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Saturday, July 29, 2017

Coffee not only tastes good to me: But this Study shows that it is Healthy for me|%20Diet%20Quality%20|%20Is%20Coffee%20Healthy?%20|%20&%20More%20ClinicalEdge

Friday, July 21, 2017

Solaice Patches for Pain Relief

One of my patients with chronic heel pain has used lidoderm patches forever, but she found this product to be actually more helpful. Passing this along.

Sunday, July 16, 2017

Brilliant: A Fun App to Teach and Test your problem solving!!

Joy of Problem Solving: Geometric Shortcuts

What is the area of the red figure? (All arcs shown are of circles with a radius of 2.)


73% of people got this right. 

I am having fun with this new app called Brilliant. Here I got the answer of 8 correct. I have to get sharp again so I can teach my grandson. Rich

Hip Arthritis

AAOS Guidelines: Managing hip osteoarthritis

You've completed the quiz on AAOS Guidelines: Managing hip osteoarthritis

Your score on this quiz: 100 %
Average score on this quiz: 52 %

Just took a quiz on hip arthritis. Wanted to show off since I profoundly beat the average score!! Not bad for a podiatrist. To be fair, I treat patients together with MDs either before or after surgery. The relative key points of this quiz:
  1. A hip replacement in an obese patient does not increase the chance of hip dislocations.
  2. Death is not sped up by doing a hip replacement. 
  3. Cortisone injections, but not hyaluronic acid, have a place in hip pain patients.
  4. Use of NSAIDs can be very helpful with hip arthritis.
  5. Physical Therapy can be very helpful in these patients. 
These seem common sense, but there is so much info out there, that you can see people, especially doctors, getting mixed information to go on. 

Saturday, July 15, 2017

Use of Lifts for Scoliosis: Email Advice

     I was diagnosed with scoliosis (not a serious one, below 30 degrees) when I was 15. A specialist ( a super doctor who was also a university professor an expert in postural problems) said that wearing a heel lift could have been useful: the legs had the same length but my pelvis was a bit twisted and one side 15 mm higher than the other. 
Dr Blake's comment: I have done this before, but love to have the MD treating the scoliosis primarily tell me it is okay. There is structural short legs, functional short legs (which this would be), and a combination of the two. Since we only x-ray rarely to attempt to avoid any needless radiation, we are probably indirectly treating functional short legs. If the body collapses to one side, and then have to use all this effort to right itself with each step, it makes sense to treat, and it makes sense the body would say "Ahhh, thank you."

     He said it was good practice not to go for a thick heel lift (that a heel lift should be half or less than the real gap since that could have cause the thoracic curve to worsen.He asked me to come back after a few months with new x-rays (taken while I was wearing the 5 mm heel lift). The lumbar curve was reduced while the thoracic curve was either the same or just slightly worse. I had less pain and he said I should wear it till I was 18 at least and that afterwords it would be useless. I kept wearing it till I was 35 then I thought I would get rid of it.

     All good, till after 5 months I started to have lots of pain like sciatica in my lower back and down my hip, left knee.. the side where the crest of the pelvis was lower (where I used to have to heel lift). The pain worsened...also, I was doing pilates and other exercises I was taught as a young patient (exercises to help cope with scoliosis I was taught for a few months on a weekly based by an expert when I was 16).
I had never had such a terrible pain in my life, I could not stand or walk anymore for more than 20 minutes. I was fine when sitting or laying in bed. My doctor said that I should see a physiotherapist. I insisted that I wanted to see a more competent person (like a doctor who studied 15 years to become an expert about posture and scoliosis, but he insisted that a physiotherapist was good enough). 

