Foot Pain without An End in Sight: Email Advice

Dear Dr Blake,

It has been over a year since I contacted you last, and what a long journey I have been on.

First I want to express my profound gratitude AGAIN for your Blog, and all you do to serve us. Thank YOU!!!!!!!!

I am so very grateful for your Blog, I honestly think it's the only thing that has kept me going at various times over this last year.

Dr Blake's comment: Thank you. I am so glad it has helped. We are all in this together in many ways. 

I had to stop working over a year ago, I received SDI for a year ($1100 a month, yikes), and now I have no income. I have wanted to see you and called your office to find out the cost, but the cost out of pocket is so high, it just has not been possible for me. Do you ever work with people on a sliding scale? I would really appreciate your feedback about what someone in "my shoes' (grin, gotta keep a sense of humor!) options are around receiving your guidance. And if you don't offer any sliding scale options - do you think you can make a difference in my treatment plan that would make it worth the cost for me, period - to see you? Or not really at this point?

Dr Blake's comment: All my self pay fees are extremely low, but I work in a hospital which has facility fees. For the initial visit, between me and the hospital you are looking at $250. You should call Mr Jim Houser, CEO of Saint Francis Memorial Hospital. Ask him if you can apply for pro bono or sliding scale, and I would honor that, for a one time consultation. 

Please let me know your thoughts. In the meantime I would be so very VERY grateful for any guidance you might offer about how best to proceed and receive support from a podiatrist, etc in my process now. This is a lot of info I know, I have poured my heart and soul into this email. 

On Monday I am seeing Dr Eric Fuller who is familiar with you and your work. I have seen him twice over the last 5 months. I get to see him at no cost at my clinic because I have medi-cal now. I live in Berkeley. I don't know when you will be able to respond to this email, and I thought I would send it off now and simply look forward to your response :) :) :)

I have gone through such a journey with this injury, I want to give you the brief summary of the main points so you can hopefully provide feedback :)

Some important facts:

****Important to note - I worked 2 times a week on my feet for many hours taking care of a disabled woman for a few days after I injured myself on March 2012, until I could no longer bear weight, walk or drive at all June 5, 2013.

****Also important to note, I was an extreme vegan for 13 years, and a year after I injured myself I got blood tests and found out I was EXTREMELY low in vitamin D (a level 6) and I began taking vitamin D and slowly reintroduced meat into my diet, which I eat on a daily basis now. My vitamin D is now 75 - from my diet alone (I stopped taking the vitamin D oil supplement).

Dr Blake's comment: With the normal being 32-87, it is good you are back in normal ranges, but your bones will need a lot of time to regain your strength. You definitely need a bone density test so that we can get a feel of where you stand now. 

****I am a generally very health woman - 43 years old. I have always prioritized my health. Now of course I am very atrophied from almost 3 years of being so limited in regard to my mobility from this injury.

The events:

March 2012 - I whacked my right foot on the bathtub while showering, and hurt my toe next to the pinky toe. It was a sideways impact.

3 weeks later - I whacked the same toe on my metal bed frame. After that I got x-rays - they determined it to be a sprain. No sign of any break. Podiatrist showed me how to buddy tape.

July 9, 2012 - the toe still did not look right and hurt more than it seemed it should, I went and got more x-rays, and the tip bone had become dis-located, which it was not when I received the previous x-rays. The podiatrist manually put the bone back into place and made me a little splint to wear.

Dr Blake's comment: So, you probably originally did not break, but sprained the joint 3rd degree. 3rd degree is a complete tear and should not be walked on. It is rare in this location, so easily missed. If you walk on a 3rd degree sprain of the toe, the bone could dislocate, which I guess it did. Splinting and taping is too weak a treatment for the toe to properly heal. Removable boots, post op shoes, can be made with accommodations to off weight the area enough to allow healing. 

The pain continued in the tip joint of that toe, and then the joint at the base of the toe at the head of the metatarsal bone began hurting. More and more.

Dr Blake's comment: I am sure you continued to sprain the joint walking on it daily. Many patients need this surgically fixed. 

January 2013 - I got an MRI - the report said nothing distinctive.

The pain continued. This whole time it hurt to bear weight, and it also hurt when I was off my feet.

Dr Blake's comment: The sprain is too far from the injury so some healing, even incomplete healing, can mess up what the MRI says. Also, MRIs on such a little area is close to impossible to read correctly. Too small, too close to the skin for artifact. Physical examination of the injured area seems better. Chronic pain, even if mechanical and inflammatory at first, can cause neuropathic pain to set in. 

