foot (but not the left one), some blood tests, and an ultrasound.  The xrays were negative, the blood tests showed slight vitamin D deficiency, and the ultrasound showed tendonitis under the right toe but not the left one.  I was given a diagnosis of sesamoiditis and started taking vitamin D3: 10,000UI daily, 5 days a week. 
Dr Blake's comment: Vitamin D3 deficiency is proving to be a be killer for runners. One of my patients that I saw yesterday has not run for 2 years due to stress fractures from low Vitamin D3.  

The pins and needles/electric shocks sensation decreased in frequency and intensity but the other symptoms remained.  The way I was walking and standing to avoid stressing the sesamoid area led to sharp pain in my heel area in the fat pad directly under the heels (both feet but more on the right) and Achilles/calf pain in my right leg.  I started with a physiotherapist in mid-March to learn how to walk properly.  He found my symptoms tricky for the following reasons:
Dr Blake's comment: Glad the nerve hypersensitivity is calming, because that can become a problem on it's own. You typically have one injury and a bunch of secondary compensatory symptoms (tendinitis, nerve irritability, achilles tightness, etc. It is important to address these issues, but not to lose sight of the original issue. 

1)      There is absolutely no pain when my flexor tendon (the one supposedly affected by the sesamoiditis) is stretched or pushed in any direction
Dr Blake's comment: I am sure any flexor tendon problems is just secondary pain, not a true injury. 

2)      The pain is in both feet (which seems to be a rare occurrence) but it is not always in both feet at the same time
Dr Blake's comment: I have some many patients with sesamoid pain in both sides, knee pain both sides, achilles both sides, etc. It really depends on your weak spots.

3)      When walking, I feel like there are pebbles under my first metatarsals but when the area of the sesamoid bones is poked by hand, I don’t feel pain
Dr Blake's comment: This is highly usual for stress fracture, so sesamoiditis may be right. 

4)       Sometimes it feels like my foot is tightening up (possibly from swelling) and moving the foot upwards (without bending toes) causes pain that radiates from just below the web of the first two toes on the sole of my foot and ends just behind the ball of the foot under the sesamoids
Dr Blake's comment: This is definitely neuropathic pain with neural tension. See my blog posts on neural flossing and Neuro-Eze. 
5)      Laying flat on my back and moving my leg upwards in a straight line reproduces the pain described in #4 but only when the foot feels tight- when it doesn’t feel that tightness, nothing can reproduce that pain
Dr Blake's comment: The sesamoid injury can cause swelling, the swelling irritates the local nerves, the swelling can come and go due to anytime that affect swelling like the foods we eat, how hydrated we are, the temperature and humidity, etc. 
6)      I sometimes feel the whole ball of the foot swell up- but there is no pain to touch
Dr Blake's comment: Swelling means your body is trying to heal something. But, swelling itself is a bell shaped curve. Some people swell alot and others little with the same injury. It is hard to judge, and if you swell, the swelling shoud be treated on a daily basis. But, you may be swelling long after you are completely healed. 

After 2 sessions of physiotherapy, my feet feel much better when I take my first steps in the morning but are much worse when the burning starts (this is the only time there is pain when touching).  The pain I currently feel under the sesamoids is burning/stinging, sometimes very intense (the skin is not hot to the touch), tightness, and pebbles or ball under my feet when I walk along with a bruised feeling on the outside of the first metatarsal. 
Dr Blake's comment: These are all nerve hypersensitivity, protection, symptoms. They are real and are not treated by typical mechanical or anti-inflammatory measures. Try neural flossing, Neuro-Eze, tylenol, warm compresses. Review all the treatments on my blog for nerve pain including medication (started only at bedtime for these symptoms. 

 These symptoms come and go, sometimes there is more than one symptom, sometimes all of them, sometimes none.  
Dr Blake's comment: This is how compensatory pain goes, not the pain from an injure that is there from start to finish until the injury heals. 

The pain in my heels gets better with rest but comes back with pressure and standing/walking (but heels feel ok in shoes like Birkenstocks). The Achilles pain gets better with rest. I will go back to the doctor to try and get an MRI approved, maybe more blood tests to rule out any infections, and maybe take some time off work so that I can fully rest my feet.  At this point, I am reaching out for any advice and am hoping you can help- does this seem like sesamoiditis in both feet or might there be something else I need to look into?  
Dr Blake's comment: So, remember to not lose sight of the primary injury. You injured your sesamoid. You need to treat the mechanics with dancer's pads, possibly orthotics, spica taping, icing, an MRI, creating a protected weight bearing environment. Good luck. Rich

Thanks for taking the time to read this.

Name Removed due to Witness Protection

Sunday, March 1, 2015

Nerve Pain: Dr Danielle Rosenman

Hi Rich,

Steven was happy to see you today, and I am happy that his feet are well cared for!

We forgot to get you some flyers for the new groups I have starting February 23 and 24, A Change of Mind: Neuroplastic Tools for Healing.  Here is a short description from the syllabus:

These innovative experiential groups teach participants basic principles and practical applications of the neuroplastic ability of the brain to change, in order to reduce symptoms such as pain, discomfort related to illness, stress, anxiety, and depression.  Participants improve their quality of life by using a specific learning method to change brain pathways along with well-researched effective techniques such as meditation, imagery, journaling, expressive arts, and changes of thoughts and behaviors.

I developed the groups within the context of  the neuroplastic method developed by Dr. Michael Moskowitz, a psychiatrist and pain specialist who is profiled in the first chapter of “The Brain’s Way of Healing,” the new book by Dr. Norman Doidge (who wrote “The Brain that Changes Itself”).  By the way, it is a great book – even more exciting than his first book.

I’ve attached the flyer – if you want to refer people, you could print it in your office, or ask me to mail you copies, which I would be happy to do.  I’ve also attached a letter to colleagues and, for your interest, a piece I wrote about my process in getting from there to here.

By the way, I have had no foot pain since about 5 or 6 months after I started using the neuroplastic tools against pain.  I can now walk easily for an hour in the hills (mild up and down or flat), and up to 2 hours on occasion!  Steven and I went to Alaska in September, a trip I couldn’t imagine 2 years ago, and on the cruise part, we danced every night.  We hiked at every port.  Hurray!   My orthotics are still working well – thanks!

All the best,

Danielle Rosenman, M.D.

Big Toe Joint Pain: Gel Products

Hi Dr. Blake,
Thanks for the heads up about the molds.
Can they be mailed to me?

If not, I think I will not keep them.  The orthotics never worked for my inflamed metatarsal/hammer big toe.  I have had good luck with
1. ‘gel socks’ from Dream Products:
2.  gel inserts…the ones from….

These two items have been miraculously helpful along with eliminating most of my shoes except those that are wide toe boxes.  I still do the taping you showed me, along with variations that I have developed to help the tendons in my foot.

Thanks for your kind assistance.  I guess the bottom line is that we just have to keep trying things.  I was very motivated to keep walking!