    The physiotherapist told me (after a thorough assessment) that my scoliosis (actually my lumbar curve) was not there when I lay on the bed, but just when I stood up. That it was a sort of scoliosis cause but postural problems that that even if my legs had the same length I had to wear a heel lift (15 mm). He said a heel lift would be useful if my scoliosis was still there in all sort of positions but that in my case it would do the job. I started wearing a 6 mm heel lift since I did not trust him (20 years before the specialist said I should wear a smaller one; half the real gap). I felt better within the following 2 days and I had 2 great months: no pain!!! Now some pain is back but on the other side of the pelvis, the hip without the heel lift (the right side) it is not as bad as the pain I had on the left side, not at all, but it is annoying. Now I don't know what to do. If I take the heel lift off from the left shoe) I will go back having that unbearable pain...I am 40, I do lots of core exercises and have a very strong core, I do lots of exercises all the best ones for scoliosis... any advice?
Dr Blake's comment: Thank you for this wonderful discussion and should help so many patients with scoliosis and back or hip pain to think about lifts. I have extenisve writings on lifts for short legs which apply to your care. You were probably at the low end of the amount of lift all those years that could help you. So, when you took them out, your body could not adjust and the nerves got pinched. Muscular soreness from changes of position can give you level 3-4 pain, but pinched nerves are 9-10. That level of pain can not be tolerated. As you work on your core, continue to correct the imbalances produced by the S shaped spine. There is typically two very tight areas and 2 weak areas on opposite sides of the curves. A physiotherapist can typically spot and help you develop a program to stretch where you have to stretch and strengthen where you have to strengthen. 
     First, you can keep the 6 mm, but use 3 mm full length and 3 mm heel for a total of 6 mm. This will spread the force over a longer area. You want to physio to watch you walk and look for dominance. Limb dominance is defined as the side you put more weight on when you walk. You want to find the right amount of lift that corrects that asymmetry. What amount of lift will put equal forces up your spine. At least make that observation, only if it is stored away for now, because it is a repeatable observation. It makes a difference to where we go as an individual if that is 6, 9, 12, or 15 mm which at least half full length. A typical Spenco or Dr Scholl's insert gives you 3 mm, so it is typically easy to stack them for this purpose.
     Second, as you go up, or get symptoms temporarily on either side, you can also put an insert in the other shoe to drop the correction for a short time. I hope this at least gets you started. Rich

Neuropathic Pain Article on Recent Studies

Loss of a Spouse: A Love Song from the Widower

     What is it to be human? For one, it is to care about others, sometimes more than yourself. Is that love? Sometimes. But, I think we know we are human the most in the extremes of sadness at a loss, and love of another. I just lost someone that everyone loved. You could not help it, she just had that way about her. I am happy I met her. She trusted her family to my care (a very high honor in my book). Her husband sent this around to her friends, he terribly misses the love of his life, his best friend. You all probably know the power in the voice of Susan Boyle. I am even crying typing these words after listening to her. Listen, cry about someone you love, and rejoice in how honored you were to have met them. Love, Rich

Accessory Navicular Excision and Continual Pain: Why?

Surgery date: 1/9/17
Accessory navicular excision with reattachment of post tib tendon w/suture 
Current diagnosis: Stage II PTTD

Please understand I am still regaining strength since surgery so not all the weakness is due to bad tendon. Prior to excision I had painful tendinitis but full calf and tendon strength in the foot.

Video of Ability to do Heel Raises

Front View Amount of Pronation

Back View Amount of Pronation

Dr Blake's comment: This patient is really struggling post op accessory navicular removal. I had her send me a video (not sure it is working for you guys) of her ability to do single leg heel raise. She could do this just fine. The standing barefoot pronated positions are fairly equal (the right had the surgery), so nothing seems amiss that I can find. The post tib tendon is Stage 2, which is still considered one that can be successfully treated with orthotics, taping, PT, icing, strengthening and achilles stretching. She has to find out what can be improved/modified in these areas. 

Here is more from the patient (out of order because I am out in left field sometimes):

Dr. Blake,

I want to send you a copy of the MRI but I am not sure where to have it sent to.
Dr Blake's comment: Dr Richard Blake, 900 Hyde Street, San Francisco, CA, 94109.