May 2013 - I began doing stationary biking to get blood flow in my feet, and the pain had gotten better enough to do this. However, I did a little walk barefoot at the gym and went up on my toes barefoot as I walked, which did not hurt at all at the time, but later that night I was in a LOT of pain and that walk on my toes was the only thing I had done differently.

June 5, 2013 - I put my foot on the floor to get out of bed and experienced sharp pain. That was the end of my walking. Got more x-rays immediately - they showed nothing. 

About a week later - a Podiatrist gave me a cortisone shot -  1cc total of 0.5cc of 0.5% Marcaine plain and 0.5cc of kenalog 40.

June 24, 2013 - got another MRI (non-contrast) later in June - this time the report said: The insertions of the second, third and fourth plantar plates appear degenerated with minor splitting and frayed appearance. I am including a copy of that report. - considering that I wonder if the cortisone shot was a terrible decision?

Dr Blake's comment: Hopefully not. Did it help with your pain? Where was it injected? Why Kenalog 40 for feet? Most patients over 40 have some plantar plate irregularities, typically no big deal, part of the aging process, and not part of your injury. Definitely know that osteopenia can cause peripheral nerve symptoms which can be painful, numb, or combination. 

July 23, 2013 - got PRP and prolozone therapy (Dr. Monagle did a combo of the 2 in the same treatment).

Dr Blake's comment: What are those treatments trying to accomplish? 

2013 - Got 2 more MRI's in 2013 - both saying little to no change.

Dr Blake's comment: Little to no change in what?? In normal??

Have seen MANY podiatrists, they disagree about what is going on. I have never had a clear diagnosis.

Many docs and pods have thought I also have CRPS - I saw a neurologist and she did not think I had/have CRPS - but I still wonder...

I basically spent a year unable to walk, in a wheel chair and crutches. Bearing weight in a boot would start causing sharp bad pain. The pain was so intense I could not have a sheet on my toe, I had to sleep with my foot hanging off the bed.

Dr Blake's comment: CRPS or not, this is neuropathic pain, not inflammatory or mechanical. You have so far indicated no normal treatment for neuropathic pain----compounding creams, oral meds, local blocks without cortisone, sympathetic blocks, heat, pain free massage, biofeedback, meditation, etc. 

Now I am very slowly weight bearing again with the assistance of Correct Toes - which are the difference that makes the difference for me being able to bear weight now. The way the "Correct Toes" brace my toes is holding the injured joints in a way that allows me to bear weight, without causing further damage (or so it seems)...

Dr Blake's comment: You so need to walk to build muscle and bone strength. I am so happy you stumbled onto a way to achieve Protected Weight Bearing with a pain level between 0-2. 

My injured toe is discolored - kind of reddish - for years now since I injured it. What does that indicate?

My whole foot is still slightly red, but much less red than it was even a few months ago. Could this indicate CRPS?

Dr Blake's comment: This is the vaso motor insufficiency associated with a sympathetic nervous system in stress. It does not mean CRPS, but it could be, and it typically points to a neuropathic pain syndrome.

SO - how do I proceed now to HEAL - and not injure myself further? How can a podiatrist help me now?

What questions should I be asking Podiatrist Dr Eric Fuller?

1. It has been a year since I had the last MRI, should I push for another MRI? What kind would you recommend I get? What size slices, is non contrast ok?

Would the results of the MRI possibly cause any change to the way I am treating this injury? On medi-cal it is VERY hard to get an MRI - and if I can tell Dr. Eric Fuller that it might change our treatment plan then he might be able to make an effective case for me getting an MRI. What do you think?

Dr Blake's comment: So far, MRIs have not helped you. A CT scan to just look at the bones would be great, but a referral to a pain management doc who deals with neuropathic pain is a must. Have Dr Fuller help you with various ways to have protected weight bearing, so you can rotate the stresses during the day. 

2. Do you find that is someone has partially torn their 4th toe plantar plate, that it may take years for that joint to get stronger, and that often with time people can eventually bear weight without bracing and without pain? Or? I am trying to figure out what to expect. You said in your Plantar Plate Tear post to the pregnant woman "You will be wearing the Budin splint while you strengthen the area for 2 years. Some of my patients run marathons in these splints."What exactly is strengthening in those 2 years? The actual plantar plate tissue and/or?

You also told her "As the pain calms down, and you get into more normal shoes, if the Budin splint is not enough protection, then you need to experiment with Hapad Longitudinal Medial Arch Pads." - again, how do I know if I need to add pads in addition to the Correct Toes? Which leads me to my next question.

