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Tuesday, January 31, 2017

Sesamoid Fracture: Email Advice

Hello Dr Blake,

I hope it's ok to write you an email. I didn't know if it was better to write an email or post a reply on
Thank you in advance to read my request here...
  • Feb. 2014; sesamoid fracture
  • Only in July 2014 (5 months after the fact) Doctors told me that it was fractured 
  • Walk boot (camwalker) for 2 months
Dr Blake's comment: Here is where the initial mistake happens. The cast typically should be on  for 3 months creating a 0-2 pain level environment. Then there is a 2-6 week weaning out of the boot all the time maintaining that 0-2 pain level. If you can not maintain it, there is more time in the boot while the shoes and orthotics and taping and physical therapy are modified/started, etc. 
  • Stopping all activities, pain while walking
  • Till end 2015 (2 years without change); many appointments with different specialists all through that time
  • My pain was chronic and I was looking everywhere for answers (tried dancers pads with relief)
  • In December 2015, for the first time, an orthopedic surgeon gives me an answer. He suggests surgery to shave/smooth the bone fragments to alleviate tendon irritation and pain. He told me that my case is very rare, seeing only one in 5 yrs.
  • 1 year passed and I finally got my surgery on November the 4th, 2016 (partial sesamoidectomy); which was anything but standard and required on the fly adjustments and «had to go deeper » (as the doctor said)
Dr Blake's comment: I have no experience, except one patient that it did not work. But, it is too small a sample to come to any conclusions. If it doesn't work, you have to finish it off with a complete sesamoidectomy, or find another conservative solution (thus the email). 
  • 2 months later; still can’t walk, I've got less pain but the inflammation persists and is distributed – sometimes I feel it in my big toe... lots of tension in tendon. 
  • I do daily massaging and stretching within pain threshold (not "assez fréquemment et sérieusement)
  • Still not capable of foot flexing for movement
Where do I go from here? Was told before the surgery that I would be better in 2 weeks, it’s been nearly 3 months now!
Dr Blake's comment: Any time a modified approach is taken that does not produce results, then a full sesamoidectomy is considered. This is similar to the hundreds of knee meniscectomies I have seen fail, only to have the patient go on to a knee replacement. Any foot surgery can take up to 9-12 monthes to get back to normal activity and still be considered in the normal healing. You were just told the most wished for course. 

But after the surgery, I was told it needed to be adapted and was a little "artistic" procedure.
What would you think in your professional opinion are the next steps to take?
Dr Blake's comment: For all I know, the surgery could be very successful, but it just going to take awhile. Typically start doing the normal things that work on the 3 sources of pain: inflammatory (ice and contrast bathes), neuropathic (massage, neural flossing, avoiding pain over 2, local anesthetic injections), and mechanical (boot, rocker shoes, crutches, orthotics with a good arch and dancer's padding). Create that 0-2 healing pain level environment and hope monthly you can gradually do more and more. 

Scheduled for 2nd post op appointment with not much difference in between.
The surgeon believes in a positive outcome (claimed pain free for a start!) maybe to keep my morale…

Thank you in advance for your opinion!
*If you need my last xrays, let me know!
Dr Blake's comment: I hope this helps you. I tell my patients if the surgeon tells you a month, give it at least 3 (and I love surgeons, we need them, but they can oversell the rehab part). Part of them making you feel good about having the surgery. Why didn't they just remove the whole bone? Was that logical? Ask for Plan B if this surgery does not work after a year. Rich

Saturday, January 28, 2017

When Flat Feet are a Pain: Guest Author Gemma Gerb

When Flat Feet are a Pain
by Gemma Gerb (Guest Author)

Elizabeth, a 40 year old woman with mild congenital cerebral palsy had been lucky enough to spend the majority of her adult life free from any disability related discomfort. As she edged towards middle age, this began to change. She developed pains in her feet and a swollen ankle that felt like a sprain which kept reoccuring.  Sometimes the pain was so bad that she had to crawl around the house and cook meals sitting down.

Pes Planovalgus

Her problem was Pes Planovalgus, or flat feet, causing her foot to roll over and sprain her ankle repeatedly. Flat feet are common in people with cerebral palsy and other neurological conditions because weak muscle control and poor posture can lead to a collapse of the foot arches.
However, you don't have to have a disability to have flat feet.  They can be inherited from a parent, caused by wearing high heels and they are more common in people who have diabetes or high blood pressure.  People who are overweight are also prone to flat feet due to greater weight loading and its affect on muscles.  Half of all people with rheumatoid arthritis have flat feet.
In most cases it doesn't cause any discomfort and if that's the case, no treatment is required.  Sometimes, though, feet without arches will cause pain in the feet, swelling and repetitive sprain injuries to the mid-foot (medial arch sprain).  Hip pain or pain in the knees can also occur.