If I could get a cheap flight my husband and I would consider flying out to see you for an appointment.  Let me know if this would be possible and how far you are booked out.
Dr Blake's comment: Only a week, but since we need ample time to perhaps make an orthotic, could you fly Thurs, seeing me in the afternoon, and again see me on Monday. 

My surgeon told me if I could come up with a situation using OTC orthotics and materials (wedges, etc.) that works for me, I could take that to a podiatrist and tell them exactly how to make the orthotics.  That's easier said than done as I don't have all the materials I would want to use to accomplish what I have in my mind.  I know I want an orthotic with a low arch that is tipped at an angle to combat the pronation, and I want the pressure points to be soft/gel.
Dr Blake's comment: So, at least start with the varus wedge from Altra.,109107172001,&utm_source=GoogleShopping&utm_medium=cpc&utm_campaign=AltraBrand

My husband will take some better pictures ASAP and send them to you.  The surgeon has told me I am in stage II of Post Tibial Tendon Dysfunction.  He recommends 1) gastroc release surgery and then if that doesn't work 2) flatfoot reconstruction: tendon transfer and calcaneal osteotomy.  He said the second surgery is a 6-month PROJECT and from what I read online it sounds like I would never be able to do high-impact sports again and would lose foot function.  Well, I guess that wouldn't be much different than my lifestyle now but it makes you wonder if it's worth it?  Considering the stiffness I have in my foot after the accessory navicular was removed I am very leery of any additional negative effects of more surgery.
Dr Blake's comment: You may well be a candidate for these, but definitely try alot of things first. I am glad I may have the opportunity to see you and assess your achilles tightness/flexibility, posterior tibial strength, etc. Nothing you sent from the photos above look bad enough to warrant anything but perhaps a posterior tibial tendon exploration. Ideally you could get an independent review from another surgeon here to get their perspective. Surgeons love to cut, and you never tell one surgeon what another one said, but they can differ alot in their approaches. 

I am really thinking it would be wise to wait at least 6 more months to see how I do before committing to another surgery.  I asked surgeon if I could try new medicines or another cortisone injection.  He said we could try Celebrex and an ultrasound-guided cortisone injection NEAR the tendon where he sees inflammation, but not IN the tendon itself.
Dr Blake's comment: I hate any thought of cortisone near a tendon, even with guided ultrasound. I would think it is resonable to put local anesthetic without cortisone into the tendon sheath to find out if it is the tendon that hurts. You are numb for 5 hours, so you have to be very careful. 

What do you think of all this?  

I am so frustrated and in so much pain and I feel like I have very few options and many years of pain ahead of me whether I opt for the surgery or not.  I know it's not a doctor's place to comment on personal life choices but my husband and I are looking at moving in the next year or so and starting a family...I can't imagine doing all that with the level of pain I have.
Dr Blake's comment: No guarantees, but you should be fine. Gastroc releases are done in extremely tight achilles that are flattening your arches, and flatfoot reconstructions in flatfeet that need to be reconstructed. I do not see any of the flatfoot. The amount of pronation should be helped by orthotics, taping, and gradually strengthening your foot. Someone would have to evaluate the achilles and see if it is tight and by how much, and can it be stretched out. I have alot of normal people take up yoga and get the achilles really stretched out without trying too hard.

I personally do NOT think the gastroc release will work and the physical therapists told me do not get this surgery.  They see patients in recovery and it sounds like they think it's not very helpful.

The tendon feels diseased.  It's the tendon that needs to be scraped or reconstructed or removed or injected or something.  It's felt this way for 3.5 years now.
Dr Blake's comment: You know your body the best then the little time any doctor spends with you. Keep It Simple Stupid is a good mantra for a humble health care provider. We are stupid if we make it too complex when it does not need to be. I can not remember the last MRI on the tendon and what it looked like. Also, please see if the radiology department can do a diagnostic tenography of the posterior tibial tendon, but no cortisone injected. I hope this helps. I' m trying. 