Dr Blake's comment: Dr Fuller can help you with this part of protected weight bearing. Getting a splint or tape to stabilize the involved joint (I am still unclear which one) is great, and off weighting the area with Hapads, etc. is crucial. It is so important to walk to build strength, even if your injured area is 5 feet off the ground with padding. You are strengthening the long flexors to the toes and the foot intrinsics. You want the muscles that pull the toe down to be much stronger than the muscles that pull the toes up. Typically you start with metatarsal doming exercises three times daily. 

3. In order to walk with less pain I can only walk with the correct toes bracing the injured joints.

Are you familiar with Correct Toes and Dr Ray McClananhan's work? If not I think you will be greatly pleased with having that tool to add to your tool box. See link :)

https://nwfootankle.com/correct-toes

I wonder if I should be adding any other bracing to the injured joint in addition to the Correct Toes, like a met pad? HOW do I discern if I should add padding to my weight bearing process - like metatarsal pads? The ONLY shoes I can wear are the Keen Whisper Lights - http://www.amazon.com/Womens-Whisper-Sandal-Black-Neutral/dp/B008J4RAUM

and I can't really add padding to their foot bed - I could tape something to the bottom of my foot...

Dr Blake's comment: I will have to look at the links later. Thank you. Have Dr Fuller help you with padding issues to create the same relief that you get with the Correct toes. 

4. Would you recommend I do Metatarsal Doming Exercises based on what I have shared with you, or do you need more info to be able to give that feedback?

Dr Blake's comment: Definitely doing met doming is crucial for plantar plate problems if that is what you have, but it can not be painful to perform. Ask Dr Fuller if that is the correct exercise for you to do based on what he thinks you have. Any exercises can irritate a sore area, and when there is probably so neuropathic pain involved, it is even trickier to do. 

5. How do I choose my rehab help, so many people have led me astray. Is there criteria you would suggest I use to help me look for someone who can really help me rehab from this injury, without causing further harm to my body?    

Dr Blake's comment: Dr Fuller is fully versed in rehab of mechanical and inflammatory pain syndromes like most podiatrists and PTs, so that should be their role. A pain management specialist should help with the neuropathic part.          

6 How can I discern if my joint has been or is being altered such that it might lead to long term challenges like what I have read about on Dr Runcos website? http://www.sdri.net/2014/09/plantar-plate-tear-why-is-it-so-confusing-to-doctors/

"...if progressive deformity occurs despite solid advised treatment it could certainly lead to permanent cartilage loss of the joint (arthritic joint). The instability of the joint causes subluxation (partial dislocation) and the repetitive mismatch of joint surfaces over time can lead to full thickness cartilage loss when high point one side meets high point on the other side. The metatarsal head can deform or the patient can develop a crossover toe deformity, starts mild and can end up severe..."

Dr Blake's comment: When I rehab patients like this, typically you can get them out of pain with splints, etc. But, if the deformity continues to worsen, surgery is recommended to fix the deformity. So, we do not wait for all the above to happen. The decision making is however slower than a snail's pace, since there is no pain, the patient waits a long time. Making a decision to have surgery, when you are in pain, is never completely rationale. Pain distorts the little objectivity we have on the situation. 

7. How do joints regenerate, and how can I support mine in regenerating? I have searched and searched for information on this topic, what I have found is confusing to say the least, there is joint immobilization, joint mobilization, etc etc. And what stage am I in, what do I need NOW? Do you have any guidance for me in this area? Anything I can read, etc?

Dr Blake's comment: I guess that is why you had the PRP and prozolone therapies. I really do not know if this is an issue for you. The CT scan made help if it shows joint displacement. But, would probably point to surgery if it did. 

8. How do we - your general Blog audience - receive the answers to the questions you posed in the information you shared from the core of your 2 lectures at the California School of Podiatric Medicine at Samuel Merritt Universitty in Oakland California October 2014?You pose this question in that post about sprains "Second Degree--ligaments partially torn (some ecchymosis) Why do 2nd degree sprains hurt more than 3rd degree sprains at times?"I REALLY want to understand why 2nd degree sprains can hurt more than 3rd degree sprains at times? I consulted with a doctor (Dr. Runco - I included a quote from his website in question #6) who completely tore his plantar plate and healed up very quickly compared to me, with far less pain. This seems like a perfect example of what you were referring to.
Dr Blake's comment: When you completely tear a structure, you get severe pain from tearing the nerves running through that structure, but then everything can calm down. When you partially tear a structure (Grade/Stage 2), the structure is very weak and the non torn part must try to function as whole. It can not, so the tissue strains and lets you know constantly that something is wrong. The torn part can scar in, which may be great, or may be very abnormal. So, between the weakness and the abnormal healing, a partial tear can be more painful in the long run than a complete tear. The complete tear does cause problems with instability, which can lead to chronic problems, so it is not better, just probably understood better by medicine. 

