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Sunday, February 28, 2021

Heel Pain Overload Syndrome Review

The following comment was placed on my You Tube video today on examination of heel pain.

Dear Dr. Blake:
I was diagnosed with heel pain overload syndrome by an orthopedic surgeon. How do you treat that condition? pain is more on the outside bottom of the foot, and same area at the heel.

Dr. Blake's comment: Thank you for your comment. This is a new diagnosis label I have been seeing lately. The diagnosis implies the heel itself is overloaded or overwhelmed by the stress asked of it and soft tissue injury occurs. The attached link here reviews this problem.

In my video above, I point out the areas of pain other than plantar fasciitis (the most common cause of heel pain). Heel Pain Overload Syndrome is a syndrome since the same overload can cause multiple injuries: heel bursitis (both superficial and deep), deep heel bone bruising (MRI diagnosis), plantar nerve entrapment (Baxter's neuropathy), and heel stress fractures (again usually only seen on bone scans and MRIs).

The following photos should give you an impression of the treatments. On my blog, type heel pain in the search engine and start reviewing other links. I hope this helps. Rich

The patient has to decide with immersion in ice water for 10 minutes or a 5 minute frozen sports bottle ice massage feel better.

With heel overload syndrome, there is a role both for heel pads for straight cushion, arch supports to transfer the weight off the heel and into the arch, and entirely soft based orthotics which do both. The above are unfinished Hannaford soft orthotic devices runners wear.

Here I have added a soft rim to an orthotic to take pressure off the bottom surface

Why do you develop this? What is the Root cause? That should be investigated so this does not happen again! Is it a poor fat pad, high arches with a prominent heel, over striding with running and slamming the heels down too hard, poor padding in the shoe choice, etc, etc.

I love support the foot tape, at least one application to rule out plantar fascia symptoms. Buy at

This emphasizes that it is the transference of weight into the arch that typically is more important than heel cushions. But it is good to try both.

We can not forget the nerves that can get locally irritated, or the irritation is in the back or another part of the spine and the symptoms just present at the heel. Of course, combinations of the two exist called "Double Crush Syndrome". Yes, another syndrome.

An MRI image of the side of the heel showing intense inflammation of the bottom one third of the heel (all white and it should be dark). This was ruled a stress fracture and needed 3 months in a walking boot.
In this walking boot, since there was still heel pain in the boot, I applied 1/2 inch adhesive felt to float the heel 80% which really helped.

Here I have customized a pair of Sole OTC inserts by adding as much arch as the patient can tolerate.

And softening the heel with first grinding out the hardness of the red material, and then adding a 1/8 inch heel cushion.

Gout-like Pain Post Vaccine Shots: Common Symptom for a Podiatrist to Hear About

Hi Dr. Blake,

It has been over 2 years since we have been in touch and I am happy to report that I have recovered well from my accident. I am very active again, including long bike rides and even jogging 3 miles once a week. However, I have new and debilitating pain in my right big toe that I think must be related to the Shingrix vaccine.

I had the second dose of the Shingrix vaccine 9 days ago. When I stepped out of bed the next morning I noticed I felt like I had stepped on something. When I reached down there was nothing there but a swelling under my right big toe. At first this wasn't really painful unless I stood on it, at which point it became a bit of a pressure point. I have been resting, icing, and taking ibuprofen but over the past week it has gotten worse, much worse now so that I cannot sleep. It still is not painful to move the joint, but there is a sometimes constant pain and a sharp burning pain when I touch the skin or put pressure on my toe. It seems like pain has radiated from the original spot (most distal toe joint) out towards the distal end of my toe. There is some swelling but not a lot to see. With all my past injuries, I need to stay active or things deteriorate fast, but right now I can't do much.

I had not exercised the 2 days before my shot and onset of symptoms, and also with the unusual symptoms, I am sure this is not a typical trauma or repetitive stress injury like I have had in the past. Due to the sudden onset after the vaccine, I think whatever is going on is due to the vaccine. I looked online and found that the Mayo Clinic website (link below) says contact your doctor immediately if you have "Ankle, knee, or great toe joint pain" after this vaccine. I have had a video call and a phone call with my doctor and now have a video appointment with a podiatrist, but so far nobody has been able to say anything about why this may be a vaccine side effect or what it means. Unfortunately I had to switch to Kaiser this year for financial reasons so my podiatrist appointment is not with you.

Have you ever heard of anything like this? Any experience with this type of reaction to Shingrix or what the implications are of such a reaction? I am at a loss. I realize you cannot diagnose my toe without a visit but I am wondering whether you have any experience with or knowledge of similar issues, because I am not finding any useful information that may explain what I am experiencing.