Problems with both feet: Email advice!

Hi Dr. Blake, I hope you don't mind I am in need of your advice. I have written you before for your advice on my left foot. Tenosynovitiis is my diagnosis and plantar faciitis. I did not have the second set of PRP injections on June 30 because I was getting considerable relief in my symptoms. At that time I was wearing the hoka one one shoes with the budin splint. I increased my activity one day at the gym using a eliptical machine that put my weight on my heels and was able to work out for 45 min at a good intensity. The next day I woke and the tenosynovitis was much worse. I realized at this time that I had been curling my toes frequently also, testing to see if they were getting better. I read your blog and came upon a quote " it is not unusal to go 3 steps forward and 2 steps back". So I went back to "Rule of Foot".  I do a 5 min ice massage on the effected area every hour. I do an ice dipping protocol every day 10 sec dip in ice water every 15 min X 2 hours and this seems to be really helping. I went back to a flat firm shoe with my orthotics ( no splint). In an effort to immobolize I do not curl my toes. This foot is responding to this regimen.  When I wake my foot is very tight with the plantar fasciitis so before getting out of bed I massage my foot especially the plantar ligament.
Dr Blake's comment: Good for you. Handling Re-flares successfully is a vital part to any rehabilitation. It is funny how rehab is always presented linear, but really spiral (sometimes we are closer to our goal, and a minute later we can be further away. I love walking the labyrinth. First saw one here in San Francisco at Grace Cathedral. It is a spiritual walk, but can be a guide to rehab also. 
You are mindfully walking, rehabbing, towards your goal (in this case the center). As you walk you find yourself close at times, only to be moved away by the path (or during rehab, a setback).

Unfortunately I now have a new problem. My right foot which also has plantar faciitis has developed symptoms. For the past 8 months I have had a tight , pressure,dry crunchy, feeling right across the ball of my foot. I do not have any heel pain. I have been limping on this foot for 8 months. If you remember I had orthotics that had heel lifts in then putting my weight on the balls of my feet. I replaced them with vionic orthotics. This right foot has some falling of the arch on x-ray. While I have been caring for my left foot I have also been icing my right. I have been stretching my right and it responds to that. My problem is that my right foot likes the hoka shoe. As soon as I went to the flat shoe for my left foot I started getting a real " ache" feeling below my big toe at the bottom inside of the ball. I feel it there occasionally  but when I push around in the area of pain I cannot locate the exact spot of soreness. After reading your blog I wonder if it is muscular? When I wear my hoka on my right foot and the flat on my left, both feet are happy. But I cannot walk anywhere like this it hurts of course. Does this tight pressure symptom accross my left foot sound like plantar faciitis to you?
Dr Blake's comment: No, could be sesamoid. Can you get an MRI on that area? You can try the flatter New Balance 928 that has some rocker. 

I have been resting my left foot with the Tenosynocitis and putting it up. I feel that the resting has been causing the plantar faciitis on the right foot to worsen.
Dr Blake's comment: When you are dealing with both sides, it is easy favor the "better" foot which can cause problems. Also, a lot of foot problems, more joint than muscular or fascial, get very tight with immobilization, even if it is from rest. Try moving the big toe joint ten times up and down per hour to see if that helps. 

I have not been going to physiotherapy because after going twice a week for the past 5 months I got no relief  (in fact all of the pulling and "digging in" on my left foot would make the tenosynovitis so much worse). I did find that the ultrasound helped the tightness in the balls of my feet.

With this sudden pain in my right foot what would you recommend?
Dr Blake's comment: Well, you have to create the 0-2 pain level for the right, without upsetting the left, how about an Anklizer boot on the left, and placing an EvenUp over the right shoe for the next 2 weeks to calm things down. 

What kind of physio treatment am I looking for?
Dr Blake's comment: Really need a diagnosis first before therapy, or they may make you worse. 