*******Is there ANYTHING I should be asking but have not?!!!!

I am including a picture I took of my feet right now. They used to basically look identical. You can see the redness in the injured foot and the injured toe deformity.

I am also including the MRI report from June 2013, and a pic of one slice from that MRI series.

Dr Blake's comment: The MRI slice is inconclusive. Sorry. If you want to send me your most current MRI CD I would review. Send to Dr Rich Blake 900 Hyde Street San Francisco, Ca, 94109

Please let me know if I can provide ANYTHING else that might help you, help me :)

Thank you, thank you, THANK YOU Dr. Blake!!!!!

I REALLY appreciate any feedback you can provide.

Very warmly and sincerely

Podiatry Talk: Over Pronation in the Left Foot

Dr Blake's Intro: This very dedicated podiatrist was so kind to call me about 3 patients she was going to prescribe orthotic devices for just prior to my July 4th Holiday. You can sense the passion and kindness that all of us would like to find in the doctors/therapists that help us. Don't worry if the numbers or abbrev are confusing. I will try to explain the gist of it.

Here is the back of a right foot (could not find a left in my immediate files) very pronated (EV) or everted. The ruler represents vertical or straight up and down (where you want your foot to be in general)

Here is Julio's same right foot very pronated with the goniometer we can use to measure the exact angle from vertical. Comparing the right to left can give you a great understanding of the degree of arch flattening of one foot over another.

Dear Rich,


I wanted to Thank-you for trying to reach me on Th am before your ( much deserved vacation for the 4th of July ). I know what is like on the last day at work before an upcoming holiday/ vacation/ absence planned. It seems as though "everyone and their mother" + grandmother + father+ child+ ...uncle... needs you... Pun intended : )

So many people in pain or in precarious weight bearing situations- (like the pts I described to you ) rely on your expertise and it all takes time. It was very thoughtful of you to squeeze me in as well.

Dr Blake's Note: my voicemail must have been cut off, however this form of communication should prove more useful.I listened to your VM to me & I am not sure what happened, but you broke off in mid sentence and the recording abruptly ended. I thought I might be able to reiterate what you would do with the patients I presented and you could let me know if I have down your complete answer.  Below I have included a recap since it has been awhile.

Dr Blake's Note: The podiatrist describes the complicated biomechanics of three patients all in their 70s and all with collapsed (everted or pronated) left feet. I think there are 2 common forces that produce unequal wear and tear on our musculo-skeletal system as we age: The presence of limb dominance produced by being right handed or left handed where right handed people have the left side as their support leg and break it down quicker, and the limb dominance of having a short leg. 80% of people have a short leg and it seems to me the majority have the long leg on the left. The longer leg has more compression forces as the body levels itself out at the spine throwing more weight to the left. The limb dominance seen in a long left leg in an adult is typically greater weight bearing on the left.



PT Backgrounds/Recap: The patients are 75+ yrs. in age with c/o recent balance problems. Each patient has their mid arch L ft collapsing with palpable bone plantarly. All have slightly boney dorsal prominences at 1st met heads.

Dr Blake's Note: There are 2 major reasons for balance problems (ie the patient feels unsteady on their feet. With one foot beginning to have arch collapse only on one side, the delicate symmetrical balance between the feet are thrown off and instability ensues. And pure arch collapse on one or both sides leads to great feelings of unsteadiness. From a patient's standpoint, they have a difficult time knowing where the instability is coming from. The medical world also wants to blame things like this on their age, failing to recognize it can be a simple (ha ha!!) foot problem, with a sometimes simple solution. Evaluation of foot structure, especially looking for anything assymmetical like uneven pronation, should be part of any balance program/fall prevention program.

PATIENT #1: RS
R.S.= Pt Male:175lbs, 5'10 The gentleman has more severe balance issues in that he shuffles,uses a walker and does not walk much. He has severe gout with tender tophi on his great toes IPJs. B/L: Tibial valgum and Extensor Substitution

Left: Tight plantar fascial band upon palpation with Pl Fasciitis pains in arch and more distal than heel region; slight hip drop, hits EV on heel strike
STJ: 14 Inv, 10 Ev ; RCSP: 2 Ev NCSP: 90 Foreft (FF) is 3 Pronated/Ev on Rearft (RF)

Right: STJ: 12 Inv, 4 Ev ; RCSP:1- 2Inv NCSP: 4Inv FF to RF is 90 ; slight Rt shoulder drop

Dr Blake's Note: Simply put the left arch is collapsed with the heel everting (see photo above). The left hip drop show limb dominance to the left, therefore more compression forces, further collapsing the left foot. The slight right shoulder drop is typically seen in a right handed individual.