Options for Treating Pain

You'll be happy to know that usually surgery isn't necessary if the patient responds to less intrusive measures. There are no cut solutions to Pes Planovalgus.

Physical Therapy Exercises - Exercises designed to encourage the correct positioning of the toes.  In very mild cases, regular exercising that keeps the toes in position may reduce strain on your feet. Stretching your calf muscles might also give you more flexibility.

Toe Spacers - Toe spacers keep your toes separated in the correct position. By aligning the toes, balance will improve and muscles in the feet and lower legs to ease pain and bring back function.

Elevation and Ice - This sounds simple but old fashioned elevation and icing will help to ease the pain and swelling of a medial arch sprain.

Anti-inflammatory Painkillers - If you don't have a history of stomach ulcers or other inflammatory digestive disorders, you may be able to take anti-inflammatory painkillers to cope with any immediate pain.

Massage - Therapeutic massage of the ankles, feet and legs can provide relief from pain as well as reducing inflammation and enhancing blood flow to the area.

Support Bandages and Braces - When attempting to walk, the foot should be supported with an arch support bandage so you can move around while allowing the area to heal.  There are heavier duty braces available but when wearing these it's important to take them off regularly. Muscles and tendons that never have to work on their own become weak and in the long term this could make the problem worse.

Orthopedic Shoes and Orthotics - For daily support that doesn't weaken your foot, a cast can be taken of it and custom made supportive shoes designed for your specific feet, with built in arch supports, or arch supports for your regular shoe gear.

Surgery: A Last Resort

If flat feet or trauma has caused a severe medial arch sprain, the affected ligament may not be able to support your bones as usual so surgery may be required to hold them together. It might also be suggested if you have failed to respond to more conservative measures.

A small cut is made on the top of the foot over the unstable bones and metal wires or screws are attached to hold them in the correct position. Afterwards weight has to kept off the operated foot and you'll be placed in a cast or a splint for up to six months while you recover, so it isn't a quick fix and should be looked at as a last resort when other options would not or did not help.

Flat foot surgical reconstruction can also be done to re-fashion an arch and repair and support damaged ligaments to reduce pain and restore the full ability to walk.  There are a variety of procedures depending upon the complication that flat foot has caused, for example, if the Achilles's tendon is too tight, this can be lengthened to release pressure.

For more information about flat feet, medial arch sprains or any other aspect of foot healthcare, contact Doctor Blake for his professional and approachable advice. For surgical advice, see his partner, Dr Remy Ardizzone. You do not have to suffer from flat feet.

How to Run Safely: Dan Chabert

How to Run Safely
by Dan Chabert (Guest Author and Runner)

As a sport, running is incredibly accessible and accommodating. You can do it basically anywhere, in any weather, indoors or out, provided you have the enthusiasm to do it and the right amount of (minimal) equipment.

Running isn’t without its risks, however. Ask any runner, and chances are high that he/she has personally been injured from running before or knows plenty of other runners who have. Some running-related injuries are overuse related, such as iliotibial band syndrome, whereas others are much more nefarious and have longer recovery periods, such as stress fractures or stress reactions.

Below, I’ll list some things to keep in mind to help you get and stay running safely. I’ve been running for nearly all of my adult life, in every distance from 5k neighborhood races all the way up to 50 kilometer ultra-marathons through the mountains, and many of my tips below originate in my own personal experiences.

Whether you’re a new runner or one more seasoned, here are some strategies to help you run safely for years to come:

Secure medical clearance from your doc. Before you begin any physical activity, particularly if you haven’t been exercising for a long time, do yourself a favor and first go talk to your doctor. Get a yearly physical, tell him or her your exercise goals, and get your doc’s go-ahead before you jump headfirst into your new plan. You’ll probably be fine, and you may be tempted to skip this step, but do it for your own peace of mind, if for no other reason.

Get fitted for a good pair of shoes. It can be tempting to buy the cheapest pair of shoes off the shelf, but if you’re going to be doing a high-impact sport like running, invest in a good pair of shoes. Go to a running store -- where runners actually work -- and ask lots of questions, try on many different pairs of shoes, and see which shoes fit your feet best. Runners love to talk about running, so indulge them. Often, an ill-fitting pair of shoes is the source of many a runner’s ailments, so don’t skimp on this step!

