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Monday, February 29, 2016

Severe Plantar Fasciitis and Oral Cortisone: Email Advice

Dear Dr. Blake.
Thank you so much for posting and blogging about Plantar Fasciitis /Bursitis.
It has been very helpful for me.
In my hospital in Amsterdam i had all the treatings. I do not
have to name it again.. I told my orthopedic doktor about oral cortisone and he was
at least suprised. He never heard of oral cortisone with Plantar Fasciitis.

He gave me a cortisone injection.
No pain relief. Yes for 4 day.s..

At the moment i.m in Marbella/Spain.
Also here i have had, Fysiotherapy, laser. insoles...
no happy end . Pain and pain.. of course I used also ibuprofen, paracetamol,
naproxen and so on and so on.
I.m desperate.. 

Reading your artikel about Oral Cortisone..
And the Prednisone Burst.
I want please to ask you.
You are working with sport men and woman.
I.m a fragil woman from 70 years old and my weight is 60 kg.

I think that for every person the quantity of oral prednisone can be different.
So in my case what do you advice me ?? How much is responsable for me, as an old fragil woman to take ?
Dr Blake's comment: Please ask a pharmacist  if age and weight are a factor. I have not come across that. 

Considering the fact that I also have a severe pulmonary fibrose IPF, and i.m on PIRFENIDONE.
Thats  a very heavy and strong medicin.
The regular dose of Pirfenicone = 9 pils a day, but I can only handle 6 pils a day.

Dr Blake's comment: Your doctor treating the fibrosis, and the pharmacist mixing the drugs, would be the best at commenting if a 8 day course of oral cortisone would be contra-indicated. 
I would be so happy to hear from you and listen to your advice.
Yesterday I started with 2 pils of 5 mg (togehter) and it was too strong already.
My body was shaking..and sweating and so on..
Dr Blake's comment: That is probably your answer not to take. Sorry.  If you can get an MRI or Ultrasound, see if you do not have a plantar fascial tear. The treatment would be a removable boot for 12 weeks but you do not need the medicine then. Good luck . Dr Rich Blake

Yes i hope you have a little time to answer me.
Thank you so much Dr. Blake and I wish you all the best..

Saturday, February 27, 2016

Accessory Navicular: Email Advice

I am enjoying your website. It has helped me to understand my navicular syndrome.
I am 64 and didn't have any problems till 2 years ago, thought I had a fracture but 
Dr informed me of my extra navicular bone in each foot.  Got thru that episode on my right foot after 3 weeks of rest etc.
Now, I wake up in the night with Left ankle pain, can hardly walk till I take ibuprofen, ice my ankle, wear my boot shoe and elevate. By afternoon it subsides and I can get around pretty well. This has happened for 3 nights now.
I do put pillows around my foot at night, it feels good. I do have a bone that sticks out on each foot.
Dr Blake's comment: Does the left ankle hurt at the bone? Does it hurt to put weight down or to move the ankle in circles or both? Answer by commenting on this post and I will reply to your comment. You should be icing 10 minutes 3-5 times a day and try the kinesiotape circumferiential wrap. The taping for the posterior tibial tendon dysfunction problem is probably the best for you. 

Your videos on taping and exercise have been informative.
I started doing the first exercise gently.

Any tips on how not to aggravate it during the night. Am I just stretching it in my sleep enough to upset the tendon ?
Dr Blake's comment: Try the posterior sleeping splint for plantar fasciitis. Works well at night for this. 

I wear my ankle compression sock or ankle brace on some nights.
This is getting in the way of my daily gardening etc.
Dr Blake's comment: Use a removable boot anklizer type just for gardening (you can put your orthotic and tape inside the boot).

Okay, not that type of boot!! Good luck, and get an MRI soon if it is not turning the corner. 
I do wear arch supports in my shoes. Ive tried a number of different types. Some aggravate it even more. 
Thank You for any help. I would rather avoid surgery. 
I use to work in SF years ago. I live North of Portland in WA now.