Kind Regards,

Dr. Blake's Comment: Sorry this happened to you. I am seeing alot of this post Covid 19 Vaccine. I am treating it like a gout attack, which it may be. Gout attacks are brought on by changes in the metabolism something that can occur dramatically with vaccine shots. If you were in my office, I would take an x-ray but that will be inconclusive (however an important baseline). I would have you super hydrate next week (at least 4 eight ounce glasses of water minimum), 3 advil 4 times a day for next 5 days, and the important ice soak 10 minutes (cold water with ice cubes) three times a day. I would fit you for a removable boot and apply a dancer's pad to float the big toe joint just so you can get around. If it was not feeling a ton better in a week, I would order both uric acid levels and an MRi (as you could have a stress fracture say in the sesamoids under the big toe joint or just some arthritis popping up). I sure hope this helps. Everyone (about 5 patients so far) that have got this post Covid shot immediately got better with this approach. Rich 

Pain in the Back of the Heel: Could the Pain be from this big spur when the Pain is only 10 days old?

This patient presented to me several weeks ago with pain in the back of her heel for 10 days. No prior history of pain and could not remember what started it. She was really limping as she did not want to put her heel down. There was no swelling (which is a sign of an inflammatory response) and the patient did not feel it the patient was nerve related (no numbness, tingling, electrical, buzzing, burning, radiating). I placed her on some achilles stretches and heel lifts. As she did not improve, I took these xrays showing the heel spur posteriorly (back of the heel area). This spur has been there forever, so really did not explain the sudden pain. An MRI taken a few days ago shows marked internal swelling in the soft tissue, spur, and achilles tendon, but not in the heel bone deep to it. I will rest the heel in a removable cast this month and send her to PT for both calf mobilization and heel anti-inflammatory measures. Wish her luck! Of course, in situations like these, you are not sure if she will calm this right down, or the spur will need to be removed. Or, if it is really the achilles tendon that is failing, and won't respond. Surgery is spur removal and achilles clean up to make sure it is healthy. 

Saturday, February 27, 2021

Assessing Correction with the Inverted Orthotic Technique

This is the right foot of a patient with posterior tibial tendon dysfunction. She is trying to avoid surgery as her foot has begun the damaging process of collapse. As the arch collapses, the heel everts to the ground, and the foot gets more and more dysfunctional ("apropulsive" in the Podiatry world). Even though this foot would look better in the shoe, from the walls of the shoe holding the foot some, this is the image of a pronating right foot through the orthotic device. The right foot is still everting at the heel and sliding laterally at the heel on the orthotic device, collapsing the arch, and abducting the fore foot on the rear foot as the front of the foot moves laterally. 

In this particular patient, the RCSP was 11 degrees everted to start on the collapsing right foot, and 4 degrees everted on the left. The patient was given a 35 degree Inverted Orthotic right (7 degree change with that orthotic technique), but only responded by inverting 4 degrees. Therefore the photo above shows a 35 degree inverted orthotic device that does not have enough power now to invert the heel enough, so the pronation still wins. Therefore the patient's right heel went from 11 everted to 7 everted (a 4 degree positive change) instead of the 7 degree change I desired. Failure? No!! The mold that made this orthotic device is back in the lab for 4 major changes: 3 mm Kirby medial heel skive, slight increase in the proximal medial arch, change in plastic from 5/32 inch to 3/16 inch (this one I should have done initially), and a full length 3 mm or 1/8 inch extrinsic varus wedge. From each of these variables, I should get 1-2 degrees more extrinsic supination moment to help center that heel at vertical (the whole 11 degrees). I think it is easy to at least see by this photo how the medial Kirby will narrow the medial heel area and let the orthotic device grab the foot better. 

Tuesday, February 23, 2021

The Effect on the Knee and Hip with the Inverted Orthotic Device

This is one of the closest articles to date on the positive effect of the Inverted Orthotic Technique on knee and hip problems. When I lectured at the University of Virginia, 2007, this is the results they got, although I never saw their study published. Rich

Monday, February 22, 2021

Sesamoid Fracture Article Review

Most of these fractures (90%) do well without surgery
Average to complete return to sports 5 and 1/2 months
10% require surgery by this study

Average healing for me is the center of a bell shaped curve. Only 1 in a thousand are not healed in one year. 

For sesamoid injuries, the 1 and 1/2 month is -4 on the graph, 2 months is -3, 3 months is -2, 4 months is -1, 5 and 1/2 months is average, 7 months represents +1, 8 months +2, 9 months +3, and 9 and 1/2 months +4. If you give or take 3 months for delayed diagnosis and inadequate treatment then 12 months is pretty normal for my slow healers. This study matches up with my understanding and treatment of this injury. Good treatment for one year, with little change on repeat MRIs, and continue symptoms normally need surgical treatment. If you are in this process, you know that there are many ifs, ands and buts. Rich 

Sunday, February 21, 2021

Balance: More Exercises to Up Your Overall Stability

Please scroll down on the article below until you get to the 6 balancing exercises: static and dynamic 
These will improve your lower extremity tone and coordination. These are crucial if there is any lower extremity instability: fall prevention, chronic ankle sprains, etc.

