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Wednesday, March 28, 2018

Chronic Pain can be Helped: Consider Dr. Danielle Rosenman

Hi Dr. Blake, 
I was reading your post on Calmare Therapy, and it triggered a desire to let you know about another brain-training-based therapeutic option here in the Bay Area that is working really well for a friend of mine with chronic pain from a cervical spine tumor surgery. 

Dr. Danielle Rosenman uses neuroplasticity principles to help patients with chronic pain retrain their brains themselves - no electrical stimulation equipment required.  I would suggest that you have a look and consider contacting Dr. Rosenman to discuss her treatment if you are asked for referrals for foot-based chronic pain.  I don't know more than this: my co-worker who had to leave her job because of the ongoing health issues from the tumor, the surgery, and the ongoing pain has gotten significant relief in only a few visits. I'm over the moon happy that I recommended Dr. Rosenman to her. 

For what it's worth,

Dr. Blake's reply: Yes, I know well of the excellent work of Dr. Danielle Rosenman. I will try to spread the word. She often gives workshops and I should attend one of them. 

Tuesday, March 27, 2018

Heel Pain: Are Pricey Orthotics Better than OTC Inserts??

What type of orthotic should you try? I think the better question is do I think my doctor wants me well or just cares about their cash register if they are prescribing orthotic devices. I want my doctor makes money by treating me when I give my trust to that doctor. I also think patients should try home solutions to get well, also follow the Keep It Simple Stupid rule, and to be actively involved in their treatment's success.

     As a podiatrist, I treat pain. The more pain, the faster patients will come in to see me. When it comes to heel problems, and particularly plantar fasciitis the most common culprit, the need is there to try to shift the weight into the arch and off of the heel. If the OTC insert does it, but the more expensive custom one does not, then wear the OTC insert. It is typically simple mechanics. 

    I have made my own orthotics for our 35 years, so the buck stops with me. I can make 20 versions of our custom orthotics, each for different purposes, so it is easy to change prescriptions based on the present need of the patient. At times they made need full arch support, and at other times, may need more cushion and less overall support. If you walk into my practice to get orthotics, I have no standard pair. If I did I would be no better than a store selling over the counter inserts. I need to figure out what the problem is, how a certain type of orthotic might help, and then go to my workshop and make that. If the patient has a different problem next year, I may be able to adjust the present orthotics, or I have to go back to the drawing board. This is what it is like to have a biomechanics practice.   

    I do not want to be known as just someone who makes orthotics. I want to be known as someone who helps patients get better. My orthotics get people better overall, but they are part of a big range of techniques I have available, and I have spent years mastering. I love to keep things simple, do the simple things if effective, so OTC inserts are used plenty in my practice. It also takes many years to develop the sense when OTC will work, and when custom is needed. 

    Any case of plantar fasciitis should be centered around 3 things that I offer (someone else may offer 3 other things): orthotics to shift the weight into the arch, stretching of the calf and plantar fascia to take tension off the tissue, and icing to cool the tissue down. These can change if there is a tear in the fascia, the patient is not responding to the treatment, or there are 2-3 injuries at once to deal with. The better doc I am, the more I want to find answers to help that patient. To look at the big picture. I have never thought that I sell a patient or an insurance company orthotics. It is not a product so much as it is what it takes for me to help the patient get healthy. The pricey orthotic suggested in the article above is as a part of me as my stretching program, my return to running program, who I am. 

Monday, March 26, 2018

Calmare Therapy for Pain Relief

I can not write a foot blog too long without mentioning something that has the potential of changing chronic 8-10 pain and make it go away. Calmare pain therapy is still not FDA approved, although cleared as safe (whatever that really means). It does not work on all pain, and there is some technique to getting it right, and it is not offered in many locations. That being said, if I had severe chronic pain, and I could travel to a Calmare Pain Treatment Center, that would not be questioned. If you or your loved ones have chronic pain, please get informed about it. 

Sunday, March 25, 2018

Altra Shoes: Wide Toebox and Zero Drop (Interesting Combination not for everyone)

Will Stem Cells be the Way of the Future: A Couple of Interesting Articles

Hallux Limitus and Hallux Rigidus: When do we allow Motion and When do we Restrict

I do not like to criticize someone's work, but the article emphasizes joint stiffness in all cases of hallux limitus or rigidus. To me, you want to allow the joint to move as much as it can so it will not freeze up. There are times when you will do something that requires too much painful motion, and then you restrict. It is like nerve pain: sometimes you honor the pain, and sometimes you push through it. I have made 2 pairs of orthotics for some of my patients: one that limits and one that restricts. But, I tend to make an orthotic with dancer's padding that allows freedom of the joint and then have the patient when they need restriction (for example, an upcoming backpacking trip that they know will irritate the joint) slip a flat carbon graphite plate under the orthotic, use spica taping, stiff sole shoes, or a combination that they have found helpful.

CRPS: Short Physician Educational Video

This is a nice video on the teaching of family practitioners on CRPS

How Family Docs are taught about CRPS

Saturday, March 24, 2018

Iontophoresis for Local Inflamation: Electrically or Not

Iontophoresis for Anti-Inflammatory Treatment

The above link is for treatment of inflammation using a physical therapy patch with topical steroid called iontophoresis. This used to be administered electrically, but now many PTs are saying that they get the same results without the electric part. If you have any feedback, please let me know. I have no experience with the non-electrical method. 