Will ultrasound help?

The right foot likes a hot bath with Epsom salt and a massage the area almost feels normal but than quickly goes back to stiff, crunchy, plaque like feeling.

How do I treat both feet with such different needs?
Dr Blake's comment: First of all, you must list the needs of each, and keep them separate. Do for the right what is needed, and separately do for the left what is needed. Send a check list to me what you have found so I can keep these clear in my aging brain. Rich


So thankful for your help,

Healing Sesamoids!!!

Hi Rich!

Just wanted to send you an update on my sesamoid injury. I'm doing great! I can walk barefoot when I'm staying indoors (been doing so for several weeks), and I can use regular footwear when walking short distances (although still good shoes, just without specific sesamoid protection). Without any significant pain, of course. I'm still using the Hoka shoes with orthotics when walking longer distances, for example an hour's walk. 

Still, I have to admit I haven't been as good as I should be at following up the contrast baths and foot exercises regularly. The reason for that is that I'm pregnant, and I've been feeling really tired and sick at the beginning of the pregnancy. Despite this, I've used Exogen every day and I've been doing the contrast baths and foot exercises regularly again for the last six weeks. Also, because of the pregnancy, I can't have any images taken of my foot, therefore I don't know what the fracture looks like at present. 

I feel like I can mostly do all sorts of activities again, but I still can't run without pain and I can't go for long walks without protective foot wear. Should I continue on with foot exercises, contrast baths, etc, any specific exercises I should pay attention to? Is there anything I should do differently now when I'm doing much better? Do you have any advice on footwear at this point? 
Dr Blake's comment: Thanks for the great news. For our reader, I placed your original posting 9 months ago below. And, congratulations on the pregnancy!! I wish you all the best for a healthy and happy little one. I just love my grandson, and we have 2 boys. Boys, boys, and boys. Lucky we have a wonderful daughter in law, and my other son just got engaged to a good soul!!
     As you feel better, and have other issues, it is easy to be lax at what you do. As long as you are doing the Exogen (and 9 months should be perfect) you want to do the contrast bathing 3 times a week as a deep flush. Ice also once a day now just to keep the inflammation under control. You should be able to do a walk run program with the Hokas by now, so if not, you may need a separate orthotic device with higher arch and more dancer's accommodation. And, some of my patients need to spica tape and use cluffy wedges to run also. But, gradually building up to 30 minutes running is the next step in your healing. You need to review the walk run program I have on the blog. As you return to full activity, you need to keep up a 10 minute daily routine of strengthening: single leg balancing, met doming, heel raises are normal. Make sure your achilles are stretched out because tight achilles lead to more forefoot pressures. Keep up the healthy diet, Vit D if you are not in the sun enough, and any other bone supplements you take. I have my patients alternate walking and alternate running with the Hokas and more normal but stable shoes that bend easily in the front at the ball. By alternating, you really get a feel of how important the Hokas are to limit the bend. You should slowly need that protection less and less. 
     As you walk with any shoe and orthotic, feel where the weight is going through the front. If it is entirely on the first, either ditch the shoe or modify the orthotic. Then weight should be even 1st and 2nd mets, or all the way across the front of your foot. I sure hope this helps some. Congrats again. Rich

Hope you're doing well and having a great summer!;postID=8800716870601474755;onPublishedMenu=allposts;onClosedMenu=allposts;postNum=117;src=postname

Wednesday, July 5, 2017

Caroline Jordan: More Reflections on her Sesamoid Healing

Caroline is a gifted fitness professional who developed a devastating sesamoid injury one year ago. This is part of her wonderful reflections on her own problem with the hope it can help others. 

