Adding Stiffness to the front of a Shoe: Help for Many Problems in the Front of Our Feet

     My retired partner, Dr Jane Denton, known world wide of the Denton Modification for over supination, continuously used this metatarsal stiffener. It is a 1/16 to 1/8 inch thickness of out sole material. All chronic pain in the area may be helped with this shoe modification. When patients tell you that they feel better as the shoe stiffness increases, this may be something that a shoe cobbler can add to a more flexible shoe. It should be done on both sides (even if the pain is on one side). It can always be removed if not helpful, or after the need for stiffness passes. 

1/8 inch Stiff Out Sole Material Applied to Add Stiffness for Painful Metatarsals

The Stiffness has to be created with 1/16 to 1/8 inch Material only. This increases someone's falling odds due to separating the ground from the foot, so has to be broken in to gradually. The patients that it works for are really pleased that they can wear some normal looking shoes. 

Adding Stiffness to the Front of an Orthotic Device

https://jmsplastics.com/product/j-suede/

     The image above was taken after I applied a very thin piece of suede leather. This is stretched before tacking down to stiffen the bend across the metatarsal heads. This is a very useful technique when trying to treat metatarsalgia symptoms, Morton's neuroma symptoms, hallux limitus and rigidus symptoms, and all without adding alot of bulk in that painful area. 

Sore on the Bottom of the Foot

Here is a patient from today's clinic. Yes, I am back after so much time off. Now, let's not blow it and forget our masks and social distancing!! I know I sound like your parents!!

     It is so important to off load sore areas on the bottom of the foot. This patient had a deep seated callus under the fifth metatarsal which I tried to dig out. Then I attempted off loading with my 1/8 inch adhesive felt. Thick moleskin also works, and you may have to layer to get the right thickness. 

https://www.walmart.com/ip/MediTac-Extra-Heavy-Moleskin-2-x-5-Yards/741713921

Metatarsal Pain: Consider Bike Shoes with Embedded Cleat

     Had a patient today with chronic bilateral metatarsal pain. As we work through the diagnosis, I suggested to get bike shoes with embedded cleats to wear at least 4 hours per day to decrease the motion across the sore areas. I find thinking about making changes in the biomechanics of the patient can usually make significant improvements. This is even true when you have the patient use those changes for parts of each day. 

Chronic Metatarsal Pain: Email Advice

hello dr Blake,

I am writing all the way from Italy and was wondering whether you could be so kind as to help shed some light on a foot problem I've been struggling with for the past 5 years. I hope you enjoy puzzles! I'm 33 years old, male, 6' 4'', 165 pounds. 