Below are several blog posts I have made regarding this topic.

Saturday, February 20, 2021

Static Stretching Helps Hamstring Flexibility: Research Proves

     The above article documents the long held belief that static stretching (holding a stretch for a certain length of time) helps with hamstring tightness. The hamstrings, calf/achilles, quadriceps, and iliopsoas are the most common muscle/tendon complexes that a podiatrist has their patients stretch. I have added a video I made on hamstring stretching. 

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Below are a few other posts about hamstrings:

Sunday, February 7, 2021

General Approach to See Patients

I thought I would share the general thought process I take with patients day in and day out. This 14 step approach has served me well (and of course complexed when a patient has multiple injuries and problems at the same time). Still the process of talking, evaluating, making decisions, and then seeing the patient in followup is time tried and true. Rich   

First, let’s review the general biomechanical approach for the first few visits (this can be accomplished in 1-3 visits based on the time you are allowed per patient). These are the common steps in a general biomechanical approach for the first several visits dealing with a new patient or new problem:

  1. History and Chief Complaint of the injury and the patient’s understanding why they were injured.

  2. Gait evaluation of walking (running is crucial if their activity requires running) to decide on gait patterns and if the patient’s complaint matches). And, if you are fortunate to use a computerized system it can help you here. 

  3. Physical examination of the injured part (begin to separate the 3 sources of pain: mechanical, inflammatory, and neuropathic).

  4. Physical examination of possible biomechanics involved.

  5. Is there biomechanical asymmetry

  6. Tentative working diagnosis made (your best guess).

  7. Common Differential Diagnosis: common not rare (a good possibility, not all of the distant possibilities).

  8. Occam’s Razor (simplest solution is most likely the solution)  and the Rule of 3 (3 most common causes and their treatment) for initial treatment help.

  9. What Phase of Rehabilitation is the patient in at this visit? Immobilization, Re-Strengthening, Return to Activity. 

  10. Should we do Imaging at this point?

  11. First Decision: What do I have to do to get the pain consistently between 0-2? This is the real reason that the patient has to be put into Phase 1 of Rehabilitation where PRICE rules. The 0-2 pain level realm is where injuries can heal.

  12. Second Decision: How Much Inflammation needs to be Addressed?

  13. Third Decision: Is there any neurological component that should be treated?

  14. Fourth Decision: What mechanical changes can I make in the first few visits that may help the pain relief, better biomechanics, and cause reversal? 

                               Patient #1

     History and Chief Complaint A 22 year old ballet dancer presents mid season with right big toe joint pain.

The rehearsals for Swan Lake had been very intense the last few weeks before her pain began. She feels that she just bruised it somehow and that it is really no big deal. She never had this problem before and can not remember doing anything. The pain is aching, not sharp. The pain is the dorsal joint, not medial or plantar. She would describe pain as 4-5 when performing, 3 when getting out of bed, 1-2 when walking around with a feel that she is walking on the outside of her foot a little, and 0 at rest. 

     Gait Evaluation In this case, a ballet technique examination may be necessary if the problem is recalcitrant or keeps reoccurring, as this sounds like a ballet overuse injury.  At the initial visit, the patient wore some flip flops as it was her day off, but barefoot she was a mild pronator, and she did not appear to limp. She did not bring in her ballet shoes for evaluation. Even if you do not know ballet well, the shoes can help in the wear patterns right to left both in the ballet pointe shoes and ballet slippers.  

     Physical Examination The examination reveals slight big toe swelling, no redness, no palpable pain, mild stage 2 bunion, and negative tendon and ligament stress tests. The patient had hypermobile metatarsal phalangeal joints, with over 90 degrees of big toe joint dorsiflexion, and a long first toe only on the injured side.                                                     

     Cursory Biomechanical Examination  and Asymmetry Noted Different from the normal physical examination of the injury, this looks further into the biomechanics of the patient that could have caused the injury or will slow down the rehabilitation, or just allow the problem to come back over and over again. The cursory biomechanical review included excessive ranges of motion allowing possible excessive big toe joint stress (as noted above), a pes cavus foot type with slight hallux hammertoe, forefoot valgus foot type, callus formation under the first and fifth metatarsals, first ray motion more than 10 mm but abnormally plantar flexed, a relaxed calcaneal stance position 5 everted right 3 everted left, no tight achilles tendons, pronation worse on the injured right side, great FHL strength. Therefore, marked biomechanical stresses (which will be discussed below), which could all be related in some way to our injury cause and upcoming treatment plan. 