Tuesday, July 4, 2017

Chronic Heel Pain: Email Advice

Dear Dr. Rich Blake,

I found out about you from the "Physical examination of heel pain" on Youtube. I have chronic heel pain that I don’t even remember when it start. I have seen physicians, physical therapists, two podiatrists and they both said I have plantar fasciitis. However, my symptoms don’t fit into the classic picture of plantar fasciitis. I reach out to you because I need another opinions and you are very knowledgeable and caring (because you take time to write blog and help people that is not in your areas). I just finished my second year of veterinary school. I didn't enjoy learning during labs and farm trips because of the heel pain. I avoid going to clinic to learn during summer because of the heel pain as well… Next semester I will start surgery class, I am now very worried how I can stand still for hours during surgery with the distraction of the pain. I live in Brooklyn and don't have budget to visit San Francisco. I would deeply deeply deeply appreciate it if you can give me some insights via the internet. 
Dr Blake's comment: One possibility is seeing Dr Karen Langone in Long Island, or at least getting a referral from her to someone closer. 

I have bilateral pain in my heels only when standing still for more than ~ 3 minutes. After about ~ 4 minutes, the pain would be too severe that I can't bear it and have to move my feet off the ground. It is very hard for me to stand still. When I wait and stand at the bus station, I have to walk around or shift my weight from one leg to another. The longer I stood on my feet, the worse the pain got.

Walking and sitting can make the pain disappear.  However, if I have been stand for really long time that the pain is very severe, at the moment I take my feet off the ground (e.g. sitting), the pain immediately become more intense and then gradually subside if the feet remain non-weight bearing. Walking for long distance can also produce the pain.

  • The pain doesn’t feel like a sharp pain. I am not sure how to describe it but I think it is more like a dull ache that gradually build up when I stand still.
  • Sitting with both my feet on the floor (bend knee at 90 degree) can also produce the pain (not as painful as standing still). If I bend my knee at more than 90 degree (less weight on the feet), there is no pain.
  • The pain seems to locate at the bottom of my heels, not at the center of the heel but more anterior.
  • It doesn’t hurt when I get up in the morning or walk after a rest.
  • Pain gets worse with continued activity (esp. standing) and increased weight bearing.
  • Pain is also worse while standing on hard surfaces.
  • I don't notice any swelling, bruising, bump, lump in the arch or heel.
  • It isn't painful when I press on the center of the bottom heel and the anterior heel area. (or maybe I didn't press hard enough) 
                         Dr Blake's comment: It does not sound like plantar fasciitis at all. Try to find pain with your fingers when you are sitting or lying. Mark an "x" on the area, maybe different for each foot. If you can not find one, it is referred nerve pain unless an MRI shows us differently. 

  • I am not overweight (normal BMI), don’t smoke or drink.
  • Wearing OTC insoles and custom insoles and shoes that have very good arch support and higher heel drop (e.g. Vonic, New Balance walking shoes ) makes the pain worse, and my arch hurt.)
                        Dr Blake's comment: Sounds like tarsal tunnel or some version.
  • Standing and walking with barefoot also makes the pain worse.
  • Wearing Keen Uneek shoes that has slight elevated heel and mild arch support makes me feel better.

Have you heard of or seen any case that is similar to my case? Do you also think it is plantar fasciitis? I have thought of Infracalcaneal bursitis but the pain is not right underneath the center of the heel. I didn't feel any bump or reproduce the pain when I press on the central heel. Does it sound like stress fracture, nerve entrapment or even partial rupture of the plantar fascia to you? Can you please help with some advise?
Dr Blake's comment: Nerve irritation from a somewhere is the highest possibility. I will have to look up these shoes. A peripheral nerve specialist is your best option right now, along with a podiatrist who is willing to rule out heel pain not caused by plantar fasciitis. Good luck. I have alot in this blog on treating nerve pain in the foot. 

Sorry this is very long. Thank you so much for your time and help. Thank you very much. 


Dear Dr. Rich Blake, 

Thank you very much for your quick reply. After I read the post, I went to my doctor office as soon as possible and convinced her for giving me a MRI referral for both right and left feet. And the reports came out today. During the scan, the technician used different method to do the scan for each feet. When my right foot was scanned, she put something under my heel close to the edge of the heel. For the left foot, that thing was put under the plantar surface of the left foot.  