These videos are the more typical method we have always used with very good success.  (this second video does describe both the electrical ionto and the to-go patch (non-electrical)

Another article on Electrical Iontophoresis:

CRPS: The Misery of Under Treatment

This email was sent 3 weeks ago, and because I had not responded, the patient emailed again today. I have to do a better job!!

Dear Dr. Blake, 

I discovered your blog a few days ago and it has been very helpful in understanding my symptoms. I'm writing to you in the hopes you can offer some advice, but if not, no worries, just consider this a thank you for taking the time to help those of us with foot problems.

About eight months ago during tennis season, I was feeling some tightness and pain in my right achilles, and at the advice of a friend, I bought some rigid, 3/4-length orthotics. I used them in both shoes and proceeded to play one of the longest tennis matches of my life. I took the orthotics out about halfway through, but at that point, the damage was done: since then I have been in constant pain.
Dr. Blake's comment: I am not sure if they were custom made, but orthotics, in general, need to be broken in, tissue stretched out, etc. Also, orthotics really make you use the ball of the foot since that is where they end. But, also there could have been something else wrong with them. 

The orthotics--the front edge of them-- damaged the ball of my feet: the pain is the worst there. But I also experience pain in the arch, the outside edge of the foot, the mid-portion of the foot, and, occasionally, at the front of the heel. I have what feels like muscle pain, but also burning that is nearly constant. I've never had any noticeable inflammation, and when I palpate my foot it is hard to locate any spot that hurts more than another. When I walk or stand for any length of time, my feet seem to go numb, cramp, and feel inflamed, all at the same time. It's not pretty. The only way to be free of pain is to keep the feet elevated.
Dr. Blake's comment: This is typical irritated nerve pain. The constancy of the pain is also classic for nerve pain, not inflammatory pain. The treatment should be directed at the nerve pain. 

After cortisone shots, night splints, a 8-day course of oral steroids, two pair of custom orthotics, every supplement and cream known to man, daily stretching of the calves, exercises, physical therapy, acupuncture, 8 Graston treatments, prolozone therapy, and astym treatments, my chiropractor gave up and sent me in for an MRI on my left foot (we decided to do one foot only as my feet show the same symptoms).
Dr. Blake's comment: If the pain is nerve related, most if not all of these can irritate the nerves more. 

Here's what the MRI says:

Conclusion: Question small tear distal in the fourth MTP plantar plate.

Bipartite medial hallux sesamoid bone with marrow edema in the distal part that may represent sesamoiditis or stress reaction. Small first MTP joint effusion.
Dr. Blake's comment: These may be the cause of pain, but they are really soft calls since these are common for many athletes with no pain. Degenerative changes in the plantar plate and stress reactions can be common to athletic participation and maybe been there before the injury. I am mentioning this only because these do not give you your symptoms right now. They may be part of the picture, but not primary right now. As your symptoms resolve, looking at the individual areas may show that they are somewhat involved. This is nerve injury in my mind right now. 

I went back to my original podiatrist, who seemed totally flummoxed, and suggested I might have fibromyalgia or some kind of connective tissue disorder (!) despite no showing symptoms of that in the rest of my body. He suggested I take muscle relaxants at night and gave me a pain-relieving cream, which seems to do nothing. He also rejiggered the orthotics, which I can't bear to wear for more than an hour.

So I've decided to have PRP treatments on the plantar plate tears (I'm assuming there's one in the right foot as well), but don't know what to do about the rest of the symptoms. I don't really feel any specific pain at the base of my fourth toes, and I can't see how PRP at that site only will be a cure for the rest of my symptoms. From reading your blog, my thinking is that I have an unholy trinity: plantar plate tear, plantar fasciitis and some kind of nerve disorder.
Dr. Blake's comment: Ask anyone with a plantar plate tear, and they can point right to it. PRP is fine to make your ligaments stronger, but it is invasive and your foot is too sensitive right now. Calm the foot down before any thought of PRP. That is for the long-term health of your ligaments, not during this crisis. 

I'm wondering if you have any thoughts about PRP. It seems that the key to calming down the nerves is getting rid of inflammation--but PRP produces it in large quantities. Perhaps it's best to get the tears healing properly and then go about working on the nerve problem.

(Also, for what it's worth, my feet never showed any signs of inflammation, even after what seems like an acute injury.)

Well, there's my story. Thanks again for being so generous with your wisdom and knowledge.

my best,

So, I am sorry it took me 3 weeks and this new email to answer.

Dr. Blake,

I'm writing to you again in the hopes you can help me. If not, I understand.

My condition has gone swiftly downhill. After having PRP treatment, the pain in my feet increased dramatically, so that in the entire foot there is constant burning and waves of numbness. Putting any weight on the feet feels like walking on glass. I've gone from crutches to being essentially bed-ridden.
Dr. Blake's comment: I am personally sorry I did not email you my thoughts on undergoing PRP in the obvious case of nerve damage or hypersensitivity. You are developing what we call complex regional pain syndrome. You should be put on the protocol for this: typically sympathetic nerve block in your back, IV Ketamine infusions, Calmare Pain Therapy. Find out who treats this, or just go to your ER right now and say you have this. There is no diagnostic test for CRPS, previously called RSD, it is a diagnosis of exclusion. It is the only diagnosis that makes sense. It can get worse, it must be treated by a nerve specialist who understands this injury. I am sorry. 

