Very Tight Tendons: Consider Heat Ice Prolonged Stretching

This patient has a very tight achilles tendon. The prolonged heat ice routine is based on a study done at Temple University years ago. The goal is to 3 times per week hold a stretch throughout a 30 or even 45 minute period. Heat is utilized here in the form of a heat pack for 30 minutes and this is followed by an ice pack for the last 15 minutes. Therefore, it is a 2:1 ratio of heat to ice, so 20 minutes of heat followed by 10 minutes of ice, or 15 minutes of heat and 7.5 minutes of ice. You can see it is a two man job! I get great results within a few weeks (probably near the 10th time landmark). The days the patient is not doing this they still need to stretch 3 times normally. 

Nerve Pain: Where Does It Come From?

     This image is of a T1 MRI section across the front of the right foot. Above my sensor marker, there is an obvious Morton's Neuroma that may be the complete cause of this patient's pain. Remember, we need to always ascertain if the pain is mechanical, inflammatory, neuropathic (like Morton's Neuroma), or a combination of these 3 factors. 

     In this foot, the section shows a typical low lying 4th metatarsal head with a very thin fat pad. This allows these plantar nerves on the bottom of the feet to get beat up too easily. The Morton's Neuroma can develop from this constant abuse over years. Why they begin to become symptomatic, when they are fairly large, is anyone's guess? 

     The onset of MRI technology now 35 years ago did teach us an incredible thing: Not all Morton's Neuromas hurt as they were found in patients where they never had nerve symptoms. Therefore, it is important, even in the face of an obvious MRI documented symptomatic Morton's Neuroma, that we make sure that the pain is completely driven by this enlarged nerve.

     The 3 sources of pain: mechanical, inflammatory, and neuropathic, also come the 3 avenues you can treatment patients symptoms: mechanically, anti-inflammatory, and nerve desensitization. So, we begin treatment with mechanical off-weight bearing pads, icing and contrast bathing, and neural flossing or acupuncture, etc. And, we follow these simple treatments with others based on the patient response and subjective feeling on what is helping. 

     Morton's Neuromas, as well as other nerve conditions like Tarsal Tunnel, have the added caveat that the majority of symptoms do not originate in the foot. This implies, and is very true, that treatment alone of foot nerve pain at the foot may not be successful. You typically should include in any Morton's Neuroma workup and treatment getting consults on the low back and spine in general. Think about the concept of Double Crush, where the nerve is only painful when irritated at least in two places, with no symptoms if you remove one of the two areas of irritation. 

     

Podiatric Question #1

Practical Biomechanics Question #1: What position is the ankle in when it is the most relaxed, or the least stressed?

The ankle is the most relaxed at a 20-30 degrees plantarflexed pointed position and in Subtalar Neutral (neither pronated or supinated).

Plantar Fascia Healing of Partial Tear: 3 MRIs (6 months apart)

Sept 2020 Medial Slip Plantar Fascia Partially Torn

April 2021 Some Darkening (Consolidation Beginning) of Plantar Fascia But Tear Remains

December 2021 Good Consolidation Noted

Big Toe Pain: Email Advice

Hi Dr. Blake,

     I found your blog after dealing with chronic toe pain for the past 4 years. It started in 2017 when I was trying to stay healthy and did a bunch of yoga. I ended up doing a lot of hand stands and every time I would end I would plant my right great toe to the ground. Didn't start bothering me until I did some minimalist incline hiking. 

     Limped for a few weeks and had some serious pain below my great toe, gradual felt better, never 100%. I wound up on a beach a month or so later and have never been the same. I walked a little and then all of a sudden couldn't plant with my great toe due to the pain. limped for weeks and finally saw a specialist. 

     I was initially diagnosed with hallux rigidus, seemed kinda crazy. Luckily I found hokas and was able to walk normal and have been in them ever since. Saw multiple other doctors and had an MRI a year later. 

     I had a sesamoidectomy after the surgeon thought there was an unhealed fx that may have been causing the issue. The certainly didn't help. Have seen multiple surgeons since and just had a 3rd MRI, this time it showed a possible partial tear through the plantar plate. 

     I initially thought this was the injury but was told it wasn't because there was no instability and the MRI read didn't mention one. But now since it did, I have a feeling that was the issue all along. 

     Anyways I am reaching out for advice. Would a partial plantar plate tear heal after 4 years? Dr. Blake's comment: Probably not, but when you had the sesamoidectomy didn't they see a tear, or make any comment? Odd. You probably have to at least send me the MRI reports: all 3 to look at. 

What options are out there for me? Dr Blake's comment: The treatments are many to control pain and allow activity including: Hokas, spica taping, off weight bearing orthotics, avoiding activities that cause pain over 2, etc. However, the diagnosis is what is crucial and 3 MRIs should be fairly conclusive. 

 I have been wearing hokas for the past 4 years and have not participated in any physical activities that I like or even ran since 2017. Really hoping to change that. Any recommendations or advice would be greatly appreciated. Thanks - 

Posterior Tendon Dysfunction: Email Advice

Hi Dr Blake,

I’ve been reading your blog all day, thank you for proving this invaluable resource. I’ve been doing lots of research into posterior tibial tendon dysfunction and your site is a wealth of knowledge.

So I’ve been having some PTTD type problems. I ran an 73 mile ultra in July this year and really damaged the posterior tibial tendon. So much so I haven't been able to run properly since the injury. I’ve done some downhill walk running which was ok 5km ish.  I have undergone reasonably intense physio protocol since September and I am now at the point where I am pretty much pain free day to day. I walk to work 45 minutes each way without pain, or with mild 1 or 2 pain on pain score.

Unfortunately my medial ankle started making a snapping sensation, which is worrying me. It feels like a ligament, possibly the PTT is snapping across the medial malleolus. Although it could be something to do with the deltoid ligament, this is where I notice the snapping sensation most, I am not sure of the cause.  My PT gave me stretches and strengthening exercises, but the snapping only started occurring after I started rehabbing the injury. Now I am at the point where I am not sure if the tendon is loose and that’s causing the snapping or if it’s tight and that’s causing the snapping. There’s never an audible click as much, it’s more of a sensation you/I can feel. It can only be felt when the foot is dorsiflexed and inverted from the normal position upwards and inwards in that order. I sometimes notice the snapping when walking up hill. If the foot isn’t dorsiflexed and inverted then the snapping doesn’t happen.

My PT has helped, but isn’t a specialist in foot injuries, I can’t see a podiatrist until February and I am a mountaineer keen to get out as soon as possible. I was wondering if you had any advice regarding the snapping or ways to make the snapping stop? Everything I’ve found online in relation to snapping talks about the peroneal tendon, but that’s on the outside of the foot, and isn’t the source of my problem. I can’t find anything that specifically helps my inner foot snapping issue.

Best regards,

Dr Blake's Response:

     Thank you so much for your question. This occurs to my patients all the time, so I am hopeful you can resolve this. There are alot of things that happen when the ankle collapses inward in the case of posterior tibial problems. Tendons get stretched, ligaments stretched, and inflammatory builds up in the the joints and soft tissues. Typically, if you are non weight bearing, and you move your ankles around in all directions, if a tendon or ligament was loose, you should be able to duplicate the snapping sound, and see something dramatic happen. In your case, it sounds like it is only with weight bearing, where the snapping is due to fluid trapped in joints and ligaments. The snapping sound is the fluid escaping as you move much like the snapping of finger joints. I would attack this hard with anti-inflammation, even if you can not see the inflammation. Icing twice daily, contrast bathing each night, 3 advils three times a day, etc. Then get back to me in one month and remind me of this blog post (attach the link). Rich