PATIENT #2: CH
C.H.= Pt Female:156 lbs, 5'6 States that she feels a "pulling" & feels like she is "walking on rocks" in and out of shoes. Likes to walk for exercise.

slightlyskewed-shaped,very pronated Left: STJ: 16 Inv; 9 Ev ; RCSP: 5 Ev NCSP: 2 Inv FF is 11 Supinated/Inv on RF slight L shoulder & hip drop

Dr Blake's Note: She is more everted than the first patient. She has the same left sided hip drop increasing the compression forces on the left. Uniquely, she has a very tilted or supinated Forefoot to Rearfoot relationship. This is opposite of the heel angle. The more supinated or inverted the forefoot is, the more eversion or pronation force is placed on the heel. The higher this number goes, the worse the problem.
RT: STJ: 30 Inv; 4 Ev ; RCSP: 2-3 Inv NCSP: 2 Inv FF is 19 Supinated/Inv on RF
Dr Blake's Note: I find this foot very unstable. The right foot has such higher forefoot supinatus or inversion, yet can not evert the heel. See the heel still a few degrees inverted. When the numbers don't match up, the body can not do something important to life and it begins to break down. This patient has two bad feet and not a good leg to stand on. Here symptoms match this degree of instability.

PATIENT #3 JP
J.P. = 82yo. rode a bike until 75yrs. leans to L in gait female: 170 lbs, 5' genu valgum
Dr Blake's Note: Here is the third patient with the lean to the left side. Is it the chicken or the egg?
slightly skewed-shaped,very pronated Left: STJ: 23 Inv; 15 Ev ; RCSP: 5 Ev NCSP: 2 Inv FF is 4 Supinated/Inv on RF slight L shoulder & hip drop


RT: STJ: 22 Inv; 4 Ev ; RCSP: 90 NCSP: 2 Inv FF is 1 pronated/Ev on RF


Dr Blake's Note: When I was left the telephone message, there were no specifics. Now that we have the specifics, the RX can be more finetuned.
So Rich your recommendation was to use a polyprop shell, covered with pink plastizote, with leather glued as the topmost cover. The poly shell should be at: A) 5/32" if I have a grinder such that I could grind down the arch if needing more flexibility/softer tics or B) 1/8" and the following materials could be added: korex (1)Thickness?)  (Dr Blake: 1/4 inch) or grinding rubber? could be added under the arch-how far along the device? (Dr Blake: from just in front of the post to the highest part of the arch) to the  to add more stability as needed, but the point was to hold that arch up as much as can be tolerated.

Dr Blake's Note: The 3 biggest problems I see with these patients that can lead to poor correction of the foot mechanics are:

1. The pronation or arch support correction is placed equal with no real difference in correcting the more everted foot. Big Mistake!! The flatter foot should end up with the higher arch support (Newton's Law: The side that has more force to flatten the arch, should have a higher support to unflatten it).
2. When you are over 70 years old, no matter how much support you need, it is assummed you must only be able to tolerate less supportive soft supports. Big Mistake #2.
3. You are not treated like a 20 year old, where perfection is sought in all treatment areas. Good enough is too often accepted, when better may be alot better. What do you expect for your age? And when medicare does not pay for orthotics, low expictations abound. Not if this is my mom or dad or me???

You discussed a discounted intro pair and what would the intro pair be made from? Do you recommend using cork or crepe as a shell?
Dr Blake's Note: When I am prescribing orthotic devices and I am unclear of the right inital correction to give, I typically tell the patient that the first pair is my trial pair (which I may hit the mark on the first try, or may have to learn from). Since I figure both I and the patient are teammates in this endeavor, we should share equally in the costs for any orthotic that is truly transitional (although without we would have not been able to get to the final result). I would leave the cost discount to the patient in each doctor/therapist's hands. I did not mean to imply that the trial pair was of any material different than what you feel is best for the patient. I use three common materials in this quest: plastazote for some support and max cushion, 1/8 inch poly for some support and cushion, and 5/32 inch poly for significant support (for heavier patients the 5/32 inch is changed to 3/16 inch poly).


You also pointed out that you would RF post and with a hi RF valgus you might pour inverted (the Blake) & / or Kirby skive. At what point do you decide to do either or both? Then you were cut off.