I found a new doctor who believes I have multiple neuromas in both feet. He did steroid injections between the 3rd and 4th metatarsal, which gave me a reduction in pain, about 30 to 40 percent, but that lasted a few days and the pain came roaring back, worse than before. I saw an ortho surgeon who believes, because my pain is bilateral (essentially equal symptoms in both feet), that it's coming from the back. I have had a bad back. Will have an MRI on the back this week.
Dr. Blake's comment: This scenario is unfortunately too common with CRPS. Yes, looking at the back is good since the nerve hypersensitivity may be initiated at the back and then the trauma of the orthotics on the foot nerves set this syndrome off. But, CRPS must be treated now. 

I saw a pain specialist, yesterday, who said I may have CRPS, but he's never seen it affect two limbs this way. He sounded just as confused as everyone else. He prescribed Gabapentin, which is the first thing to have given me some relief. It has taken the edge off so I'm not experiencing constant pain, which is a godsend. 
Dr. Blake's comment: Tell him, and this is the only person you should be seeing right now, that the injury was caused by orthotics in both feet with equal stress on the nerves. Ask him about sympathetic blocks, Ketamine Infusion, or Calmare. The Gabapentin is really the first thing you have taken that works only on nerve pain. See!! I am invested now, keep me in the loop. Rich

These are the best doctors where I live, and they're all coming to vastly different conclusions, taking shots in the dark, it seems. I'm scared, to put it mildly.
Dr. Blake's comment: You are not alone with nerve injury. This is such a common presentation. 10 years ago in the US we really did not have pain specialists, so the profession is evolving. Fight for good treatment of CRPS. Forget inflammatory and mechanical treatments right now. At least for now!

my best,

And the patient's response:

Dear Dr. Blake,

I have been diagnosed with CRPS. While I suspected this, your email spurred me to get a proper diagnosis. It's amazing how fast this disease is advancing. In just the past few days the pain has moved into my calves and my legs feel weak and numb--I can't stand up, even with crutches, without feeling they'll collapse under me. I fear I'll be a cripple soon. I'm trying to find a doctor who understands this condition, but it's not easy.

To be honest, I'm very scared. I'm trying to come to terms with losing the active, independent life I once knew.

I have a question or two if you have time to answer. You mentioned that I should get a sympathetic nerve block, ketamine infusions, and Calmare therapy. I have the option to have all three, but I learned that to get Calmare therapy, I patient must be free of ketamine for six months. If it were you, which would you choose: Calmare or ketamine? (I suppose I could try Calmare first, and if it doesn't work, go to ketamine).

For someone who's just been diagnosed, what would you consider the most important first steps?

I want to do everything I can to limit the advance of this disease and try to live a full life. I have a family who needs me.

Thanks again for your blog, and for your humanity and compassion. 

my best,

Dr. Blake's response:

     Please do the 10 days of Calmare, you will know in 3-4 days if it is going to work on you. I will pray the technician hits the right areas. Also, get a sympathetic block as soon as possible. They can be done at the same time. It should be a 3 or more level sympathetic block on both sides. You can do that tomorrow. Rich

Fractured 5th Metatarsal: Email Advice

Hello Dr. Blake,

My 14-year old daughter just got out of a cast (2 weeks) for a fractured 5th metatarsal (no displacement). Apparently, she's had the fracture for up to 7 mths and has been doing up to 30 hrs of gymnastics on it per week (competitive gymnast). It finally got to the point where she couldn't walk (up until then, it was on and off pain). So, after 2 weeks of a hard cast, her xrays were 'good' (whatever that means). Her doctor (orthopedist) put her in an ankle brace (??), which after wearing for a day, was hurting her foot, as it cuts right into the fractured area. 

Next step was "no jumping/running" for 4 weeks. She says she still has pain when she walks. 

Is there something specific we should be doing?? How should she be taping? I feel like her doctor was in and out--not giving us much to go on. 

Dr. Blake's comment: 
     I am very late in this response, so if you like, please get me up to date. Yes, you are right to question this. Ankle braces do cut right across the area of injury so I do not understand its use at this time. You have to create the 0-2 pain level so walking in pain is not desirable at all. You typically advance from the hard cast to a removable boot while a lab is preparing an orthotic which will protect it out of the cast. 2-3 weeks out the patient can tend wean from the protection of the removable boot to the protection of the orthotic. I use KT tape (or some other similar) circumferentially around the foot once or twice to stabilize even in the removable boot. It takes 3-5 times of doing it yourself to get the right tension, without irritation. I have copied more from my book on this subject below. Sorry for the delay. Hope she is doing better. Rich

This is an excerpt from Secrets to Keep Moving. It is hard to know which of these rules are important for your daughter, but they are definitely at least asking questions about if the treatment is stalled. The fact that every step she takes places full weight on the fifth metatarsal unless she is severely limping makes the progression from cast to full activity a thoughtful process. 

