Ball of the Foot Pain: Email Advice with MRI Images

This nice patient mailed me her CD from New Zealand. She is suffering from pain under and in the big toe joint from many years. This is my report to her.

Image of Tibial Sesamoid under the first metatarsal showing irregularities within the bone. The bone does not look totally healthy, but is not fractured or fragmented.

A slightly different image of the tibial sesamoid. The fibular sesamoid looked healthier. This can simply be from favoring her foot with some demineralization of the bone.

Here a large bursae or ganglion cyst is seen under the tibial sesamoid.  Sesamoid Fractures are often diagnosed when, in fact, the source of pain is in the soft tissue swelling under the sesamoid

Another image of the soft tissue swelling with some swelling in the tibial sesamoid (very slight).

Here we are at the joint level with our slice. The irregular white areas can be also seen below in the next image. This abnormal tissue arises from the plantar (bottom) medial side of the joint (arch side). This tissue, referred to as chronic synovitis, can get trapped in the joint and constantly irritated. Again, since it is on the tibial sesamoid side, it is often misdiagnosed.

Here the irregular soft tissue appears to be coming from the side of the joint. 

Another image of the same soft tissue swelling. When it arises from a joint, it is called a ganglion cyst. This may need surgery to remove the sac of tissue and tie off the stalk where it comes off the joint. 

Great image of this soft tissue mass causing so much problems.

These sacs can be injected with cortisone, not into the joint, to see if they will reduce. If not, they are removed.

Another side image of this mass.

From this view, and others, we know the cyst is filled with fluid. The problem with cortisone is not to inject other than the cyst which is quite small. If your doc feels uneasy about injecting, he/she may recommend surgical removal as a safer approach. Cortisone placed in the wrong spot can be dangerous.

Achilles Tendon Injury: Email Advice

Hi Dr. Blake,

I wanted to ask your opinion about which direction I should next take with my treatment.

I am a junior college lacrosse player. Last february (9 months ago now) during our preseason my achilles tendon was stepped on during practice. It hurt at the time, I had my trainers look at it but it didn't seem like anything serious so I did the usual treatment options, especially ice and anti-inflammatories. As the season went on, however, the pain got worse and worse. I saw our team doctor who said it was the sheath around my achilles that was inflamed, so he had my trainers place a heel lift in my shoes. But the pain didn't subside and by the end of the season I was placed in a walking boot for 3 weeks to calm the pain down.
Dr Blake's comment: Typically achilles tendinitis is an overuse injury, so your description of being stepped on makes it harder to get a read on. Putting yourself in the Immobilization Phase was the right idea, and it should be coupled with anti-inflammatory treatments as well. 

Over the summer I continued to work out but focus more on weights and cycling/swimming as running continued to be painful (although I did continue to run some). In addition, over the summer I began to do strengthening exercises.

Dr Blake's comment: This was the right order---Immobilize, Cross Train, and strengthen. You were beginning the ReStrengthening Phase of Rehabilitation. 

 When I came back to school in August I continued the strength exercises and lots of stretching but the pain didn't improve. We had a month long fall season and by the end of the month I was back in a walking boot as it was nearly impossible to walk because of the pain. 

Dr Blake's comment: The Immobilization Phase should take you to Pain Levels 0-2. I am not sure of your pain, but it sounds worse. You should stay in this Phase for 2 weeks longer than you think you need to. The restrengthening should continue, as well as the cross training as long as all of this can be maintained in that 0-2 pain scale level. If not, you are just fooling yourself that you are progressing. 

I had an MRI recently and our team doctor said that, while we had thought it was mostly achilles tendinitis, it appeared that while I did have some achilles tendinitis it was mostly bursitis that appears to be the issue.
Dr Blake's comment: Bursitis in front or behind the achilles is a common side effect of achilles tendinitis swelling, or the bursitis was the only source of pain from the beginning. Bursae are fluid filled sacs that collect fluid in the wrong place and act as an irritant to the surrounding tissue. Bursitis elsewhere is treated with cortisone shots, but these are risky close to the achilles. I prefer electrical stimulation with contrasts, or iontophoresis, while going to PT. 

 He checked by strength and noted that my left gluteus (it is the left achilles that is the problem) was weak. My trainers switched up my strengthening program to include more gluteus exercises to improve this.

At this point my doctor also prescribed a topical anti-inflammatory saying that if that didn't work we could consider doing a  cortisone shot into the bursa, but that after the shot I would be in a boot for a month as to avoid rupturing the tendon.

My question to you is that it has been a month and the topical anti-inflammatory doesn't seem to be doing anything (it hasn't helped with the pain or decreased the amount of swelling at all) would you recommend considering the cortisone shot as the next treatment option or do you think that custom orthotics might be able to provide some assistance? Clearly I would like to avoid the cortisone shot.

Dr Blake's comment: Definitely the shot is risky, but I like the idea of a boot for 1 month afterwards. I would not like to do a shot anytime soon. Consider an 8 day Prednisone Burst to reduce the bursitis, while you are doing iontophoresis in PT (transdermal cortisone). 

http://www.drblakeshealingsole.com/2010/12/oral-cortisone-king-of-anti.html

Follow up the oral cortisone with voltaren or another NSAID with a good daily dose. Do Contrast Baths, the best way to reduce bursitis swelling, twice daily and remain in the removable boot for the next month. If you are not significantly better in one month, send me the MRI to look at because something will not make sense. Hope this helps. 

Thank you so much for you advice.

Dr Blake's comment: Tendinitis treatment follows the BRISS formula and The Good Pain vs Bad Pain formula. Memorize well. Good luck!!