Go slowly. It can be really tempting to run as fast as you possibly can for every run you post -- or in broader terms, to go at 100% of your maximum effort every time you exercise -- but this is a recipe for disaster. It’s really critical that you take things slowly and ease into your running routine. Listen to your body, and take things slowly. Your runs should be pretty conversational and relaxed, particularly if you’re training for an endurance event like a half marathon or marathon. Oftentimes runners get injured because they begin running and do too much, too soon, too fast -- running too much distance before their bodies are conditioned to handle the distance, running distances way before they’re ready, and running at speeds that are too advanced for their current state of fitness. Don’t be that runner. When in doubt, err on the side of safety, and take things slowly.

Take lots of safety precautions when you run outdoors, particularly in the dark. If you run outdoors, it’s imperative that you do everything that you can to ensure your own personal safety. Make yourself visible to other pedestrians and motorists by wearing clothing that is reflective (and technological accessories that light you up even more, like headlamps, knuckle lights, and safety vests), and always carry some sort of ID with you, if not also your cell phone. Avoid listening to music if you’ll be running by yourself in the dark, and exercise sound judgement when you decide where to run, particularly if it’s dark or in the early morning, sparsely-populated hours. Let your loved ones track your run in real time through certain apps like Garmin Connect, Glympse, or Strava Beacon, and tell your loved ones your likely route and when they should expect you home; it may be a tedious step for you to take, but it’ll give them peace of mind while you’re out. Finally, depending on where you run, mind the wildlife that you may encounter, particularly the nocturnal buddies.    

Don’t compare your efforts to others’, even when you really want to. It can be really tempting to compare your training and racing with your friends, but realistically, it probably won’t do you much good. Particularly if you are new to running, comparing yourself against people who have been doing it for a very long time and thus, have a competitive advantage over you, can only be a disservice to you. It’s completely understandable to feel a little competitive with other runners, but try to abstain. Comparison is the thief of joy, as cliche as that statement is. There’s a difference between being inspired and motivated by other runners and being jealous of, or unnecessarily competitive with, other runners. Know the difference, and act accordingly so you don’t unwillingly undermine or sabotage your hard work and efforts.

Running is an enjoyable and affordable sport that nearly everyone can do, and luckily, there is no shortage of races out there for runners to conquer: short stuff, like 1-milers or even briefer track races, all the way up to (and beyond) 100+ milers or multi-day events. It’s ultimately a matter of finding the best fit for the runner and for what he/she can adequately train toward each season. However, running isn’t without its risks, as is the case with every activity, but with some planning and a commitment to taking things slowly, it’s a sport that most people can safely do day after day, week after week, month after month, and year after year.

Writer’s Bio:

Dan Chabert
An entrepreneur and a husband, Dan hails from Copenhagen, Denmark. He loves to join ultra-marathon races and travel to popular running destinations together with his wife. During regular days, he manages his websites,Runnersclick, Nicershoes, Monica’s Health Magazine and GearWeAre. Dan has also been featured in several popular running blogs across the world.

Slow Sesamoid Healing with Symptoms: Email Advice

This email was sent by a patient gradually improving from a sesamoid fracture with some nerve and inflammatory symptoms. 

Dr. Blake,
Happy New Year!  How are you doing?  I hope all is well with you!   If you have some time, could u help me out with answering a few questions.  Thanks a million!  Tom

1.)    Request for MRI, for the following reasons:

Big toe sometimes feels sore, and when I flex it, I feel a very mild soreness there, and also where the sesamoid fracture is.

Warmth radiating along the entire side of my foot (the right side)

When I stand on my tippy toes, it feels sore on the big toe, and also the sesamoid area (pain level 1-2)

2.)    Can peripheral neuropathy be taking place, and if so, how can we rule this out?

3.)    Can I do physical therapy to strengthen the area, or will this make the break worse?

4.)    Sometimes, the top of my big toe, throbs.
5.) since this fracture was not identified until 6 months later, do I have less of a chance of it to heal?
6.) can it ever heal, and if so, what is the time frame?

Dr Blake's Response:

Hey , I'm doing well. My wife and I just got back from a week in Hawaii, so life is pretty good. Thank you for asking. I glad your symptoms are getting better. You want followup MRIs 6 months or greater apart to check healing, so you should be getting another one soon. Peripheral neuropathy is abnormal nerve sensations, typically on both sides. There is a nerve biopsy they do now on the lateral side of your leg, but I am unaware of what podiatrist do it. No, as long as there is no jumping or impact forces you are fine to get physical therapy. The therapist has to be aware of your fracture and they spend alot of time strengthening the core as well as the foot and ankle. Delayed diagnosis can delay healing, time frames are hard. I use functional guidelines while I wait the 6 months between MRIs. These guidelines include a progression of function: when you can get out of the boot, when you can walk 30 minutes without pain, when you can finish a walk/run program? We should see gradual improvement, and make changes if necessary if we hit plateaus. Rich

Lisfranc's Injury initially Missed: Email Advice

Hi Dr Blake,

Thank you for the helpful information on your blog, especially the foot strengthening exercises. I have a long and complicated history of foot pain, therefore I wanted to reach out to you personally and ask for some advice.