Dr Blake's Note: So much of this is up to the skill level of the lab. I have toyed around with this for years and have concluded many things. These include:

1. When the Resting Heel Position is over 2 degrees valgus/everted, you can not just rely on arch support, the medial side of the heel must take some of the force to control pronation. This, of course, can be accomplished by either some form of inverted pour, or a Kirby skive. There are many sublties that can effect the correction like FF supinatus/varus vs FF pronatus/valgus, whether the heel is rounded or flat on the bottom, and whether their is a low arch or high arch.
2. When the presenting complaint is in the arch, the patient normally likes more heel correction (Inverted vs Kirby) and less arch correction.
3. Less arch correction can be accomplished with sweet spots,  plantar fascial grooves, or softer materials, but it is a mistake to low the entire arch.

I usually like to make an actual dell in the orthotic device to semi off weight this most depressed point of the arch in order to support it & alleviate pressure. This would match the weight -bearing position. Around the "dell for the boney prominence" I just created, I leave ~1cm raised unskived doughnut section.(unskived immediately adjacent to the "dell for the boney prominence" Then I gradually skive around a ~1cm doughnut which is full thickness to blend with the arch. Dr Blake's Note: Here is a nice example of a Sweet Spot being created.

I am very interested in whatever you have to say and appreciate your thoughts and time.  I  thank you for your pearls of wisdom. I hope you had a great vacation. I look forward to hearing from you. Take Care.

Sincerely, Karen

Karen, Thank you and I know I am late with this response. I hope taking this time on my blog will prove more meaningful than my cursory voicemail comments. So of all of the orthotic devices we have available what should be done.

With as long winded as this post, I best get right to the point. I hope you can follow based on the earlier discussion points. I will try to always prescribe differently for the right and left feet, so we have 6 feet presented to prescribe the initial orthotic to, and learn from. With this learning process, we may have hit gold early, or at least seen how the patient responds to the certain correction. All these orthotic devices should be with 5/32 inch poly to start, 0 degree birkocork rearfoot posts, with 23 mm Heel Cups Left and 21 mm Heel Cups Right and unless I mention a change or possible modification below.

RS #1 Left Pour 2 degrees Inverted or 2 mm Kirby Skive (Skive best effect with a rounded plantar heel and pour inverted best with flatter heel), maximum arch support with minimal fill yet sweet spot accommodation created.

            Right Pour Vertical.

CH #2 Left With the High FF Supinatus on both feet with CH I use the resting heel position to calculate the Inverted Pour. Here 25 degree Inverted pour will correct for 5 degree Ev RCSP. Maximum Arch Support with minimal fill and sweet spot accommodation.

            Right 15 degree Inverted Technique with Maximum Arch Support.

JP #3 Left 4 mm Kirby Skive with maximal arch support or 5 degrees inverted pour. It is good when you have the negative cast to look at the heel and arch from the medial side and imagine how the arch would change when you add a Kirby vs just Inverted Pour. Remember the Higher the Arch initially, the more effect an Inverted Pour with Maximal Support would have over a lower arch. This is also true with a flatter heel. Kirby Skives are better with rounder heels in general.

          Right Pour Vertical.

Karen, I must go for now. Took 3 nights to answer your great email. Hope it makes some sense. Rich

Plantar Fasciitis?: Email Correspondence

I live in San Francisco and am a 59 year old woman in great shape. I retired a few years go because my mother's Alzheimer's

had gotten bad enough that she had to go into assisted living. She is pretty happy now. Before I had her hospitalized, she had been bipolar all my life, and it had caused a lot of problems for me.
Once hospitalized, her bipolar disease was diagnosed, and she was put on meds that instantly controlled it. In the past three years,

she has never been mean or angry once. I visit her daily, have her living near me, and we have become close and she is always kind and affectionate, even though her memory is shot and she often forgets I am her kid.

I have always been otherwise healthy. I am pretty athletic and go to the gym three to five times a week, or more, until this foot problem began. After a month in France the last few years, I came back with my feet suddenly hurting. The first time, the pain went
away after a few weeks. I had worn Crocs the whole month in France. This past year I also wore Crocs the whole month, and the pain started when I returned.


My doctor said it was plantar fasciitis and I saw a podiatrist who sent me to a guy who made me orthotics. They only seemed to make the pain worse, and I found it really hard to ice them often, especially after first getting up. I did a minimum of the exercises they told me about, but didn't go to the gym because it made it worse, especially the elliptical machines.