5 years ago I suffered a minor injury which caused capsulitis on my 1st MTP joint (right foot). Eventually the capsulitis resolved, but at the same time I gradually started to experience additional discomfort on the same foot for reasons which in hindsight seem to be attributable to increased weight/pressure on the affected foot when walking. For example, the metatarsal pad of the orthotics I had been prescribed to treat the capsulitis after a few months started to be painful (whereas with my left foot I could barely feel it), and after I switched to a pair without the met pads (April 2016), the discomfort shifted to other areas of my forefoot (sometimes lateral, sometimes medial, and always when pushing off). Sometimes I had the unpleasant sensation of 'feeling' my metatarsals when walking. Fed up with the orthotics, I tried to go back to walking without them as I had always done for 30 years. After a few days of walking pain-free I thought the condition had finally resolved and everything was back to normal, but shortly after the old symptoms came back. 
     So I went to see a podiatrist (January 2018), who said that my discomfort was due to unilateral over pronation and that I needed semi-rigid orthotics. The new orthotics worked very well for a couple of days, but then again symptoms-wise I was back to square one, with modest improvement. The podiatrist then made me a rigid pair of orthotics, but again, very little changed. Since he couldn't see any structural faults he came to the conclusion that the problem was muscle-related, more specifically my right calf was weak. This was maybe due to the original injury, since the capsulitis made it painful to push off as usual and so probably I started to use my calf muscles less and less. Nowadays I can rise on my toes on a single leg but I find it much easier with the other limb. I signed up at the gym, carried out a 4-month program with a fitness instructor (nothing specific for my problem though), experienced some improvements but very discontinuous, and finally went to see a physiotherapist (March 2019).
     The PT noticed a number of compensation patterns on the affected side, mainly internal rotation of the leg, pelvic tilt, an overactive tibialis anterior, and something about my latissimus dorsi which on that side was working harder than normal to maintain balance. I did 5 sessions where they manipulated mainly my pelvis and trunk, the reasoning was that all of those imbalances were affecting my foot, and not vice versa. On some days I noticed a definite improvement, but again, a bit discontinuous, so eventually they referred me to a podiatrist they knew in order to rule out intrinsic foot problems (April 2019, i.e. this week). 
Dr. Blake's comment: First of all, I am sorry I am late answering. You are not overweight and I am not sure that their is any association with the original capsulitis. All of your symptoms could be related to your unilateral pronation. If you look at your two orthotics, are they asymmetrical, with more support to the unilateral pronation side. 
     The podiatrist noticed a number of things apart from the unilateral over
pronation (ligamentous laxity, not much forefoot fat pad, big toe tends to make little contact), but the main thing seemed to be that the affected leg is 0.4" longer).  Thus, I would need a new pair of orthotics that took all of these things into account. I have no qualms about that, and I am willing to believe that 0.4" could go a long way to adding weight on my leg and foot and contributing to the problem. The affected leg is probably a bit longer, my fitness instructor once filmed me while walking on a treadmill and it clearly showed that the affected leg tended to circumduct (is that a verb?), and the anatomical leg length discrepancy may be compounded by a functional one.
Dr. Blake's comment: Yes, the long leg tends to be the more pronated, and 11 mm is a lot. I tend to try to separate the orthotic therapy and the lift therapy. So, I would gradually over one month build you up under the short side. When the patient is more pronated on the long side, correcting that aspect will make that side even higher, so you may need up to 1/2 inch. 

     I am willing to accept all of this. What I really can't wrap my mind around (and this is my main question) is this: if it really is a matter of bearing too much weight on the affected foot then why did it become symptomatic only in recent years, after the original injury? If the leg length discrepancy is truly anatomical, shouldn't I have had similar problems before the injury as well? The injury itself was no big deal, I hit a curb with my big toe but no fractures, just the capsulitis. Until 5 years ago I had never had the slightest problem. Could compensatory postural adjustments or lower leg muscle weakening post-injury have played a role in adding further weight to the affected side?
Dr. Blake's comment: Yes, for sure, an injury can cause other stresses to manifest for the first time. I am never sure if it is due to the deconditioning from the injury, or the compensations from the injury, but it happens all the time. I joke to my patients that at least it will stop after the third area begins to hurt (sometimes they get my humor). The long leg does put more stress on that foot for sure, and if you add the tightness that develops in the achilles with injuries, the stress to the injured foot can be quite bad. 

I'm adding a few bits of info which might help:

• I tend to feel much less discomfort when walking barefoot (Dr. Blake's comment: for sure, shoes for sure add stress across the metatarsals as we try to bend at push off. Only stress fractures and other bruises hurt worse barefoot. This of course could be a clue for you to try very flexible shoes in the forefoot). 
• x-rays and MRI have always come out 'clean' (Dr. Blake's comment: Negative MRIs to me mean nerve injury first until ruled out. Nerve injuries show negative MRIs. Have you had any nerve symptoms like numbness, sharp, tingling, buzzing, electric, etc. It is also a good sign for the future as you do not have early onset arthritis).
• pedograph analysis showed more pressure on the affected foot when walking, thought barefoot they were even (Dr. Blake's comment: Many times the difference only shows up running as are bodies have a harder time distributing the weight evenly.)
• I tend to think that I am bearing more weight on the affected foot, but there are no signs of that on my skin (there is a slight degree of 'hallux valgus' though, could that be a sign?) Dr. Blake's comment: Yes, unilateral bunion formation or hammertoe formation is a sign of more stress.
• as I mentioned before the discomfort I have on my forefoot is quite changeable, most times it's on the head of my 5th metatarsal, sometimes it's bit generalized, other times I don't feel anything on the 5th metatarsal and it's more on the big toe. In any case, it's always during push off. Dr. Blake's comment: The variability is more a stress syndrome than an injury. Change the mechanics, get stronger with single leg balancing and metatarsal doming, and stretch the achilles tendons several times a day. 
• judging from what I see and from the pedograph analysis the arch of the foot seems fairly normal

I would be really grateful if you could share some thoughts on all of this, I've been through so much and am getting a bit depressed

thank you

Dr. Blake's comment: I hope you are feeling better. Get more flexible, get stronger, get at least 1/4 inch full length lifts and see if you are better with these changes. Rich 

The patient then answered:

hello dr Blake,

thank you very much for answering. I am writing a follow-up email to let you know how I am doing. If you feel to add any ideas or suggestions that I could pass on to the professionals that are looking after me (also in terms of diagnostic tests) I would be even more thankful (I have made a small donation to your blog as a token of gratitude). I don't want to take advantage of your kindness so if I don't receive further communications I will fully understand.

Over the last month and a half I have been wearing the new pair of orthotics (they have a 5 mm heel lift on the shorter leg, so the lift is not full length), my gait has improved as now I find it easier to push-off (last pair of orthotics were rigid and with little padding), while symptoms have also improved a bit but have not resolved. I am still doing physical therapy and next Wednesday I have a check-up with my podiatrist so I hope to clear things up a bit, but in the meantime I have been doing some research on a number of topics and I have come up with some new elements that may be worth mentioning. As my foot is apparently subjected to increased stress, I'm trying to understand what is causing it.
Dr. Blake's comment: Explain to the podiatrist to perhaps experiment with another orthotic device for the short side without the lift attached and with 2 (1/8th inch) full length spenco or other soft material as lifts one full length and one cut at the toes (sulcus length). That will add cushion but not pitch you forward as much onto the metatarsals. If you use soft material as lifts, you typically can go up a mm or 2 due to the compression. 

One of the working hypotheses is that it may be bearing more weight for some reason, but I've noticed this is something that hardly ever pops up in podiatry or PT. I have read several textbooks and at the most they talk about asymmetrical weight distribution foot-wise (i.e. more lateral or medial) and not body-wise (i.e. right leg/left leg).

Dr. Blake's comment: One method of getting some idea of the right to left weight bearing is looking at old inserts, ones that you have worn awhile, to see if one side is broken down more. The other common method is to stand evenly on two bathroom scales that you know are equally calibrated. Try to stand with equal weight in your mind, and have someone else take the measurements of left and right side. As soon as you look down to read the scales, you throw off this technique. It is only one tool, other than more sophisticated force plates/mats, but seems to be helpful. 

 I am wondering whether muscular imbalances in terms of tightness/weakness between the two halves of the body might play a role in how weight is distributed or force is transmitted to the lower extremities but I haven't been able to find any bibliography on the matter. Also studies on LLD and body weight distribution seem conflicting as to which leg bears more weight, so it's all a bit confusing to me. I did another pedobarographic analysis last month which apparently ruled out this asymmetrical weight-bearing hypothesis, as it showed that mean pressure was actually higher on the healthy foot when walking barefoot, but I don't know if such a test is supposed to be conclusive on this matter.