I am a 52 year-old woman who has struggled with pain in my feet since 2005. I first injured my left foot after I fell on the sidewalk while on vacation. My whole foot hurt and was bruised and swollen, but the x-ray didn’t show any fracture and I was thus told by a specialist it was only a sprain. I rested the foot for about 6 weeks, but the pain didn’t go away (although it didn’t hurt as much as immediately after the injury) and I used pain medication ( painkiller containing  paracetamol and codeine and painkiller containing tramadol) to relieve the pain so that I was able to walk. 

However, my foot didn’t get any better and the pain slowly got worse. After about 1,5 years, I again visited an orthopedic specialist and both CT and MRI scans were taken. These images showed major strains and damage to the Lisfrancs and I was told this was the reason for my pain. I was also told that there wouldn’t be much to do with my injury, and that surgery wouldn’t be advised other than as a last resort. The only treatment I got was that I had orthotics made that actually helped me some with the pain – at least they kept me going until 2014.
 The middle of her foot where the Lisfranc's Joint is shows marked arthritis.

The CT Scan showing Mid-foot arthritis where the bones look irregular

In 2014, the pain was so bad that I had surgery done. Over the years, a large cartilage lump had formed on the top of my foot, and the pain was so bad that walking even short distances was difficult. The surgical procedure involved fusion of the 1st to the 3rd Lisfrancs in order to relieve pain and stabilize the joints. The surgery was successful; I had significantly less pain and could walk normally on the foot although the foot became less flexible and I’ve noticed that my balance is worse than it used to be. Still, it was worth it because my quality of life improved a lot.

All the Hardware to stabilize her foot

Sadly, shortly after the surgery of my left foot I began experiencing pain in my right foot. About one year after the surgery, in 2015, I had an MRI of the right foot. These images showed strain damage to the Lisfrancs similar to my left foot. However, in contrast to my left foot, I hadn’t injured my right foot in any way. The orthopedic surgeon told me that there probably is a heritable component to my injury – that I’m prone to Lisfranc strain because there is something innately “wrong” with the bones in my midfeet. I’m sorry I’m explaining this so vaguely – I don’t know the medical term of my “condition” and I haven’t got any other information than this. My orthopedic surgeon said that he was able to see this partly heritable condition on CT scans.
Dr Blake's comment: Unfortunately we do have weak spots in our bodies, and they tend to involve both sides at different times. Thus, my mom has had 2 knee replacements, with good hips. My father in law has had 2 hip replacements, with good knees. Midfoot arthritis tends to occur on both sides, at variable times, and this is separate from your original injury that forced you to have surgery. 

So, now I’m waiting to have surgery on my right foot too. It will probably be in April 2017. I have some questions I’m hoping you can answer:

1.       What can I do to relieve the pain? Non-weight bearing is not an option because of my profession. My right foot hurts a lot after a normal day, it becomes swollen and sometimes I have trouble sleeping because of the pain.
Dr Blake's comment: You have to use good stable shoes, good orthotic support, and arch taping. You can use a removable boot for short periods of activity (you will know when after you begin to use it).  You should ice for 10 minutes twice daily, and do a full 20 minute contrast bath as close to every evening. Get a bone density evaluation, and make sure you have solid bones to heal. Stay away from NSAIDS if you can, slow down bone healing, except the occasional 2 advils or 1 aleve when you are more riled up. Consider a scooter, where you have no weight on your foot, for shopping, museums, etc. You probably have one for after surgery of the left foot. 
2.       I also often get muscle cramps under and over my foot after a regular day. Is there anything I can do to prevent this?
Dr Blake's comment: Not push through pain, roll the arch over a frozen sports bottle for 5 minutes twice daily to get massage, resting your foot more with boot, scooter, occasionally crutches, mix it up!! Massage the calf to loosen that up. Make sure you are getting correct vitamins like K.
3.       What foot strengthening exercises do you recommend? Are some exercises contra-indicated because of the surgery? Similarly, are some exercises contra-indicated when I’m waiting to have surgery in my right foot? I’ve tried some of the foot balancing exercises, but my right foot becomes quite painful when I do them.
Dr Blake's comment: You have to let pain be your guide unfortunately. So many to the muscles attach into the sore area. Typically you can balance on the left only, but both sides can do active range of motion exercises like moving your foot 3 times a day through the alphabet. Metatarsal doming should be great. Theraband for only the left for right now.
4.       Do you have any advice on foot wear? I’m currently using Hoka shoes without orthotics. What kind of orthotics (if any) is recommended?
Dr Blake's comment: Hokas is a great choice if they are wide enough. You sometimes even to use the New Balance 928 to great the rocker effect and the width (up to 6E in some styles). I hope your left can now take a plastic orthotic with good support, but the right may have to use tape and a soft orthotic device. Try to support the foot tape online and see if it helps before you buy alot. Or experiment with kinesiotape methods. 
5.       I have quite a lot of metal plates and screws in my left foot, and although I have significantly less pain in this foot after the surgery, I still experience some pain and  stiffness  and I wonder if some (or all) of the metal should be removed? If not, what can I do to improve the functioning of my left foot as much as possible?
Dr Blake's comment: Only a surgeon can tell you about the screw and plate removal options, most of my patients leave them in. A good functioning foot needs a very stable foot, which it should be, flexibility across the big toe joint (which you should have), and a powerful achilles tendon. Not knowing anything about you, I would stay start there. Try to develop a plan that gradually and progressively strengthens the achilles/calf of the left foot. I have some videos that I will include, but experiment. 