. Fifth Metatarsal Fractures: A Special Breed

    The top 10 initial treatments for 5th metatarsal fractures are:

  1. X-ray evaluation to decide on surgery vs conservative care.
  2. If surgery, protocol to be set by the surgeon and not purpose of this writing.
  3. If conservative care is chosen, some form of immobilization for 8-12 weeks is typically done based on injury (Immobilization Phase).
  4. During the Immobilization Phase, lower limb strengthening with some cardio should be orchestrated by a physical therapist. Even one legged stationary bike is very beneficial.
  5. Bone health is analyzed with dietary calcium and Vit D3, consideration of a bone density screen, and typically healthy diet.
  6. The transition period from cast to no cast, with or without surgery, can be very difficult. Custom orthotics with full lateral arch support very helpful. At times, extra big shoes as a transition can be purchased so added padding/accommodation can be used.
  7. When not using a permanent cast, 24/7 compression bandages, ice pack 15 minutes twice daily, contrast bathing each evening, as much as possible elevation, 3 times daily 10-minute self-massage for desensitization and swelling reduction, and hourly pain-free ankle circles are initiated.
  8. Weight-bearing for bone mineralization, even in casts or boots, is done as early as safe (Good Pain vs Bad Pain)
  9. All fifth metatarsal fractures, except a few styloid process avulsion fractures, should have an Exogen Bone Stimulator for 6 months (when insurance allows).
  10. Follow up xrays need only be done when symptoms plateau or worsen. As long as the patient makes steady, gradual, progress, it is better to base improvement on function, not x-ray or palpable tenderness. 

Friday, March 23, 2018

Hallux Rigidus: Avoid Aggressive Mobilization

Dear Dr. Blake

I wrote to you last August re my hallux rigidus in my right toe which flared up after a physiotherapist manipulated aggressively. 

I am now on orthotics after seeing a podiatrist in Hong Kong. The pain has lessened but I still can't do the Latin ballroom dancing which I love. I am so depressed. Now my only exercises are walking, stationary bicycling, pilates, etc. I have been dancing for over 20 years. 
I am even afraid to dance aerobics in the gym.

My podiatrist says the toe should fuse naturally but no one knows how long that would take. I don't want surgery either because of the unknown.

The toe still hurts on a daily basis. I used to just feel a bit of pain after wearing high heels but after that physiotherapist messed this toe up its constant unpredictable pain.
Any advice would be appreciated.
Attach the latest x-ray of my foot.

 Marked joint degenerative disease 

This oblique view actually shows the joint is a long way from fusing. Only a small amount is bone to bone.

Dr. Blake's comment: I am so sorry, and I wish I could predict how fast this will calm down. I have attached my original article on Hallux Limitus/Rigidus to emphasize to treat it as a sore joint and boot it at least 4 hours per day to get complete rest. You can have a physio use EGS with ice to calm the joint down for 6 visits--no manipulation, please. The joint is too open to expect fusion in the next 10 years, but 3 months in a boot may do the trick. I would also spica tape it every day to immobilize also. Your bone health looks good in the photos. 

Here is the link to my early comments on this subject. 

Wednesday, March 21, 2018

Sesamoiditis: Email Advice


I wanted to share some info on my foot injury and get some get feedback.

In the summer of 2017, I was walking at work, in my steel toe metatarsal boots, and I felt a nerve-type feeling in my right foot.  It was as I rolled my foot up and pressure from my boots was applied to the back side of the ball my big toe.  The nerve feeling seemed to go back toward my arch.  I repeated this a number of times once I first felt it.  The boots I was wearing were fairly tight and narrow on my feet and I had worn them for 6-7 months without any pain until that one step where I triggered something.  I immediately got new boots that were much roomier, the back side of the ball of my big toe began to hurt when I rolled up my foot while walking and pressure applied.  The pain wasn't severe, and I figured it would go away on its own.

In November 2017, it got worse.  I believe this was from wearing tight boots while walking outside in the woods.  The arch of my foot experienced a lot of pain, I had trouble placing weight on the bottom of the ball of my big toe, and the pain was starting to go into my big toe.

I went to a podiatrist at the end of November, was diagnosed with sesamoiditis.  The doctor checked for range of motion, pushed on the sesamoids, but could not replicate the pain and there was no stiffness in the big toe joint.  I then was given a prescribed anti-inflammatory, was told to offload the area and received custom orthotics. I also had an x-ray and MRI, which didn't reveal anything alarming.  After taking the anti-inflammatory, the pain under my big toe went away and I stretch the arch of my foot in the morning for a few days and the pain went away.  The pain in my big toe also went away.  After returning for my follow up visit on December 22, I was basically released.
Dr. Blake's comment: Good drug!!

Then, a few days later, I wore my tight boots in the front of my yard for 10 minutes, and the back side of the ball of my big toe became very painful.  For the next 3 weeks, I experienced a lot of pain.  I hurt to walk up and down stairs.  The first few steps I would take after sitting for an hour.  Very soft surfaces (like gymnastics mats for my daughter, of very soft running shoes) would hurt more than walking barefoot.  I had a lot of tenderness on the backside of the ball of the big toe, and it would not tolerate much pressure.

In the middle of January 2018, I decided to call a foot and ankle orthopedic surgeon but had to wait over 3 weeks to get in.  During this time, I went to work and tried not to aggravate my foot.  And, in the evenings at home, I elevated my foot and iced.  By the time I got into the orthopedic surgeon, I felt a little better.  The tenderness went away and was able to walk around in my orthotics place in running shoes with minimal pain.  But, my steel toe boots at work still hurt my foot.