I got the special shoes they told me to get and so far have had the orthotics adjusted twice, but now the pain is terrible in my ankles and above. When I go down stairs, I suddenly scream sometimes because the pain is so bad.

I saw my internist while my podiatrist was away and he told me to stop using the orthotics which I have, but the pain is still there.

My internist looked at my feet and said the plantar fasciitis problem is caused because I have hallux rigidus. He made me an appointment with my podiatrist to discuss surgery on each foot.

I've been reading about the surgery and it sounds awful and not with very great odds of it curing the problem.

Please tell me what to do???? I have pretty high anxiety because I am my mother's trustee and have a lot of responsibilities andit is very difficult to watch her getting much worse, and I am close to many people at her home because no one visits them, so I have taken them on as friends. I'm living on a teacher's pension which is pretty amazingly low.





So I especially need to exercise to fight my insomnia and stress. These two foot problems are making working out hard, and I am due for my yearly vacation in July, because I need a break from Alzheimer's once a year or I start getting too depressed.

I was planning to do the hallux rigidus surgeries in the fall if I have to do them, but I just read your article about not doing the surgery. How do I know what to do????

Should I come in to see you?Janis
 
 
Janis, Hopefully we can initially start communicating my email until I get a handle on this. Do not even consider Hallux Limitus surgery if you have no pain in your big toe joints!! Please read the post on medical history taking and answer, then email, all the questions back to me. That will give us a better beginning focus. Go to REI and purchase a pair of the soft athletic red Sole inserts, heat them up if they bother you. If I do see you, they are extremely easy to adjust. I am putting this on my blog tonight. And we update with each email I receive from you. Let's get your feet back, or at least working in the right way again. Rich

http://www.drblakeshealingsole.com/2010/06/giving-good-medical-history-for-pain.html

PS Is there anything that does not make sense when you are contemplating Hallux Limitus surgery, on the most important joint in your foot, when you have had no conservative treatment on it?

Complicated Musculoskeletal Problem: Email Advice

Email sent to drblakeshealingsole.com on 12/3/10

Dear Dr. Blake,


I had just recently been following your website and other works you have done and decided to email you. It is very rare to find a doctor these days who actually communicate and educate people who are not necessarily their patients. For this alone, I already know you are a different doctor - one that we need more of these days. I decided to write to you because of this. As I have problems in the low back, hip, knee, and ankle, I have been given fragmented diagnosis of my condition and none of which I can put into perspective. I chose to write to you because of your experience with biomechanics hoping that I could get a better idea of what os going on with my body. Forgive me, but my medical history is quite long and I will try to make it as simple as possible for you. I am in the hopes that you would be able to give me a better perspective of what is going on.

On Nov 2009, I noticed my right foot did not feel the same. It did not necessarily hurt so I ignored it. On january 2010 I started having right knee pain. My orthopaedic told me I have CMP and sent me to physical therapy. I have been working as a teller for 9 yrs and stand at least 8 hrs a day. My PT told me that my right arch was falling and I needed to get orthotics otherwise I will have hip and back problems. So I started PT in May 2010 and by then I noticed that when I stood up my right knee would always be bending inward and I had to consciously extend it to keep it straight. In August 2010, I started to develop left hip pain and mild left low back pain. I went to a chiropractor who told me that I had LLD in my rt leg and that my left pelvis was anteriorly rotated which was causing a mild low back scoliosis. I got orthotics then and he gave me a heel lift of 5mm. I had mixed feedback with the heel lifts as PT told me I did not need it since my LLD was apparent and not true. I did not wear the heel lifts and I carried on with PT and chiro and I was getting better - knee and hip pain going away with the help of FMLA at work and not having to stand all day.

On October 2010 I made the grave mistake of lifting a sofa. An immediate pain shot right through my left groin to my left back and to the right back. For the next few days I was having back pain and oddly enough right groin pain this time (left groin pain went away) and I could not keep my balance when I walked. A few days after as I was walking I felt a rip in my left buttocks down to the right buttocks that made me lose my balance more. I quickly regained myself but then when I started walking again I couldn't walk straight! As I stride my left leg forward, the right leg would go over towards the left leg. This went on for a day after which was causing me a lot of left knee pain that felt like it was being twisted. A few days of limping around with a locked left knee, I started noticing that both my ankles were hurting. My left ankle actually hurts more than the right. For treatment of such a poor diagnosis (not that anybody gave me a straight one) I went to PT again for the left knee this time, and to my podiatrist for my ankle who said i have the sinus tarsi syndrome and gave me steroids as I refused the shots. I went to 2 hip doctors of which one said I may have torn my cartilage and my gait has probably changed and thus the knee and ankle pain but another hip doctor said MRI came back ok and its just a glute strain.
 