6.       Finally – is there any possibility to avoid surgery in my right foot? These types of surgery are so comprehensive and there is no “going back”. Would conservative treatment be futile in my case?
Dr Blake's comment: Sure, please right another email and just focus on the right. Do not even mention the left. That will get my brain working better. You can see I even mismatched the photos. Send the right photos again. Only the right. Overall, I hope it was helpful.

I would be really grateful for any answers! Attached are CT and x-ray scans from September 2016, which are the most recent images of my right foot. It is also a x-ray scan of my left foot taken right after the operation in January 2014.

Best regards,

Sesamoid Fracture: Email Advice

Hi Dr Blake,

Thank you very much for writing this  blog.  Your website is the only one which has wealth of information regarding sesamoid issues. I have been following your blog and taking advise.

I have sesamoid fracture, I have been to 3 podiatrists, the advice so far, I got was, custom insoles and surgery.
The pain I have has gradually begun over many years, 5+, more so in last 3 years. My right tibial sesamoid has a fracture.

It started as little bit tingling and 0-2 pain while driving long distance, slowly the pain grew. I ran with the pain and even experimented with barefoot. The pain eventually got lot worse and even walking in dress shoes became painful.

My first podiatrist made a custom insole (it’s been over a year), which help off-loading my weight. The pain did not go away and he wanted me to go for surgery. As I was researching, I stumbled upon your blog. I changed podiatrist and pushed him to do MRI and prescribe Exogen bone stimulator. I got my MRI done June 2016 and finally got my Exogen Bone Stimulator on 18 Aug 2016. I have been using bone stimulator since then and had 151 (5 months) treatments so far.
Dr Blake's comment: Are you creating a 0-2 pain level? Due to the time from injury until now, it will take another MRI after 9 months of bone stimulation, to compare and see if you are improving/healed. So, in May (3 months or so from now) get a new MRI so we can compare them. 

I took your advice and started icing, contrast bathing and Spica taping. I have to admit that, I have not been regular with icing and contrast bath, last few weeks have been better. The pain and inflammation is down. I walk couple of miles back and forth from work. My pain is between 0-2 for few months now. But if I overdo anything, like brisk walking for couple of miles, I will see some soreness the next day. I have no issues bicycling or doing weight machines in Gym. I can’t do free weights as it puts lots of pressure on sesamoid and I see soreness for the next few days.
Dr Blake's comment: See if you can pad your foot with an off weighting (my four books with a whole in the sesamoid area) so you can do your free weights. The day you walk briskly, only do 2 ten minute ice packs or ice soaks that night and no contrasts bathes. If something particularly irritates it, heat in any form can inflame it more. 

I sometimes wear Salonpas Pain patch (camphor, Menthol, Methyl Salicylate) and it helps. Should I use this on an on-going basis? Will it interfere in anyway with healing?
Dr Blake's comment: No that is a great idea, and I should recommend those more. Just do not use before activity to deaden any pain, you need to feel if you are irritating it. 

Does my MRI point to any other underlying issue like blood supply issues with sesamoid or the biparte causing damage to tendons or first metatarsal? Which may force me into surgery?
Dr Blake's comment: The MRI report did not discuss anything bad like metatarsal damage or avascular necrosis (patient shared some photos with me of her foot, and the orthotics, and MRI report over google drive with I was confused that the orthotics have no off weighting padding, they need to be full length and have a dancer's pad incorporated. You do not need another orthotic, just have the top-covers redone with the above.