- Unremarkable MRI scan of the right ankle and tarsal region of the right foot.
- No soft tissue or bony abnormality are seen along the plantar region of the heel at the annotated area of complaint.

- There is a 6 mm bone cyst in the distal tibia at the level of the previous growth plate. 
- There is a small tibiotalar joint effusion, though no apparent disruption of the collateral ligaments.
- No soft tissue or bony abnormality are seen at the area of concern along the plantar surface of the foot adjacent to the heel.
- The remainder of the left ankle and tarsal region of the left foot is normal. 
Dr Blake's comment: This makes tarsal tunnel (nerve pain) the highest possibility, although with bad mechanics of fallen arches, the nerve pain can be secondary. The nerves are not injured, just irritated due to poor mechanics. 

As you said, the MRI showed that the plantar fascias are normal. I am not sure if the bone cyst and effusion are significant on this MRI in my case. 
Dr Blake's comment: I doubt it. Typically, the MRI can tell if it is an active cyst or old. If not, then a bone scan to rule out high activity in the cyst is needed. See what the doc says. 

To answer your question, yes, I have both back and neck pain... swayback , functional shorter right leg, upper cross syndrome, carpal tunnel. I have been doing some core exercises (based on my visit to a PT last summer) to improve my postures. My posture is slowly improving. My gluteus medius and right lower back doesn't hurt as often. When I stand for longer than 1 hour, my lower back, hamstrings, calfs start to hurt. Usually my feet hurt before my back starts to hurt so I did not connect them together. My doctor didn't think it is a neurological issue (cause it is not a tingling pain), so she refused to give me a EMG/ nerve conduction test referral today. 
Dr Blake's comment: Tell her that it can just hurt. Nerve problems produce pain alone (1/3 of the time), pain and abnormal sensations like tingling, bugs crawling on your foot, buzzing, etc (1/3 of the time), and only abnormal sensations (1/3 of the time). 

I feel like there are multiple diffused areas and they don't hurt all of the time so it is hard to draw a cross. The anterior plantar region of the heel bone has been hurt for few years and always hurt when weight bearing. Starting this summer, the lateral ankle area starts to hurt as well when I stand or walk. The medial ankle area hurts when I start to rest but disappear after enough rest. However, it is not absolute, sometimes both sides hurt at the same time some time they doesn't hurt. 

When I wear shoes with good and thick arch support, the area that hurts the most is the area of abductor hallucis (Area 1). I feel the arch support is pushing onto my arch and it is very dis-comfortable, pain appear only after 10s I stand on these shoes. Not sure if the pain is come from the muscle or something else in that area. Keen unkeen sandal and crocs helps with this problem. 

Dr Blake's comment: Patients in general love orthotics and that feeling of good arch support. On the contrary, tarsal tunnel nerve patients can not stand that pressure. It is fairly diagnostic in my mind. 

Also, starting this summer, I feel a sharp pain behind the heel but very close to the edge (Arrow 2) once in a while when I walk or stand. 
Dr Blake's comment: There is a good pesky branch of the sciatic nerve that hates shoe pressure, hates achilles stretches, and is often confused with achilles tendinitis or even plantar fasciitis. Someone skilled at the difference with nerve heel pain and tendon/fascial heel pain, can usually sort it out. If it hurts when your knee is straight and you try to bend your toes towards your nose, but does not hurt with the same ankle motion when your knee is bent, then that makes it easy. Or if bending over to touch your toes hurts the heel/foot, but not if you bend your knees first, you always have the diagnosis of nerve pain. 

On the other hand, I feel pain behind the heel (Arrow 3) when I take the first few steps in the morning. It doesn't happen everyday but It will definitely happen after I stretch the calf or take a long walk the day before. On a bad day, it will hurt when I press on it or lay on the bed. It forces me to sleep on my side instead of on my back. Does sound like insertional achilles tendonitis? Or an irritated nerve issue?
Dr Blake's comment: Still irritated nerve. 