Frozen Ankle post Sprain: Email Advice

Dr. Blake,

Good afternoon.  I just came across your blog and I just want to say thank you for taking your time to respond to so many people!  I would love any information you could provide me after I tell you about my injury. 

Ok, so here we go. March 16, 2015, I went to one of those
wonderful trampoline places for a birthday party and badly sprained my left ankle.  I had to be carried off and my ankle swelled up instantly.  It took me about a month to get an appointment to see a podiatrist.  In the meantime, I kept it iced, elevated, wrapped with an ankle brace and I was using crutches/cane/knee walker to get around.  My first appointment with the doc,  after x-rays, I did not break anything.  He said it seemed like a 3rd degree sprain with a high ankle sprain and it was frozen, which does not happen very often after a sprain.  He said this happens maybe 1 in every 1,000 sprains. Just my luck, huh?
Dr Blake's Comment: High ankle sprains involve the ligaments between the two ankle bones (tibia and fibula). When those ligaments get sprained, you lose forward bend of the ankle, thus "a frozen ankle". The more common lower ankle inversion sprains have full mobility to bend, it is the side to side ligaments that were injured and have to be protected. So, everything makes sense so far. Rich

I was put in a knee-high air boot, weight bearing and sent to physical therapy and  to check back in 6 weeks later.  After about 2 weeks, we realized my ankle was not moving or going to start moving, so we moved my check up to be seen earlier.  I had an MRI, and my doc said it was a basically a frozen joint and still the high ankle sprain and 3rd degree sprain. 
Dr Blake's comment: This is good medicine to get an MRI early in the game to rule out cartilage or bone injury. So far, you have been in the Immobilization Phase, and you are not going to gain alot of motion at this point until you are out of the boot. So, everything still seems normal. 

 We tried numbing it in the office about 3 times and tried to manipulate it, but that did not work.  So, he wanted to try a manipulation under anesthesia, where I could not fight him, but my insurance didn't cover that.  We are also in June 2015 by this time.
Dr Blake's comment: So, since a high ankle sprain can take 12 months or so to gradually loosen up as you balance pain free protection with gradually more and more stress, why was there so much concern about your ankle. Was it totally locked? How much did it hurt? What was the range of motion with the knee straight bending the ankle and with the knee bent? Do you have an excessive scar formation problem? Are we 100% sure that there were no bone/cartilage injuries?