When I saw the surgeon, they also diagnosed me with sesamoiditis. The doctor showed me on the MRI where my sesamoid was inflamed.  They also pushed all over my foot, but could not generate pain.  They placed me in a walking boot for 5 weeks and gave me a prescription for the anti-inflammatory.  And, another MRI and cortisone shot are the next steps.

After 12 days in the boot, I not sure if I'm making any improvement.  I experience burning feeling and dull aches when I'm sitting around, or in the middle of the night when I'm sleeping.  And, I'll get a sudden pain if I lean/turn a certain way.  And, these pain are on the back side of the ball of my big toe.  Toward the outer side.  And, a couple times, I put on my shoe just for a few steps (to put gas in the car), and there is a lot of pain in the tendon as wraps from the back toward the bottom of the ball of the big toe.  But, that slowly went away as I was standing and took a few more steps.

My questions are:

Do you feel the doctors are on the right path with the diagnosis? Dr. Blake's comment: First of all, I am sorry for my delay in corresponding. I am having trouble shaking this cold/flu bug completely since Thanksgiving. I think the doctors are doing okay. They have ordered the right tests. You have some inflammation, some nerve irritability, some tension in the tendons in the area. You have to figure out how to not trigger this for the next 6 months: looser shoes, 100% wearing of orthotics with dancer's padding, icing for 10 minutes twice daily, every other day a full contrast bath. Perhaps the walking boot for the next several months when you are not working to relax the tissue. 

Are these treatment correct for the injury?
Dr. Blake's comment: The treatment of sesamoiditis is threefold: mechanical support to off weight, anti-inflammatory to cool the itis down, and neuropathic when the nerves are too irritable (wide shoes since nerve hate tightness, pain-free massage into the tissues to tell the brain that everything is fine, etc)

Is there anything I can be doing to help with recovering?
Dr. Blake's comment: Look back on all the times you irritated it, and try to not do that for 3 months. And, at the same time, constantly attack the inflammation and relax the nerves. Stay away from long-acting cortisone which can delay healing and mask pain. I am never sure 100% when the bone is inflamed and when it is has a stress fracture. I think they look the same on MRI. The first is a bruise, and off-weighting mechanically should solve. The second being a type of fracture may need more Vit D screening, bone density workup, even an Exogen bone stim. Try the Hoka One One shoes to see if they help you. You put your orthotics in the shoes and walk around the store. Good luck. Tell me if you still have questions or other comments. Rich

Thank you

The Patient's response: 

Thank you for the response.

I came out of the boot a few days ago.  Things are going a little better.  The nerves are calling down, but the tendons on the back and outer side of the tibial sesamoid seem inflamed but do not hurt to the touch.  The sesamoid bone doesn't hurt either, even if I take a couple steps on it.

I was recently given a topical anti-inflammatory, which seems to take the edge away.  I'm also using a graphite insert with cut out plastazote padding to unload the sesamoid.  It's almost like the boot.  My PCP suggested this, along with rolling my foot on a frozen water bottle at night to stretch the tendons and cool the tissue. 

I've tried the contrast bath, but it seemed to inflame the tendon on the outer side of the ball of my big toe.  Even just soaking in warm water does the same thing. Dr. Blake: So, just stick to ice. Definitely, pure anti-inflammatory measures help.

The orthopedic surgeon said the next step is injections, then a removal of the bone.  Which I obviously don't want to go that route, and don't even want to do injections.

This is the most frustrating injury I've ever experienced.  From what I've read on your blog, this can take a long time to heal.
Dr. Blake's comment: Yes, please send me the CD or images via WeTransfer if you would like for another look. Keep figuring out how not to overload the next 6 months, while reducing the inflammation and reducing the nerve irritability. You are going in the right direction. Time tables are tough, but benchmarks are important. What you can do in April should be more than March, and on and on. Rich


Tuesday, March 20, 2018

Tibial Sesamoid Fracture: Email Advice

Hi Dr. Blake,

I have been reading your blog and was hoping to get your advice on a tibial sesamoid fracture I have been dealing with.

I am a 27-year old female living in Japan (from bay area originally).
I am currently trying to decide if I need to return to the U.S. for treatment.
Please see a brief history below.

May 2017: Pain began
October 2017: Pain was so unbearable I could barely walk. Diagnosed with a tibial sesamoid stress fracture, and poor biomechanics (forefoot varus/overpronation/flat feet).
Feb 2018: Still stress fracture. In fact, it seems the fissure/crack has progressed more than October! Swelling still present.

Since October I stopped all exercise, offloaded the fractured region using custom orthotics, and tried taping the sesamoid area. I tried physical therapy also.
The past few weeks the situation worsened so I have been working from home and barely leaving the house. 

The most recent doctor said it may take another 6 months to heal and to keep offloading and continue physical therapy. If not, the next step would be a cortisone shot, and ultimately surgery.
However, even with my extremely sedentary efforts, the bone is not fusing together.


Sorry for the lengthiness!
Podiatry (not recognized as a discipline here) and foot orthopedics, in general, are so far behind in Japan, it has been difficult to get help.

Do you have any advice on the above/alternative treatment options?
I could send my MRI/X-ray data if needed.