Sometimes, I feel my ankles are stuck, especially the right feet. I need to pop it to feel better. If it cannot be popped, the whole day i will feel uncomfortable in the lateral side of the ankle.
Dr Blake's comment: On the photo you sent, your foot is pronated. This can lead to lateral ankle and subtalar joint impingement. When patients can not wear orthotics, they usually can tolerate a 4 degree varus wedge at the heel only. This is something podiatrists make, but are also sold on line. You would want a podiatrist to tell you if it is stable.

Above are all the feet problems that I can think of. Are these symptoms more likely to be related (neurological) or individual problems? If the feet pain is neurological, how to tell if it is come from the ankle (e.g. tarsal tunnel) or from the lower back?
Dr Blake's comment: The tests above give you some idea of the relationship to the back. The neural flossing is another way to tell. One version is when you point your foot and straighten your knee, you always bend your neck and look at your toes. See my video on neural flossing. But, it takes a good neurologist or physiatrist  or neuro-physical therapist to put the pieces together and come up with a logical treatment plan.

What is the next step I should take? Do I still need to see a podiatrist? Which other specialist I should see next? Is nerve conduction test necessary?
Dr Blake's comment: For this you need a team. Podiatrist to work on foot mechanics and treatments, neurologist or physiatrist to work on diagnosis and treatments, and physical therapist to work on diagnosis and treatments. Start with who can see you first. Below is one place you can start. Good luck Rich
Thank you very much for your time and advice!!


Reflections one year post injury sesamoid Injury

Post Op Accessory Navicular and Posterior Tibial Tendon Surgeries

Dear Dr Blake,

I came across your website and hopefully you can help with some advice.

I am 44, male and had a operation in December 16.  I had an excision of accessory navicular on left foot with reattachment of of tibialis posterior tendon. I was suffering from inflammation and pain on the tendon for many years and got worse ever after having custom orthotics (two pairs).  (being overweight not helping).  I used to play a variety of sports – badminton, tennis and cricket and hoping to resume soon.  I did play tennis for 1hr at moderate pace last week and did not suffer any issues.
Dr Blake's comment: Functional orthotics are actually designed to make the posterior tibial tendon work better, so that is a problem we sometimes face when we are trying to support and prevent the tendon from being over-stretched. Post-op hopefully they will work better for you. 

I have done all the rehab, physio and still do some physio now when time allows.  I only get mild pain now but want to make sure I have full recovery.
Dr Blake's comment: Hopefully you are using level 6 theraband 2 sets of 25. I will send you the link below. 

The problem is that I have quite large (size 11 US) and wide, flat feet and find wearing insoles very difficult as they invariably do not fit my feet.  I have been wearing the attached in my work shoes (3/4 length, full length don't fit) and seem to work fine, although I can’t wear too thick socks.  I was advised by my physio that I should wear some sort of low arch insoles which would help.
Dr Blake's comment: Could you go back to the custom ones? They should work, although I know you are a bit leery of them. Taught to the doc who made them. Your photos show fairly wimpy orthos for a big guy. 

Do you have any recommendations for insoles that would fit my requirements as my current ones do not fit my trainers and more importantly I want to buy some trainers which I can wear during my sporting activities. (ideally will wear one pair for all, or running shoes)  Ideally I would like to wear trainers that have appropriate support without the insoles.  Any advice on trainers?
Dr Blake's comment: If you want to stay OTC go to Sole inserts since they have more support. Also, get the New Balance Cross Trainers about 1/2 size larger. They have good width selections. The New Balance 1260, 990, or 860 should be fine. But you want to pick the one that feels the most stable to you.  Hope this helps you. 

I hope you can help in this matter.

Many Thanks

PS You also do well taping for long activities for the next several months while you get your strength better.