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

Best,

Gretchen (name changed)

Bursitis: Email Advice

Hi Dr. Blake,

I have what seems to be a stubborn adventitious bursa under and around my fifth metatarsal that developed because my foot was very supinated. 

Dr Blake's comment: A bursae is a fluid filled sac that develops between the bone and soft tissue, deeper than a blister, in response to abnormal pressure. One can see from the video below that over supination will cause excessive pressure on the outside of the foot.



 I've been able to stretch and ease the peroneal tendons that seemed to be causing the supination.
Dr Blake's comment: As the foot supinates, or rolls to the outside, the peroneal tendons must be strong to stabilize. Focus you attention on strengthening the peroneal tendons. The video below emphasizes the peroneus longus exercise with the ankle in neutral. If you do the same exercise with the foot pointed downward, you will also get the peroneus brevis tendon. 



  The burae comes back with any type of pressure, even stretching.  
Dr Blake's comment: Once the bursae forms, even normal pressure can keep it irritated. I love deep ice massage three times daily to try to break it down, physical therapy with ultrasound and deep friction massage if self treatment is not successful, and injections or surgery if those are unsuccessful. You must off weight the area on a daily basis. You need a dancer's pad not for the first metatarsal, but for the fifth metatarsal. See my video from yesterday on using 1/8th inch adhesive felt from www.mooremedical.com to create an off weighting system in all your shoes (great if you can attach this to your orthotic device). 





I'm wondering if cold laser therapy or some other treatment might help.  The bursa doesn't respond to cortisone, and it won't let me bicycle, even with orthotics.  Because it's on the bottom of my foot and is connected to other tissue, surgery probably wouldn't be a good idea.  Thanks in advance for your advice,

Regards,

Dr Blake's comment: I like the old beating up of these bursae, and I have no experience with cold laser. I like, and have good results with cortisone shots when the icing and PT not help. The surgery is rare, so I would not go there right now. Get an MRI if it is stubborn to make sure you are really dealing with a bursae and not another cause of a soft tissue mass. Good luck!!

Ganglion Cyst/Bursitis Medial Ankle Area with MRI Image Presentation

This video shows a fluid filled ganglion cyst or bursitis on the inside part of the lower ankle area. The MRI views clearly show that the mass the patient presented with was indeed fluid filled and not a dangerous tumor. The patient is using ice massage techniques three times daily to reduce the swelling, and I will consider injection with drainage if it does not respond. Unfortunately, some of these cysts need to be surgically removed. 

Heel Pain and Physical Therapy Modialities

The following video briefly goes over some physical therapy modalities commonly used in the treatment of heel pain, such as plantar fasciitis and plantar heel bursitis.





Ultrasound is commonly used as a source of deep heat.

Ultrasound is typically used for 5 minutes.

Ultrasound must be kept moving to prevent burns.

Interferential is used to reduce pain, swelling, and muscle spasm.

Interferential must be diagonally crossed.

Interferential is typically used for 15 minutes.

Deep tissue work is used to breakdown scar adhesions. A skilled manual therapist can even break down a bursae, but it is very tricky to not inflame the bursitis further.

Heel Bursitis (Plantar/Bottom of Heel): Typical Physical Therapy Regimen

9/6/10
Hi Dr. Blake!
I hope you have a fun-filled long weekend planned!.
I'm checking in at the two week mark as we discussed. My stubborn little
calcaneous bursitis is still causing me grief. I did try the contrast bath -
but it seemed to irritate it, so I've stuck with icing. I have not been jumping
in dance class or standing in spin. In fact, releve seems to bug it as well, so
I've eliminated turning. Since I wasn't making the progress I'd hope to on my
own, I thought I'd finally book the PT. I work in SF, so I would
consider coming over to St. Francis, but if you know of another good place in
the East Bay, it might be more convenient.
Thanks so much! It really is wonderful having someone I've known for 24 years
(!!) I can come to with these bothers. And even though it's an injury that
brings me in to see you, it is always great to see you! ;-)
Have a fabulous weekend and talk soon,

Tracy

Tracy, Physical Therapy for calcaneal bursitis (under the heel) should be done twice weekly for 4 weeks and should include in this order: Ultrasound as a way of producing deep heat to the bursitis tissue making it vulnerable to the next two treatments. The ultrasound is following by deep friction massage to break down the bursae. The deep tissue work is following by 5 minutes of vigorous ice massage to calm down any aggravation of the inflammation and further the breakdown process. Since plantar fasciitis is normally part of the problem, the PT may address part of the treatment for that also. If calcaneal bursitis is a major part of the pain, make sure that the 3 components in the order of ultrasound, deep friction massage, and icing are the central part of the treatment. I will see you following the first 4 visits to make sure we are all on the same page. Good luck, and great to see you again as always. Rich

PS. During the time you are in physical therapy, you must continue to ice massage 3 times a day (since the contrast bathing did not help), and do as much physical activity as you can without flaring up the symptoms. It is normally a mistake to go to physical therapy at the same time you are resting an injury completely. The physical therapist never gets a good feel of your improvement, or lack of improvement. Use the information on the post Good Pain vs Bad Pain to base your Activity Modification Program.
http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

Also, the next step with calcaneal bursitis is cortisone shots, but that requires 2 weeks off activity/shot, and could require up to 3 shots (the response to the shot is evaluated in 2 weeks), so most athletes try to avoid with a passion. Please see the separate post on the thought process behind cortisone shots.
http://www.drblakeshealingsole.com/2010/05/cortisone-shots-thought-process-behind.html

Good luck Tracy, email me after 4 physical therapy visits.