Dr. Blake's comment: 
     We will have to have a running dialog which I will keep as part of this post. Any imaging you can send would be great. Try and use WeTransfer since that site seems to work. Even a photo of the most current xrays would help for now. 
      Any investigation into sesamoid healing should involve bone density screen and Vit D, so see if you can get that over there. 
      One of the tried and true methods of healing anything is an attempt to create a 0-2 pain level. Most need a removable boot to stop the bend of the toe. At times you have to use 1/4 inch adhesive felt to off weight the sesamoid inside the boot. Or, at least, use the orthotic inside the boot. What does it take now to achieve that goal is crucial to find out? 
     There is always three types of pain that we deal with after this long from the start: the mechanical pain of the break itself, inflammatory pain from the healing process, and neuropathic pain from the hypersensitivity or protection of our bodies to avoid pain. So, your daily treatment should involve mechanical floating of the sesamoid probably around 1/4 off the ground, anti-inflammatory with ice and contrast bathing, and nerve desensitization with pain-free massage, Neuro-Eze topical gel or something similar. 
     I hope this gets us started. I am sorry for your problem. Rich

Monday, March 19, 2018

Abnormal Leg Sensations: Email Advice

Dear Dr. Blake: 

I wanted your opinion on an experience I have had off and on, day or night, for at least 20 years.  Recently it has increased and is worrying me.

I will have sensations that are hard to label, similar to very small contractions, twitching or pulsing in my legs. They are like phantom contractions because I have no pain and no actual movement of my legs.  I don’t feel an impulse to move the legs or walk.
Dr. Blake's comment: These may be dyskinesias or abnormal sensations caused by the sciatic or femoral nerves originating from a tension spot in the low back, cervical area, piriformis, hamstrings or calf. These are places that the sciatic nerve typically can be pushed on causing neural tension which presents in a third to half of these patients with these abnormal sensations. They can be from a slow clot or venous reflux formation and the irritation of the soft tissues. 

Doctors have dismissed the experience as unusual but not concerning.  Recently online I have learned it is not that unusual as others have the same experience.

I had a bad flu and over two months of very bad cough.  Perhaps unrelated but now I experience the sensation anytime I awake at night. It is primarily in my left calf and now in my left ankle and top of the left foot as well. The sensation is much stronger than before.
Dr. Blake's comment: Definitely get a doppler ultrasound to rule out a blood clot, and get a venous workup for reflux. Do you have any swelling? Have someone look at your spine with the possibility of a disc bulge could be causing peripheral nerve hypersensitivity. 

Additionally, my left calf is tight and I keep wanting to stretch it out.  I have been wearing hiking boots and that could give me some shin pain or tightness.
Dr. Blake's comment: A tightness in the calf that cannot be stretched out is sciatic nerve irritation or blood clot until ruled out. Then, you look for more minor problems.

I have wondered if these sensations are somehow related to mechanical issues that stimulate the body or brain in some way.  Perhaps related I have always had leg spasms that go away if I walk on the afflicted leg.
Dr. Blake's comments: I think leg spasms are always somewhat related to nerve irritability, perhaps coming off your back. What is your back history? Have you had surgery or sciatica in the past? 

Can you think of an explanation?  Should I get a Doppler? Yes I am going to Maui in April to boogie board in celebration of my 75th birthday so want to be safe flying!  By the way, I still try to jog and climb stairs but the flu and weather have prevented me from doing much.

Sunday, March 18, 2018

Oral Cortisone for Nerve Pain with Inflammation

Dear Dr. Blake
I wonder if you would be able to answer a quick question for me?  I'm here in the UK and have been suffering from neuromas in my feet (2 in each foot) for around 17-years.  The right foot was operated on in 2012 and now I have 2 stump neuromas (both >1cm).  The neuromas in the LT foot are also >1cm.

In an attempt to avoid further surgery I have had radiofrequency ablation, cryosurgery, alcohol injections, steroid injections etc.  None of which have really worked that well, though the steroids do help a bit.  The surgeon I have been seeing is reluctant to offer any more steroid injections because he is concerned about foot pad atrophy (he is not the surgeon who operated on the RT foot). 

My neuromas are causing me a lot of problems at the moment, though I can still cycle (which is a great passion of mine).  Later this year I plan to ride from Moscow to London, then at the end of the year, proceed with surgery.

My question is whether you think a course of oral prednisolone might be worth a try, just to get me through this exacerbation of symptoms/

Thanks so much for your help
Kind regards

Dr. Blake's comment: A 6 to 8-day course of oral cortisone to drive down inflammation is okay. Remember no strenuous activity for the duration of the meds and another equal time, including cycling! It can only be done once every 6 months! Rich

Two good articles:

This article above is great in cautioning it not to be used in skeletally immature athletes and limiting the total dose under 400 mg. But, there is no mention of not exercising while on it or for the next 6-8 days. This helps prevent bone problems like osteonecrosis, stress fractures, etc. From what I have read, these tips are anecdotal but an important precaution. One rheumatologist believes that any form of cortisone should be limited to once per month, with oral once per 6 months. The article below talks about the prednisone burst dosage and how wired people feel the first 4 of 8 days. Rich

This I wrote this article 8 years ago, I would add not to be used if you have Vit D deficiency or Low Bone Density, or any problems that cortisone may affect (slight Adrenal Insufficiency). 