  I was supposed to have surgery right after 4th of July weekend and found out that my surgery was not approved less than 24 hours before my procedure.  They would only cover the scoping.  My doc didn't want to just cut into me, so we tried to appeal the surgery and 30 days in, we found out the appeal was never started, so 60 days total, it was denied again.  This is now September, and by this time I would have rather him do both, the manipulation and scope, to be safe because the joint has been frozen going on 6 months now.  So, we scheduled my surgery and after it being cancelled one more time, the big day was October 22nd.  I had my one week follow-up and he released me to start back up physical therapy.  My 2 week follow-up, he removed the stitches.  We wanted to be aggressive with the therapy so the joint did not freeze up again, but not too much so the body went into shock and froze up by being to forceful too soon.
My physical therapy doc wanted to start dry needling me, but we had to wait until I could do a good stretch.  By the beginning of November I was being dry needled twice a week and she started grastoning me as well.  She thought because I had such short movement from the knee down for so long, that my muscles were so tight and that is why my ankle could still not move up very well.  I went from PT 3x per week, to 2x about a month ago.  In January I had a follow-up with my foot doc and he released me to full physical activity like I used to before my injury.  I was pretty active, working out pretty much everyday, so not working out for about the last 10 months or so has been killing me.
Ok, so I've been going to pt since my first post op and doing all my home stretching and my ankle is still not moving very well.  The front is better, but I am super tight in the inside,  like I can feel it pulling when I try to move my foot upwards.  After many breakdowns at pt, my pt doc told me a frozen ankle can take 1-3 years to fully heal, called it "a thawing out period".  After accepting that a few weeks ago, I am still not convinced.  I am tired of everyone telling me this does not happen very often and not really sure what to do.  We get it to stretch pretty good while Im at pt, but then it freezes back up.  I want to know what to do to fix this.
Dr Blake's comment: You definitely want a new MRI, because a one year comparison can tell you what is wrong and if there is anything to do to fix it. But, what did the surgery find? Too much scarring? Scuffed cartilage? More info on this tight ankle is needed. Make a comment to this post and I will reply directly to the comment. Yes, these can take this long, but I agree something does not make sense. Something is missing. 
Last week, I went and got a second opinion from another podiatrist.  He took more x-rays and looked at my MRI from before the surgery and I had pics from my scoping.  He told me it looks like he only scoped the front of my joint and not the back.  He showed me my MRI and the notes, and  there was no evidence that it was a high ankle sprain.  He said I did a number on it, but in the lower bones, I banged both together in 2 spots and he showed the bruising.  From the x-rays, he said it looked cloudy in the back part and when he showed me that my heel doesn't move side to side, because he believes the scar tissue it still there.  That was a pretty hard pill to swallow.  He recommended getting a steroid shot and ordered a JAS splint for my ROM issues.  The doc said he had a similar patient and he did the scope of the ankle and then put a cushion in the back to help with movement and she is at 80% mobility.  Here I am 4 months post surgery and unless I am very warm and all my weight is stretching the joint, I am not where near that.  I didn't get the shot that day, but I have it scheduled for Monday, Feb. 22, and I am very nervous.
Dr Blake's comment: Okay, now we are getting somewhere. So, I am sorry I am answering this after that appt. Definitely opt for a new MRI. If the initial MRI was misread as no bone injury, no wonder you are not better. If you injury bones, they need to heal before you can begin to get mobility back. I did have a PT who could not work for 3 years waiting for her bone edema (swelling) to completely resolve. Exogen bone stimulators can definitely help, along with flushing with contrast bathing nightly. There is still hope. Can you send a snapshot of the MRI image or two that shows the one edema?

I have a follow-up with my main doc on March 1st and I am going to ask if he scoped my whole ankle or just the front.  I am also going to ask about my MRI. 
Dr Blake's comment: Most docs just scope the front in these cases, the back being too hard to see. To access the back potentially can cause more tissue damage or scarring, so he probably erred on caution which makes sense. 
I guess my question to you is whether you think the shot is a good idea? 
Dr Blake's comment: If you had a shot on your visit fine, but keep them to a minimum until you know the bone/cartilage has completely healed. So get another MRI, get an Exogen bone stim if the bones still light up, get me some pictures. Hope this helps you somehow. Rich

 That is how I came upon your blog, looking up info about the steroid shots.  When they told me they would have to inject the shot into the ports where I was scoped, I freaked out because I am still in pain when my therapist tries to work on the scars.  I am only 31 and I just want to be able to be active again.  I thought after my surgery, I would be fine and now to find out that it is still frozen in the back, I am not sure what to do.  I asked the doc I had the second opinion with, was all this dry needling to get my foot to move basically a waste if the scar tissue is still there?  He said it isn't hurting anything, but I said it isn't really helping anything either and he said no.  I just spent the last 4 months going through some rough stuff and to find out my ankle it still messed up, I don't even know where to begin.  I have been reading reviews about these shots and I am reading more negative ones than positive.  I just want to make sure I am doing the right thing.  I really hope this and the JAS splint helps, because I really do not want to go through another surgery if possible. 
Any help would be greatly appreciated.  Thank you for taking the time to read this.
Very Respectfully,

Monday, February 15, 2016

Words to Live By

This was an email sent from a friend. I agree with everything said. It is always good to reflect alittle on how we are living on this earth. Love, Rich

As we grow older, and hence wiser,
we slowly realize that wearing a $300. or
$30.00 watch   - - - - - - -
they both tell the same time...
Whether we carry a $300 or
$30.00 wallet/handbag - - - - - - -
the amount of money inside is the same;

Whether we drink a bottle of $300 or $10 wine - - - - - - - - - -  - -
the hangover  is the same;

Whether the house we live in is 300
or 3000 sq. ft. - - - - - - - -
loneliness is the same.
You will realize,
your true inner happiness
does not come from
the material things of this world.
Whether you fly first or economy class,
if the plane goes down - - - - - - --
you go down with it...
Therefore.  I hope you realize,
when you have mates,
buddies and old friends,
brothers and sisters,
who you chat with, laugh with,
talk with, have sing alongs with,
talk about north-south-east-west or heaven & earth, ....
That is true happiness!!
1. Don't educate your children to be rich.
Educate them to be Happy.
So when they grow up they will know
the value of things not the price.

