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Saturday, October 28, 2017

Foot and Ankle Pain Post Surgery: Email Advice

Hello, Dr Blake. 

     I have suffered with foot pain for 2.5 years now.  I have had MRI, and X-rays which show no tears, showing a heel spur, inflamed plantar fascia, inflamed post tib tendon, and the nerve that runs through tarsal tunnel area.  There is fluid around the tendons as well.  

     Approximately 4 months ago I opted for a Hyprocure stent that is supposed to help with these problems.  The Doc also ground down my heel spur at the same time.  My heel pain is much better now, but I still have arch pain and post tib pain, and what I think is a bit of tarsal tunnel or nerve pain.  I have tried everything that I could imagine. 
Dr Blake's comment: This device helps with pronation like orthotics on a permanent basis. It will help the mechanics, but not the inflammatory or neuropathic pain. 

     I had to drive out of state to do the Hyprocure so that doc is a very long drive.  I went to a more local (1.5 hr away)  doc 2 weeks ago and he gave me a Trilok brace and injected traumeel and did a 3 min shockwave.
Dr Blake's comment: Why not normal physical therapy? Have you tried it? Where was the Traumeel injected? The brace looks good, does it help some of your symptoms? 

    I believe the only thing that helped at all was the brace.  Went back 2 days ago and ended up doing 2 cortisone injections.  One towards the plantar fascia, and one near the tarsal tunnel area.  It seemed to help so far.  The problem is, 2 years ago I had a cortisone shot that worked but only for 4 or 5 weeks.  I have a home ultrasound and an afx machine which is for strengthening the foot for plantar flexion, dorsiflexion, inversion, and eversion. 
Dr Blake's comment: Please be cautious with the shots. Could not find reference to afx machine, but definitely, continue to strengthen your foot and ankle so you do not de-condition. 

    I have really considered buying an AFO such as the Deroyal Element Sport Ankle Brace. 
Dr Blake's comment: This is not an AFO, so not sure if any better than the other brace. I hear from your email that you are trying all these things, but what about starting all over with a removable boot placing yourself at least part of the day in the Immobilization Phase with daily foot, ankle, and leg strengthening work. This should include core work and some cardio (can you swim, use an elliptical, or ride a stationary bike?) Main question is what does it take to get you to 0-2 pain level and then maintain that? 

    I'm just not for sure when I need to strengthen and stretch, vs just keeping it immobile.  I have studied on these issues for many many hours and finally came across your website.  AWESOME!  Thanks for all you do.  I am seriously depressed for the first time in my life and I'm running out of options.  The only other solution from one doc was a complete reconstruction.  That seems like too much considering nothing is torn.  I am a very healthy 43 yr old male, normally pretty active (not now) 6 ft, 225 lbs with quite a bit of muscle.  I am even losing weight just to see if that will help.  Any suggestions on the timing of strengthening or bracing after cortisone injection?
Dr Blake's comment: You are asking all the right questions. You should have supportive orthotics to rest your foot, it is in a new position with your surgery only 4 months ago, and needs a year to re-strengthen. You should immobilize some time of the day in a removable boot, because I need to know what pain relief that gives you. Important info. If the immobilization does not bring you to 0-2 then you have too much inflammation or neuropathic pain, and there are many ways besides shots and surgery to help that. I hope this helps some. Rich

Thank you,

The Patient Response:

    Hello, thanks for the response.  I did try physical therapy and didn't have much luck.  After the hyprocure surgery, I did the physical therapy on my own using ultrasound and ankle foot maximizer (afx).  I also used a blood flow stimulation therapy wrap (electromagnetic heat).  For some reason, any orthotics custom or otherwise seems to aggravate the arch area now. 
Dr Blake's comment: When the posterior tibial nerve is irritated, off the tarsal tunnel, patients have an intolerance to orthotics. Which means to me that the primary direction of your treatment has to be neurological and not mechanical. Read my postings about nerve pain, they are some the same treatments we use for CRPS (like the meds and Calmare or Quell). 
    I am finding that cushion seems to help.  The only shoes I can wear at the time are Asics Kayano, which is a stability cushioned shoe.   The traumeel was injected into the post tib insertion, which really wasn't where the pain was.  When I went back, we got more specific with the cortisone as to the exact location of the pain with 2 shots(that was my choice to switch to cortisone.) 
1)  I believe I have the Ossur air walking boot from the hyprocure surgery, would this work for part day immobilization?
Dr Blake's comment: Yes

2)  Orthotics seem to aggravate now, any suggestions
Dr Blake's comment: If we want arch support without pressure on the nerve, you need to experiment with the many arch or posterior tibial tapings available. See my video on posterior tibial taping with leukotape and coverlet 

3)  Should I start strengthening exercises immediately, and what frequency.  (ex 1x/day for 3x/week)
Dr Blake's comment: Only in the evening. Never through pain that does not get better with 10 minute icing after, or sharp. It can be sore due to the nerve irritation. Start with active range, then isometrics, then progress to progressive resistance. May want PT to guide you. See my video on Posterior Tibial strengthening for the order. 

4)  Icing, ultrasound, or bfst wrap?
Dr Blake's comment: May be time for a new PT to guide you. When you are dealing with strength, nerve irritation, and inflammatory issues, along with taping, etc. a PT should be very helpful to find the balance. Rich

Thank you so much!!!

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.