If I can continue to do what I do, will it heal eventually?
Dr. Blake's comment: No guarantee, but no negatives right now. With the new MRI you will get a good idea of the healing. 

I live in NJ and work in NY city. I would like to know, if there is a podiatrist you know in PA/NJ/NY area which shares your view and can help me.
Dr Blake's comment: I recommend these these in no particular order: Dr Karen Langone, Dr Robert Conanello, and Dr David Davidson. They are around NYC, not in, so there will be some driving. One of my patients just saw Dr Joseph D'Amico in NYC and really liked him. He is at the school of podiatry I think.

Here is the MRI report from lab.

--------------------------- Report Start -------------------------------
Final Report
History: Chronic forefoot pain for 6 months. No trauma. Possible sesamoid fracture.

MRI of the right foot

Technique: Routine multiplanar imaging of the right foot was performed on a 1.5T MR scanner according to standard protocol. Field of view is focused on the metatarsophalangeal joints.
There is no prior study available for comparison.


A Vitamin E marker has been positioned at the plantar aspect of the first metatarsophalangeal joint.

There is a fracture of the tibial hallux sesamoid, with associated bone marrow edema. Associated high signal of the adjacent first metatarsophalangeal medial plantar plate is also present, suspicious for underlying partial tear. There is strain of the abductor hallucis tendon. Subcutaneous edema is present within the adjacent plantar soft tissues. The fibular hallux sesamoid is unremarkable.

The joint spaces and alignment are maintained. The articular surfaces are intact. There is no aggressive osseous destruction. There is no significant joint effusion. There is no synovitis.

The visualized extensor tendons and ligaments are intact.

There is no Morton's neuroma.

There is no abnormal signal in the musculature to suggest atrophy or denervation. The subcutaneous tissues are unremarkable.

Nondisplaced fracture of the medial sesamoid with associated bone marrow edema as described above. Associated grade 1/2 strain of the adjacent insertion of the abductor hallux tendon.
Dr Blake's comment: Keep your focus on the nondisplaced fracture aspect. Great sign. Good luck. Rich

Plantar Fasciitis: Email Advice

Dear Dr. Blake,

I apologize for what will be a somewhat lengthy e-mail, but I'm at the end of my rope dealing with local medical professionals and could really use some advice. I spent hours reading your blog yesterday when I came across it and it was very helpful, but every case of PF is different so I thought I would write in with my story. The foot pain is quite scary and debilitating, and to top it all off it has been mismanaged by medical professionals, making a bad situation worse.

I've had heel and now arch pain for 9 weeks now (12 weeks since the email was answered), not as long as some, but it has become pretty nasty. It started on Halloween after I moved to a new machine at work that required me to stand a lot on metal grating. Treatment was delayed as I was sure that the "bruised" feeling in my feet was simply my muscles adjusting to the different work surface. When it didn't resolve over a four-day weekend with me resting and doing supportive care (Epsom salt soaks and arnica creams) I became worried. I got to where I was almost pain free over the weekend, but when I went back to work my feet started hurting again. When I did make an appointment with a podiatrist, I got hit with a 2-week wait, so I wasn't seen until 11/17. In the meantime, I was taping my feet when I worked (it didn't make me pain-free, but it helped) and trying to rest as much as possible on the weekends. When I finally did get seen by the doctor, they took x-rays, and then he sat down with me for 5 whole minutes, manually palpated my feet (at the time, they were not sensitive to palpation) and cast me for orthotics. Said it would take 3 weeks, but 7 weeks later, I am still waiting. He did not release me for work at all and told me just to "use pain as a guide" even though he knew I did factory work on concrete floors and metal grating. He did not offer to tape or brace my feet even though I told him the taping helped and was the only way I got through the day at work. I have not been back to that office.
Dr Blake's comment: There are 3 phases of rehabilitation: Immobilization (which you are in and were trying to do for yourself), Re-Strengthening, and then Return To Activity (typically why you are preparing orthotics to allow function but still resting and supporting the arch). So, you are out of Phase in your treatment. You need to be immobilized with tape, removable boot, crutches if need be to create the 0-2 pain level environment of healing. It is all about timing, and at the relatively early times of treatment, doctors usually get this right. You not so. 