2. Best awarded words in London ...
"Eat your food as your medicines.
Otherwise you have to eat medicines as your food."

3. The One who loves you will never leave you
because even if there are 100 reasons to give up
he or she will find one reason to hold on.
4. There is a big difference between
a human being
and being human.
Only a few really understand it.

5. You are loved when you are born.
You will be loved when you die.
In between, You have to manage!

If you just want to Walk Fast,
Walk Alone!

But if you want to Walk Far,
Walk Together!
    1. Sunlight
    2. Rest
    3. Exercise
    4. Diet
    5. Self Confidence and
    6. Friends

Maintain them in all stages of Life and enjoy healthy life.
Sent with Smiles,
Affection and Love !!

Post Sesamoidectomy

Hello again dr Blake!

At 10 months after tibial sesamoidectomy I'm happy to report some progress. There has ben no severe flare-ups since November. I have been able to do all my daily activities pain free (working, even standing for up to eight hours in the OR, shopping, walking to the store etc) and have noticed that I've gained back my usual, quite fast walking pace. I've also started the walk-run program, and progressed up to 3 minutes of running but at that point there was some pain again so now I've got to start over at 2 minutes. Somehow, running seems a lot worse for me than walking, even though I have a thicker dancer's pad while doing that. The winter weather has been very crappy (pardon me) this year, and I've not tried cycling yet. It's a hobby I used to love and I'm anxious about not being able to do that again.
I'm happy about living pain free now, but still I long for the long hikes and cycle rides I used to do... Should I just forget about those now and find other hobbies? Can I still expect progress this long after the surgery?
Dr Blake's comment: Definitely, as you gradually stress the joint, the scar tissue will become more normal, and the body's own neurological protection will lessen (less sensitiivity). Hope you are continuing to ice twice daily to keep the inflammation down, even on relative non-exercise days. Making sure the biomechanical support and off weighting is correct is crucial in the Walk Run Program (link below). Thanks for inspiring others with a similar situation. It is typically a 2 year post op course. 
I'm contemplating about getting PT to analyze if my gait is stressing the sesamoids too much, and also to guide with some exercises for the foot. It's hard to find the time for rehabilitating the foot with my busy schedule and now that I'm pain free on 90% of the days, I just kind of forget about it...

Wishing you a lot of sunshine in the coming spring!

Referral Source: AAPSM for quality sports medicine

Hello Dr. Blake,

I am a nurse, 66, very active (till recently) with hallux limitus. I had the issue a few years ago but it went away with shoes, rest and so forth.  I would like to see someone like you in the Austin Texas area (or fly to see you if necessary - this could be difficult but I would do it!) but cannot seem to figure out how to assess by websites.  I have seen one person so far but did not like his nonconservative approach as I think orthotics and PT could really help.  Short of learning how to tape and get shoes and orthotics from web reviews I feel kind of on my own.  Austin must have some good people but I cannot find.  I wonder if you have heard of anyone here from one of your professional meetings or so forth?  I know if you mentioned a name that would not mean you know they are good, but just that I would go see and assess for myself.

I really want to do the right things for myself.  I stopped jogging and don’t want my overall health to deteriorate because of pain but also don’t want to ignore the pain.  I just bought 2 pairs of Finn Comfort shoes with a sort of rocker bottom and I am feeling lots better after that.

Thank you for your time and being so great!

Thank you so very much for your email. I am past president of the AAPSM (link below), and the members in general are more into sports medicine and keeping their patients going than most podiatrists. This is where I would start. There are 4 podiatrists listed from Austin and I personally know Drs Valencia and Brace. Good luck!!