By now Dr, Blake, I have to say that my hip, back and knee are doing better but not my ankle. It is still very unstable and now I have taken the shot just yesterday to see what happens. My podiatrist and the hip doctor think that when I was walking and lost my balance perhaps I twisted it. I don't think so being that the ankle pain came after the knee pain (then again I'm not a doctor). I have been researching and trying to understand my condition and since no one has given me a clear perspective of what is going on I have been self diagnosing. So far, this is my self diagnosis:


I believe I do not have CMP in my right knee. I think that my right knee pain stemmed from my right foot flatenning/pronating. I believe that my left pelvic anterior tilt was because of my right foot that caused my right knee to keep on bending inwards. I dont know for sure if i have LLD. I believe that because of all that has just been mentioned in this paragraph it has unlocked my SI joint causing the low back pain. For the second injury when I lifted the sofa, I believe that there is nothing wrong with my left knee. I think it was compensating for whatever happened to my hip/glutes/low back. For the low back I am sure it is my SI joints as MRI for lumbar came out ok. So right now I am down to my SI joint/ rt hip/glutes in relation to my ankle. Now my left foot has pronated more and my podiatrist said it s because of the cruciate ligament stretched or tore (Im not sure which one). He said if i dont get better with the shots I may have to have that surgery where they put that screw in my ankle which I dont want. I'm afraid that my ankle pain comes from my hip/glutes/SI joint and that if I dont fix them my ankle will never heal. I am not sure what to make out of everything after this point.

Dr. Blake, I know you are a busy man and I am only one of the many people that you have to attend to. I am from Las Vegas NV and I wanted to tell you my medical history to see If I am one that you would be able to help if I come see you to your clinic in San Francisco. I think that perhaps a gait analysis will give me more info about my condition and of course with your expertise I am hoping to fully understand and get a right diagnosis so i can have the proper treatment and get better. I am sorry this is such a lengthy letter but I have exhausted all other doctors whom I cant get a straight answer from.

Thank you for all your time.

Sincerely,

Carina

Dear Carina, Thank you for emailing me about your condition. I left it in its entirety on the blog because it is an excellent example of when one thing goes wrong, especially our feet, the whole deck of cards can collapse. When I get a history like this, you look at the first symptoms to tell you what is the root cause of the problem. You felt something was wrong with your right foot, probably a collapsing arch. As the arch collapses inward, the knee twists inward, the hip and pelvis get out of alignment, and the first symptoms probably follow the pronation pain syndrome mentioned in my previous blog.

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-14.html

I know if you are right handed, and you injure your right side, the left side easily wants to compensate. This would lead to left hip pain from favoring the right.  I will assume you are right handed. Even not, enough limping protecting of your right side can lead to a breakdown of the left eventually.

http://www.drblakeshealingsole.com/2010/10/right-handed-vs-left-handed-affect-on.html

After you had orthotics made, did you feel equally supported right to left? Do you feel that the orthotic devices eliminate all or 95% of your pronation? This I think is crucial to making you well. If you look at the link above and the video on pronation you could email me one of your own with a help from a friend. I would be happy to analyze for you. When symptoms arise like this I believe you have to have great orthotics, not just good orthotics. You may be in good orthotics, which control the pronation of your feet 60-70%. But, I would shoot for 95-100% correction for the next year. It serves like a cast for the pronation. This can only be analyzed with stable shoes and power lacing. Definitely get great a power lacing.

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-8.html

And, only until the orthotics are perfect can you really do the standing eval for leg length difference. Ask your podiatrist if the orthotics completely correct the pronation once you power lace. Ask a good athletic shoe store known for their expertise in running shoes. Watch the videos on pronation with a loved one, and have them watch you walk. Once the orthotics are fine, the standing LLD measurement can be taken.

http://www.drblakeshealingsole.com/2010/11/short-leg-syndrome-video-showing.html

Carina, I think your summary was excellent. You may have a syndrome called posterior tibial dysfunction and there are many conservative treatments for. This is why I need to see you walk to make sure, but you can ask the podiatrist if you have this also. Make it your goal to get the feet perfect and see what falls into place. You probably should consider an ankle brace temporarily. Look up ASO braces. Ice your ankle 3 times daily for 15-20 minutes (see the post on icing). If you got a shot into the ankle, what was in the shot, and how did it feel over the next 5 hours? Ask the podiatrist exactly what did you get, and into what joint (ankle or subtalar)? Hope this helps until you get the video to me. It is fun making videos. Rich