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Monday, November 29, 2021

Treating Nerve Pain at the Foot: Algorithm



     I treat many patients with nerve pain, some as the primary injury like Morton's Neuroma, and some as secondary nerve hypersensitivity develops following an injury. This algorithm can help the patient with nerve pain review their treatment and discuss other options here with their doctor. 

Sunday, November 28, 2021

Plantar Fasciitis: Treatment Algorithm

     The treatments are typically non-painful stretching as outlined in this video. 


Weight transfer concerned getting the weight into the arch with an orthotic device. This is successful when most of the pain is in the heel or ball of the foot areas. 


Podiatrists always love to recommend the Rolling Ice Massage technique 5 minutes twice a day to get the inflammation under control. 




Tuesday, November 23, 2021

The 1 Day and 2 Day Pain Level Increase Rules of Rehabilitation

     When I am rehabilitating a patient, we always talk about good and bad pain. It is so important for the patient to know the difference. And, it is very important for me to know where their pain is in my rehabilitative process. 


     When you are rehabilitating a sore area, and you are progressing the patient through the 3 Phases of Rehabilitation, increased stress to the area is applied routinely every other day in activity progressions. This is typically Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. You have kept the pain between 0-2 successfully, but this increased stress (important for healing and return to activities) will elevate the pain for a period of time following. The goal during rehabilitation to keep the increased tissue soreness within 2 days or the 2 Day Pain Level Increase Rule. Therefore, if I am starting a more strenuous activity, like progressing to the Walk Run Program, or allowing small jumps in ballet, the increased pain needs to be contained within 2 days and not linger more. If you exercise on Monday, by Wednesday's start you should be back to square one even if Tuesday showed increased pain. 
     The One Day Pain Level Increase Rule is for the maintenance program. You are back at your normal level. You are exercising at a good level 3-4 times per week. Any increased pain after an activity is normal as long it is not during activity, not increasing in severity week to week, and contained with one day. 
   It takes alot of understanding to excellently rehab a patient, or yourself, of these 2 rules to avoid serious setbacks. Good luck 

Saturday, November 6, 2021

Big Toe Area Pain: Years after Healing Sesamoid Injury

Hi Richard,

I wanted to write to you because of pain in my big toe that has been bothering me for the past few weeks (about 5 weeks). Unfortunately, this pain is fickle and elusive, and very hard to describe.

My history:
- turf toe and sesamoid AVN in 2019-2020, which I recovered from thanks to your wonderful blog
- I was walking perfectly fine for a ~6 months
- played tennis one day and had pain the next day in my big toe, but a different one than I'd had before - it hasn't gone away unfortunately

The pain:
The pain is sometimes very sharp when I put weight on my foot right after getting up, but then immediately subsides. At first it felt like "pins and needles", but now it hurts more "traditionally". I can't tell where exactly my toe is hurting, but it definitely hurts when I press in the webbing between the first and second toe. My joint clicks a bit (though when it does, it is painless), and to be honest I can't remember whether it did that before feeling the pain or not. Moving my big toe doesn't hurt, I have full range of motion, my sesamoids seem fine. It occasionally hurts when I compress my first phalanx with my hand, I think it's called the "proximal phalanx of the big toe". Overall the pain tends to be better in the morning, and worse after a whole day of walking.

Please let me know if you have any leads, because I admit I'm quite perplexed by my current condition!

May God preserve you and your family in this difficult time. 

With all my consideration


Dr Blake’s Comment: Thanks for your email and glad the sesamoid AVN finally healed and you were back to good activity. Some of the symptoms are definitely nerve, like the pins and needles and pain that comes on and disappears quickly. In your case, it could have just be the body trying to tell you that something is amiss that needs protection. Your original injury was to the big toe joint. Previous joint injuries tend to pop up from time to time. Like you are doing now, you have to take them seriously, but they represent that the joint is not perfect. Imperfect joints (for me they are the left ankle, right knee, low back, and right shoulder) from old injuries are generally alittle stiffer (so they can get jerked easier) and the body’s reaction is quicker (from nerve memory). 