Children's Health Article

With the rise in childhood obesity and diabetes, this article emphasizes the role of moderate to vigorous activity to improve health. 

"Physical activity seemed to be the main explanation for the differences in childrens’ adiposity. Every 10 minutes per day of moderate to vigorous physical activity was associated with 3.5 percent lower body fat at the end of the study, even after adjusting for fitness levels and the amount of screen time. This amount of exercise was also linked to a 4.8 percent increase in insulin sensitivity."

Exogen Bone Healing System recommended by Dr Blake

     Over the last 10 years, Exogen has been the only bone stimulation system I have used. I am very pleased by the results. I have no financial connection with this company. My patients use 20 minutes once a day for 6 to 9 months. It has almost eliminated surgery for some injuries like sesamoid fractures. 

Sunday, February 14, 2016

Post Op Sesamoid Removal: Email Advice

Hi Dr. Blake,

I'm not sure if this is the best thread to ask my question on, but I couldn't find exactly what I was looking for.
I just had my stitches taken out yesterday from having my sesamoid (tibial?) removed. I had the same procedure on my other foot 4 years ago by an awesome doctor in Monterey. Unfortunately, this time it was done by a Navy doctor and I had no choice. They don't seem to care all that much about recovery and follow up and the only instruction I was given yesterday was to grab my big toe at the base and push it as far forward and backward as I could for an hour a day. She said if after a month it's stiff, then I could do PT. Does that seem normal to you? Last time I did PT right away for a couple of weeks. 

It just seems really stiff and there is a lot of numbness. Nothing like last time. I just want to make sure that there isn't anything else that I can be doing since I've been left to my own devices for healing it.

Thank you so much for any info you can send my way for stretches or ice/heat therapy suggestions for 2 weeks post op!

Dr Blake's response:

Hey Amber, sorry for my delay in responding. I hope you are healing well. You should definitely get a referral for PT which is typically started between 2 and 6 weeks post op. Three times daily you should either just lay your foot on an ice pack for 15 minutes or do contrast bathing (as long as you are doing something three times daily to influence the joint swelling). I do not think you should just move the joint up and down (see my post on Hallux Self Mobilization). Do you have protective orthotic devices and/or can you make dancer's pads, but it is important to off weight the surgical area for the next year at least to some degree? You can definitely start doing metatarsal doming three times a day, and even flat footed balancing with the ball of the foot off the ground. Hope this helps you some. Rich

Photo of the Dancer's Pad Placement 

Saturday, February 13, 2016

Recurring Tendinitis (primarily peroneal): Email Advice

Hi Dr. Blake,
I have had recurring tendonitis diagnosed in various tendons in my lower leg and foot over the past 2 years. Started with overuse sesamoiditis, posterioal tendonitis and peroneal tendonitis. MRIs of foot, knee and even back after an EMG because of calf muscle atrophy. I am a climber so this constant injury is very frustrating to not be able to walk lain free, let alone climb. A podiatrist and now an orthopedic surgeon recommend a tendon sheath injection for the Peroneal tendon issues. I have pain at attachment under arch and at side of calf below knee. Weakness and increase pain wih movement. Also tendon pops at ankle. I have done pt and various therapies only to platue. Do you thimk the shot is best way to go? What questions do I need to be asking to make sure it is safe?
Thanks, Sarah 

Dr Blake's response:

Sarah, sorry for my delay in responding. I am assuming that the MRIs only came back with tendinitis and no tears. The PRP injections are gaining popularity, make some sense, but I just have no experience with it to recommend clearly. Definitely no cortisone into the muscle, tendon or sheath for fear of rupture due to transient weakness (which could last up to 9 months). Review the blog article on BRISS for tendinitis. See if there is anything missing in your treatment. Have you been adequately immobilizing in a below the knee removable boot for up to 3 months? Do you then to supinate excessively even with orthotic devices? When you return to activity, do you just go back to an overuse situation? Sounds like unless you can not get the tendon strong, it will be permanently the weak link for activities. How can it be made stronger? Or why haven't the PTs been able to make it strong? Sorry more questions than answers. Rich