     Tentative Working Diagnosis (your best guess) is based on your experience, historical review, and physical examination. Definitely ballet can overuse the big toe joint. My best guess would be a sprain of the big toe joint as a stress fracture would be more swollen. 

     Common Differential Diagnosis (2ndary Working Diagnosis) is not a list of the 10 possibilities in a standard differential, but the next best guess if proven that the tentative working diagnosis is wrong. For me, in the sports arena, overuse injuries are stress fractures or stress reactions until proven otherwise even though the examination does not match her pain level. 

     Occam’s Razor and Rule of 3 Occam’s Razor to me means the simplest solution is usually the solution. In this case, the simplest solution is to stop ballet until all the symptoms are fine, and then gradually wean back into ballet. Here is where the Rule of 3 helps out tremendously. Most ballet dancers would seek care elsewhere if told to stop dancing. The Rule of 3 means that we need to find 3 treatments based on our examination of possible causes that should help the patient progress. And, you can add 3 more next visit also if needed. The joint was sore and the dancer probably sprained her joint, so taping the joint to immobilize some is one good treatment. With a bunion deformity and a long hallux, the big toe joint typically gets stretched medially and pinched laterally, so the taping can try to correct that. Since the patient has a plantar flexed first metatarsal (typically causing more pressure on the first metatarsal), a dancer’s pad (aka Reverse Morton’s Extension) can help. And #3, using a Hapad adhesive felt arch support in all her ballet shoes, and her day to day shoes can both off weight the sore area and prevent the excessive pronation she presents with. Therefore the Rule of 3 helped us start treating based on her specific biomechanics. 

     What Phase of Rehabilitation? This patient is typically like so many patients really between phases. She needs some activity modification (in an attempt to get her pain more consistently 0-2). She also needs to ice, and will get some daily PT for anti-inflammation since she is in a ballet group. These are Phase 1 treatments, but she will continue to dance as we experiment with padding, taping, etc, so I would put her in the Return to Activity Phase 3. She is hurt, but she can dance completely, therefore she is definitely Phase 3. Phase 1 you are completely restricting her activity, and Phase 2 she can not dance professionally but you are working her through her sports routines. If she worsens as we attempt to get a handle on the injury, we may have to put her into Phase 1 or 2. Sometimes this is a big rehab failure, when the patient is not put into the right phase of restriction when they present with worsening symptoms. The patient should improve each visit, or changes are needed. 

     Should We Image? This is presenting as a minor soft tissue injury, so imaging will be delayed. 

     First Decision: How to Reduce Pain 0-2 This is for everything. The pain 4-5 when performing is too high. We have to reduce her rehearsals, and experiment with the above treatments to see if the pain can be reduced (our local dance medicine expert Joey Levinson had her get wider shoes just after her visit that helped). I prefer not to use NSAIDs at all as it masks pain and slows down bone healing (which we presently do not know if she has). Therefore my standard anti-inflammatory cocktail is icing twice daily, and contrast bathing each evening. 

     Second Decision: Inflammation Concerns This blends into the first decision as working on any inflammation (swelling, sudden stiffness, redness) found is crucial at helping these patients. If inflammation is found, and there was only a slight amount of swelling in this case, it needs to be addressed. My icing twice daily (especially just after she aggravates it) is important. 

     Third Decision: Any Nerve Component? This appears hard for patients and doctors to assess. Nerve pain can be numbness, radiating, electric, buzzing, vibrating, sharp, and just a hyper-sensitivity. Chronic pain (pain over 3 months) can lead to nerve hyper-sensitivity or tissue neural tension. The pain from nerves alone rarely swell, and it is characterized as pain out of proportion to the physical findings. In this case, no nerve pain was discovered or considered.  

     Fourth Decision: Initial Mechanical Changes This is now I end my initial visit with the patient--with 3 or 4 easy but effective mechanical treatments. Many times they are in a prescription to purchase. Sometimes, I am able to dispense something I have in my laboratory, or show them some tape technique (I pretty much love to tape all of my patients if I can find something to help them). Some of these treatments will be temporary until a more permanent fix can be found or made. Some of these day one treatments are forever (like toe separators for bunion improvement). In this case, the initial mechanical treatments were spica taping with an effort to straighten the bunion deformity, dancer’s padding instructions for her to attempt (luckily she had a PT who worked half days at the ballet), and medium Hapad longitudinal medial arch pads for pronation control and off weighting. 

     For this individual patient, the initial treatment was completely successful. It did take about 4 weeks with reduced dancing (50%) to really get her symptoms in control. For this injury, I did see her one other time for ballet slipper and pointe shoe application of arch supports (Hapad adhesive felt) and dancer’s pads. She was advised to wear medium gel toe separators long term for her bunions. Due to the pronation right greater than left, I had wanted her to get orthotic devices for her daily shoes (athletic and fashion casual) but I am not sure if that ever happened. That was for long term prevention.