Posterior Tibial Tendon Dysfunction with Accessory Navicular: Email Advice

Hi Dr. Blake,

I wanted your advice on my situation. I have been diagnosed with posterior tibial tendon dysfunction - stage II and accessory navicular syndrome. My doctor suggests the following surgical procedures: removal of accessory navicular, FDL tendon transfer and evans flatfoot. I had a recent MRI which showed some wearing of the tendon including a 1 cm tear. 
Dr. Blake's comment: As long as you are in Stage II, where there is no rigid deformity, you can undergo conservative treatment. So, if your arch looks close to normal non-weight bearing, you would be considered stage II, even in the presence of a tear. The tear needs to be treated with removable boot typically for 3 months, then ankle foot orthotics, then foot orthotics with posterior tibial taping or bracing. This should be done at the same time you are strengthening the posterior tibial, anterior tibial, achilles, arch, peroneus longus, and external hip rotators. This is a delicate matter and sometimes it is the inexperience of the health care provider in conservative management that leads to failure. You must find someone that can attempt to rehab this. 

I have been researching these conditions and come across studies which show that wearing an AFO with physical therapy can resolve PTTD. However, it is not clear to me if my accessory navicular or if my tendon tear would be an issue in the success of this protocol. 
Dr. Blake's comment: Definitely they are factors, but as long as your arch collapse is reducible when you are nonweight bearing, I would rehab. 

I would like to avoid surgery if possible but also do not want my PTTD to progress further.
Dr. Blake's comment: That is what is at stake. Surgery is very successful, but Stage II is fixable without surgery if it can be rehabbed. While it is being rehabbed, if the pain can not be controlled, and or the deformity of your arch gets worse, then you should sign up for surgery. I do not do this surgery, I have a wonderful podiatric surgeon as my partner, so I see the patients up to the point of surgery, and then 3 months after the surgery to finish the rehab. Whatever is done initially, if you eventually need surgery, then those same devices and skills can be used in the postoperative period. For example, the same AFO initially, can be used postoperatively until you get strong.  

Some more background: I am 41 years old and have been symptomatic for 4 years. Three years ago I wore a boot for 6 weeks and my symptoms seemed to resolve completely for one year. After that year I had some pain and limitations off and on but nothing that disrupted my life. I had not been wearing inserts until recently which I now realize was a mistake. Now I am in inserts and the air cast boot. 
Dr. Blake's comment: With or without surgery, orthotic devices can be vital, so I am glad you have a good pair. Begin strengthening, and stay in the air cast boot until you have your custom AFO made. Typically they start with a rigid model, and then as you improve, go to a hinged version for more mobility. Good luck!!

Thank you for your advice!

Useful review article: 

Saturday, March 17, 2018

Hallux Rigidus with Spurs: Role of Spica Taping

Dear Dr. Blake,

I am curious if you can see this Taping treatment as a way to restrict ROM for those with hallux rigidus + bone spurs in activities such as running (and other exercises that cause joint flexion)? I have been using a rigid foot plate for my hallux rigidus that was diagnosed about 6 months ago, but I believe it's throwing off my gait / causing further injury to my arch/heel/ankle. I am curious if you think taping could be an effective replacement treatment protocol for this condition... longterm! :) Thank you for this video, Dr. Blake! There isn't much info out there about using taping for hallux rigidus, so I would appreciate your thoughts!

Dr. Blake's comment: Yes, Spica taping is a very suitable alternative to carbon plates, without the dramatic effect on the whole body. That being said, there are many things you should do, and it is okay to rotate. I think using the flat carbon plates one out of workouts, maybe your easy workouts are great with or without the taping. You should develop with a local orthotic person an arch support that gets the weight centered on your foot with the arch part, and then uses a dancer's pad construction to take pressure off the big toe joint itself. Some shoes it will be good to skip the lace closest to the bone spur, and just design dancer's padding and use hapad longitudinal medial arch pads in shoes that cannot fit orthotics. If you have not tried the Hoka One One line, please do. The built-in rocker lessens the stress through the ball of the foot. Get some 1/4 inch adhesive felt from and apply on top of the foot just off the joint towards the arch. Usually, you use a one-inch square piece. For this problem, you can place another piece over the big toe itself (nothing over the spur) to help limit the bend of the joint.
But, I digress. Back to the taping. Once you are good with KT or RockTape, try to advance to 3M Nexcare Waterproof Tape and then Leukotape with Coverlet. These get stronger and stronger to do the job intended, but they are harder to work with so you better practice first with KT. The leukotape, the stronger tape I know, cannot actually touch the skin, thus you need the coverlet first placed on your skin. With 3M or Leuko start very loose to get used to it and the tension it gives. Good Luck. Rich
PS The key point, tape is good, but use other methods to take the pressure off the joint with it. If you are pronating, you must get a shoe that eliminates that problem, or the tape will not work in the long run.

Ankle Sprain: Email Advice

Hi Dr. Blake,

      I was googling Contrast Bathing for ankle sprains when I came across your website.  Thanks for the info!  I sprained my ankle on Jan 6 this year.  I knew it was really bad when it happened.  I've sprained this ankle now 4 times that I can remember and thought I could rehab with just home therapy after taking 2 days off work. 