At the beginning of December, things worsened and I obtained a work release over the phone from the first doctor. I also made an appointment at another office and got in right away. My left foot at this point was very painful and had a big, tight knot right in front of the heel. My foot was now painful to palpation. They taped my feet using the Low-Dye method and extended my work leave for one more week. I kept the tape on, and after a few days, had much better mobility. I went in for more tapings and kept the tape on until Christmas break, when I didn't think I needed it on due to how much I would be sitting around over the weekend. I'm not sure if I did a little too much barefoot walking (it felt great the first night I had the tape off) or if it just wasn't ready to go from support to no support, but I ended up being in a lot of pain over the weekend, even when non-weight bearing. I was able to massage some scar tissue out of my arches and I think some of the pain was from my muscles, but the fascia was definitely tender too.
Dr Blake's comment: So, an MRI to know if you have a plantar fascia tear would be nice. Please order support the foot tape online. Since you have definitely found taping helpful, I would not be without taping for the next 3 months. Hopefully the orthotic devices are coming in now, so they will help. But you also should be spending some time in a boot. Associated with Immobilization is Anti-inflammatory. I am not a big believer in drugs, especially without a definitive diagnosis, so I would rather you lay your foot on a reusable ice pack for 10 minutes 3 times a day to constantly cool your foot off. 

I went back into the second doctor's office and they finally did an ultrasound to rule out a tear. He said everything looked pretty "healthy" except for the fascia being enlarged consistent with being inflamed. He insisted on doing an injection, and I relented. It was ultrasound guided, but I'm not sure the exact location he injected into. The needle went in the side of my foot, not through the back of my heel. I did work immediately after and did 30 hours of work that week, but doing a pretty sit-down job. My foot was painful for about a week (they said it would hurt for a couple days but it took longer than that to stabilize). Meanwhile I found out there was a discrepancy in the paperwork (two conflicting dates as to when I was cleared for work) so I went back to sort that out and he was extremely rude, blowing up at me and accusing me of wanting long-term disability. I reminded him that my work has a rule that unless I'm 100%, I need to be out on disability. They don't do light duty. He ended up giving me another month off but insisted that rest would not help my condition. He has been a decent doctor (better than the first one) but after him blowing up at me over something that was his mistake (not being clear on when I was allowed to go back to work) I'm hesitant to go back there and throw more money at him. He did say the boots and orthotics I had bought myself were beneficial (more on that in a moment).
Dr Blake's comment: Creating a pain free environment often requires time off work and feet are the most needy since you have to stand on your foot. If injection therapy is being used, it can take 3 injections to get full relief waiting one month between injections to make sure of the results of each. I personally would rather start with physical therapy. Ultrasound typically shows thickening of the fascia when there is some tearing (micro or macro scopic). This means that there is some degeneration of the fascia, or weakness, and putting cortisone into the tissue is risky. Do this the least possible. There is no excuse for his rudeness, I am sorry. 

So as it stands now, I'm a couple weeks post-injection. I have not done any weight-bearing stretches (even before the injection, they hurt too much, so I refrained). I stretch (pull toes back) before getting out of bed and wear a night splint for a couple hours before bed and additionally during the day if I have time. I did not have any morning pain up until a couple weeks ago and it is slight and transient (5 minutes or less duration). I have quality orthotics (not custom but they fit my high arches very well) in my shoes and I am trying Z-Coil work boots. I also tape or brace my left foot when I am out and about. I am trying to transition to a brace and get away from taping as the foot muscles are very weak from being taped all these weeks and I would like to try and strengthen them again. The brace seems to work well enough. With that, the orthotics and the Z-Coils I don't have pain when walking or standing (but I haven't really "tested" it yet like I will have to when I go back to work). I also use a cold laser on it every day. 
Dr Blake's comment: Sounds like you are moving in the right direction, just a bumpy road. I would not stop taping until you are back to work for 2-3 months and doing well. The taping has worked for you since day one. As long as the orthotics seem to transfer weight off the painful spot, you are good in that area. If you are worried about foot strength, see my you tube videos on foot and ankle strengthening. Go to YouTube and type drblakeshealingsole foot and ankle strengthening and they will pop right up. If every evening you do 2 or 3 exercises, you will be fine. Just do not push through pain. I should recommend the work Z-coils more often. 