     So, what does this all mean? Typically, we are not dealing with anything serious if the range of motion is normal and there is no swelling, black and blue, or redness. Also, it is a great sign that there are times of the day that it does not hurt at all. These aggravations of old injury areas need to be treated seriously since this joint is a weak spot for you. The 3 areas to address are mechanics, probably spica taping or bunion toe separators to start, inflammation (so icing and contrast bathing once or twice daily), and nerve hyper-sensitivity (neural flossing with non painful joint motions, and non painful massage for 2 minutes twice daily. This should be done for 2 weeks, and then based on the response, either lessen your treatments or increase them in some way. 

     I hope this makes sense. Rich 

Resolved Calcaneal Stress Fracture: Email Advice

Hi Dr. Blake,

Good news - my foot is back in action!  I’ve put it to the test over the summer and all systems are a go.  I’ve been running 100%, gone backpacking, and hiked dozens of miles (including a 17 mile day) without pain!  Thanks for all of your help getting me back in action!

I don’t see a need to meet up again, but am curious about how I should proceed over the long term.  My recovery program was focused on 1) protecting my damaged heel (now recovered), and 2) supporting my high (collapsing?) arches - presumably until they can hold their own.  I’ve got orthotics in all of my athletic shoes, am using cushy HOKA’s or Oofos 90% of the time (in everyday life), and am doing 15 minutes of stretches after all of my runs.  Since I’ve been babying my heel and arches for 2+ years, I’m wondering if I should be conditioning them over time to "toughen them up" and/or get them more used to “unassisted”  or “less-assisted” walking/running.  Questions:

  • At what point (if any) should I stop wearing orthotics?  I’ve been rotating shoes and orthotics, sometimes going without (eg. Just walking around) with the thinking that they shouldn’t get too comfortable with one set system.  My hope is that at some point my high arches will be able to “hold their own” without the aid of my heavily-built up supports, but I don’t want to rush it.  Just wondering if I should be taking some sort of gradual approach to ween them off of the super-duper high arch supports that I’m currently using.  

  • Are HOKA’s a good choice from here on out?  I have several pairs of different levels of cushiness that I use for all athletic activities.  Is there value in moving back to (or rotating in) non-rocker footwear or shoes that aren’t so cushy?  

Many thanks!

Dr Blake’s Response: Thanks for your feedback and great questions. I reviewed your chart today before answering so everything was clear. You developed a heel stress fracture from pounding at heel strike while running. The goal of each of your mechanical treatments are: cushy shoes for impact shock attenuation, arch supports for weight transfer into the arch and off the heel, and rocker bottom to decrease the pull of plantar fascia that push off on the heel bone. 
     So, theoretically you could now just go “cold turkey” back into traditional shoes with no rocker and no orthotic devices. I love to gradually change stresses since you are doing so well. You may find that you love either the orthotic devices or rocker bottom cushy shoes so running forever, or the orthotic devices while you have the added weight in backpacking. So, as you gradually change the mechanics, each level should be evaluated for any symptoms. 
     If would emphasize, especially for the reader, that orthotic wearers should do single leg balancing for 2 minutes each evening and metatarsal doming once a day (10 repetitions). You can use the search box on this blog to find these videos. This keeps the feet very strong if any weakness is occurring with the orthoses. 
     So, for now I would start and do half of your runs in Hokas and half in traditional shoes. Listen for any symptoms. You could very easily keep this pattern for years to expertly vary stresses. Initially, start with longer runs with Hokas and shorter runs with traditional shoes, but over the next month you will not have to be particular about the distance any more. 
If there are no increase in symptoms, in 2 months start not wearing your orthotic devices on short runs only, and short walks. I would stay this way until 4 months from now (therefore all the highest stress activities have the extra protection of the orthotic devices). If all is going well, the next 2 month interval you could either go without Hokas completely, or without orthotics in all activities but running. In two more months, you could then go with no orthotic devices at all. 
     So, this outlines a gradual 8 month progression into both traditional shoes and away from orthotic devices if that is your goal. If you have some symptoms as you change, we would have to address that if it comes up. Right now you are doing so well with all this protection, but like a cast, we eventually have to cut it off! 
I sure hope this makes sense. Rich