     It's been up and down, aggravated by my overstretching and probably doing too much too soon.  Xray 5 weeks post-sprain was negative for anything acute and only showed an old avulsion injury.  Just had an MRI almost 10 weeks post-sprain which showed findings consistent with full-thickness ATFL tear.  I'm wondering if it's possible the complete tear can still heal this long post-injury.
Dr. Blake's comment: I have been around long enough to see the cycle go from surgery on these grade 3 sprains, to just rehabilitation, to some surgery. Truthfully, a lot of the success of rehabilitation has to do the expertise of the healthcare provider, or team, and the desire of the patient. I know too many patients who have had surgery, but probably could have rehabbed successfully, and I have rehabbed patients only having them need surgery down the line. It takes me a year of rehab on these sprains to decide on the few that need surgery, but of course, that is my bias from the start. 

  I've been off the foot as much as possible a good week now while waiting for the MRI auth and results during which the most stubborn area of the swelling has improved some.  But now that a peroneal tendon tear and OCD have been ruled out, I'm doing some weight-bearing and limited activity again. Any thoughts or advice you have would be greatly appreciated!
Dr. Blake's comment: A bad ankle sprain has on average 3.5 months of swelling which causes instability. You are right to do your contrast bathing daily, and twice on weekends. If you have functional instability, a feeling that you may sprain your ankle, you should wear an ankle brace during these stressful activities. Physical therapy is wonderful to progress you in terms of strengthening, especially the fast twitch muscles and proprioceptive nerve endings, and then return to activity. If you keep the 0-2 pain level healing environment as you decide what you can do now, each month for the next 3 months, you should be able to do more and more. One the best things if it is at all swollen is to wear a compressive wrap or sleeve when you sleep. Definitely start Single Leg Balancing now and progress each month making it harder and harder. If you have more specific questions, I will try to answer. 

Thank you so much,

PS: Here are some other videos that may help.

Friday, March 16, 2018

Short Leg Treatment: Email Advice

Dear Dr. Blake,

     I came across your blog online and am hoping that you will have a moment to read and respond to my question- I would REALLY appreciate it.  I am a 38-year-old woman.  When I was born apparently there was a glitch with the movement of my right leg that the doctor noticed and said might just go away on its own.  My parents never pursued it any further so I have no idea what was noticed when I was born or whether it is at all related to the current issue I'm trying to address.

     For many years I've noticed that my right hip and shoulder sit slightly higher than my left side.  I would typically walk with my right foot toes pointing out about 40 degrees.  My right knee has always turned in toward my left leg when I'm in a standing position.  A couple years ago I started wearing some Powerstep insoles on both sides, which helped turn my right knee out a bit straighter.  Growing up I was told I had slight scoliosis.
Dr. Blake's comment: You are describing a long right leg with more pronation or internal rotation on that side. When you stand is your right knee in and right foot out as mentioned above, or is it only in walking. You can turn your right foot due to the long leg and excessive pronation that collapses the arch and drives the right knee in with it in attempt to shorten that leg. 

     So, I've been to a couple chiropractors for adjustments and they said that my left leg was about 1/2" shorter and that my right hip was tilted forward, which they adjusted.  They didn't seem to really look at my legs or hips much but said that the leg length difference was because I needed regular adjustments. 
Dr. Blake's comment: The chiropractic world is to adjust out these imbalances that can start as leg length differences when you finish growing, and end up with pelvic tilts and scoliotic curves in the spine. Podiatrists, not skilled in these adjustments, tend to want to lift and support the short leg. It is an art though since there are many variables to consider and many ways patients adjust to lift therapy. 

     I felt that perhaps they didn't have much experience addressing these issues.  I think maybe I do have a structural leg length difference that has contributed to these other issues.  I tried a small heel lift on the left side but that seemed to make me feel more imbalanced on the right side.  Now I'm wondering if I should try a full length (as opposed to just heel lift) maybe 1/8" lift on the left side (in addition to the Powerstep insoles on both sides) and gradually work my way up to 1/2"?  If you think that's a good idea can you recommend a brand of full-length insole and over what period of time could I work up to 1/2"?
Dr. Blake's comment: I prefer full length lifts to balance the foot out throughout the gait from heel contact to push off. You can cut out the toes to give yourself room. You can go with simple Spenco Insoles without any arch, just flat. You can use the left as the first lever, if it feels okay in two weeks, try the right turned upside down as the second layer on the left side. The second layer you may or may not need to cut out the toe area, but keep the lift under the metatarsals or ball of the foot. For the third layer and possibly fourth layer, you will have to get another pair. You should feel better and more stable with lifts. If not, you should consider getting an AP Standing Pelvic Xray in normal stance barefoot to document the true structural leg length. 

Thank you very much!

Dr. Blake’s comment: Yes that sounds right. I tell my patients to get Spenco flat 1/8th inch insoles, you just flip the right one over to make a second left. If you are crowding the toes too much, you can stand on the insert, and mark between each toe. Cut out the area of the insert in the area of the toes. Typically you go 1/8th inch every 2 weeks.

My remaining questions after spending additional time on your blog-

Should I try switching from Powerstep to Sole insoles since those are what you recommend?  I have not tried the Sole brand before.
Dr. Blake's comment: Yes, you should try both to see what is more stable and fits you better. From my standpoint, they are both easy to adjust and customize for the patient. 

Just to make sure- would the full length lifts be placed under the Powerstep/Sole insole in the shoe?
Dr. Blake's comment: Yes, they go under the arch support. Hope this helps Rich

Thanks a million!

Here are some of my videos on short leg syndrome.