I'm eager to get back to work but also anxious about re-stressing it again too soon. I work 10-hour shifts on concrete floors and metal grating and there is a lot of walking and standing involved. With the taping/bracing, good boots and orthotics, can I chance going back to work, or should I try to rest it longer? I'm so scared of this becoming a chronic condition, and some sources say to avoid stressing it at all costs or it'll cause permanent damage, and others say it won't cause permanent damage and it just has to work itself out. 
Dr Blake's comment: You do not go back to work the first day you feel better, but if you have had 2 weeks of consistent relief, then back to work you go. That does not mean you tolerate pain however, so if you can not modify your job, and you can not keep the pain between 0-2, you have to go off work for another month. This is what we tell all our injured workers. You have to go back to work to test it, but it may not succeed. There is no guarantee that if you rest for the next 2 months, that it will be any better. What you have tried is going back to work, but having physical therapy twice a week during the first month you go back. That, along with your icing 3 times a day, taping, orthotics, Z-coils, some body shifting, and 800 mg ibuprofen 3 times a day for 5 days on, 2 days off can all help you. Good luck my friend. Rich

Feel free to use any of this for your blog (if it's not too boring), and I very much appreciate your time in reading this.

And the Patient's Response:

Thank you very much for your response. I hope your time in Hawaii was good. I agree with what you said, I think I would be better off if I had just kept up with the taping over the past month I would be better off, I actually was doing well for a couple weeks without being taped but I increased my activity a bit and am now hurting again because of it. I got my foot taped up again and will keep the tape on when I go back to work on the 1st. I do have an appointment scheduled for the 3rd so if those two days of work don't go well, I can beg for more time off. 

One other question, what is your opinion of prolotherapy and PRP for my situation? Which (if any) would you recommend? They were both options my doctor mentioned going forward if the steroid injection did not work. They are both expensive (PRP more so) and not covered by insurance but I would rather go that route than trying more steroids. I don't think my doctor will sign off on more time off work unless I agree to another expensive treatment, sadly, so if I have to do that I want to go with the best option. It seems to me that prolotherapy might be more aimed at cases of chronic degeneration, which I don't believe is right for my situation, but I could be wrong.
Dr Blake's comment: That is blackmail, unbelievable!!!
I agree with the role of steroid injections, they are meant to bring the pain from a consistent 5 or more down to a controllable 0-2, and that first one seemed to do the trick. I think prolotherapy has some place in a tear, which you do not seem to have. I think PRP would be good, but it is only in theory, and just have not seen that many patients to recommend it. Are you considering PT which would be a logical next choice? You are really at that stage in my mind. 

My "custom orthotics" finally did come in after close to 8 weeks, and they are absolutely useless. They are not true custom, they are prefabricated and slightly modified according to the cast of the patient's foot (this is according to to lab's website). The orthotics I bought online provide better support. So another option is to be re-cast by my current doctor for orthotics. I'm hesitant, though, as even though I've seen good results with my orthotics and Z-Coils, they still weren't enough to keep me from overstressing things when I tried to ramp up my activity levels a bit with a short hike and some stairs.
Dr Blake's comment: Yes, try to get a custom pair that works, that would be a great place to go. Tell this doc why the last pair did not work. Too low in the arch? Too hard in the heel? Etc. Something that he/she can go off of. Can you get an MRI for more information, especially to see if there is bone swelling? That will not show up on an ultrasound, and can be very sensitive. Rich

And More Response:

Yes, PT was another option he mentioned as well, and while he seemed not as enthusiastic about that option, it might be good to try at this point along with the orthotics. I've been hesitant to try any more injection-based therapies for the reasons you stated, so I appreciate your perspective on the prolotherapy and PRP. I would likely try PRP if it was covered by insurance, but it's not, and due to my high deductible and this injury occurring late last year/beginning of this year I've had to pay for everything out of pocket thus far. I obviously would pay any price for a guarantee to put my foot right, but there are no guarantees in any of this and paying repeatedly for treatments that don't work is disheartening.

One more thing I want to add while I have your ear, I've noticed a light burning sensation in my foot at rest. It's not really a "burning pain" sensation so much as it just feels like heat. It comes and goes, sometimes I notice it more than others. It's not towards the heel or the midfoot, it's more toward the ball of my foot. I noticed it after the initial pain wore off from the steroid injection, and it's stayed. Is this sensation of heat indicative of inflammation? Something going on with my nerves?
Dr Blake's comment: Either. Just make sure you ice the whole foot, and make sure you are putting weight and not limping onto the ball of your foot. You do not want to stress another part of your foot out. Typically, it is just a warning sign that you are favoring your heel too much, and that takes some self correction to fight against. Good luck. 

Saturday, January 7, 2017

Barefoot, but Need Some Support and Protection

Nike Studio Shoes

There may be many times that you need less shoe, but still good support. Nike Studio shoes can fill that need. It may be that you are recovering from a bad case of plantar fasciitis, and around the house you like to go barefoot. It may be that your goal is getting back to dance barefoot, but you need a transition plan. This line of shoes can be very helpful. Rich