Dr. Blake's comment: I am not aware of any research on this matter, so I apologize. When a patient is bearing more weight on one side because of short leg syndrome, scoliosis, tight hamstrings or calves, weak muscles, etc they create postural instability as they try to compensate. This postural instability can lead to the measurements varying from step to step, with one side greater with one step, and the other side greater with the next step. Or, something like this. The force plate analysis as an office tool makes it difficult unless you do the test multiple times, and a definite pattern emerges. Most researchers feel you must walk over the force plate 10 or more times even to begin to practice the landing. This is actually why in a busy office I have not purchased these, but I understand their help in many situations. 

You mentioned in your reply to check for neurological signs, and this is something I didn't include in my first email. I do think there is something going on in that regard as well. One sign involves the dorsal aspect of the big toe, so I don't know if it's related to the general problem (forefoot plantar discomfort) but nonetheless it's worth mentioning. Sometimes I feel a mild burning sensation coursing along the big toe which is (sometimes, not every time) elicited if I move my leg after a period of inactivity when seated or lying down, and on sitting down after a walk.
Dr. Blake's comment: This is classic L4 nerve root irritation.

Or, also, when I'm doing sit-ups with my leg fully extended. What makes me think it's neurological is the fact that this burning sensation is sometimes elicited by stimulating the anal area (e.g. when I wipe after going to the bathroom), a very distant area that is directly connected to the foot only by means of nerves. I know that the deep peroneal nerve innervates the first web space and that it can get irritated when sitting with your legs crossed (something I used to do), but that doesn't match 100% my symptom in terms of location, as it's more dorsal 1st toe rather than 1st web space, and the peroneal/sciatic nerve is more 'buttock' than 'anus'. This burning sensation started post-injury, and I definitely remember that a few years ago sometimes I felt it coursing down my medial calf, on the side. Might it be that some nerve got irritated/damaged with the injury (big toe stubbed against a sidewalk) or consequent capsulitis? I know also that overpronation can cause tarsal tunnel syndrome but in that case symptoms involve the arch/ankle (not my case).
Dr. Blake's comment: This is up to a neurologist to put together, but sounds very neurological. The dorsal of the foot is irritated by tying your shoes too tight or above the knee problem like tight hamstrings, piriformis, or low back, not the tarsal tunnel. 

On the other hand though it's puzzling because other than the burning feeling I've never experienced the classic neurological telltale signs, i.e. tingling/numbness/electrical sensation, and it's something which is elicited with specific motions, and never at rest or at night.

All of this dorsal-big-toe-burning-symptom, though, as I said may not have much to do with the general problem, but I have come to think that there might a neurological component in the plantar aspect as well. Might it be that some plantar nerves are being compressed/being put under stress for some reason, and that weight-bearing pressure is 'felt' much more than usual? On the other hand, as I said before, the telltale signs of neuropathy are absent, and even on forceful palpation the sensitivity of my foot appears normal, so to my layman eyes it appears more a matter of stressed soft tissue than nerves.

Dr. Blake's comment: You have some minor nerve problem, and nerve problems cause a hyper-sensitivity that can make something hurt more at the foot. This is called "Double Crush". Definitely worth to check out, and right now deal with them separately. I hope I have helped and thank you for the donation. Rich

Again, thank you very much for your reply and for any further help you can provide

Antonio

Metatarsal Pain: Email Advice

Dear Dr. Blake,

I am so grateful I found your blog a month ago after suffering strange left foot problems for over a year!

In August 2017 I unexpectedly was taking care of my 84 yr old mother-in-law (stroke victim) who lives on 20 acres in the country with the clothes on my back and a pair of cheap flip flops for a week. Of course, I developed Plantar Fasciitis in my left foot - wearing non-supportive shoes all day long!

Fast forward, I had 2 visits to my family doctor (who gave me steroid pills, told me to ice 3x daily and do foot exercises), saw a Podiatrist (who saw me 10 minutes, barely touched my foot for $330, gave me an injection and suggested orthotic inserts for $450) and then I saw my Chiropractor, who adjusted my foot, did x-rays (they were normal but I have a heel spur) and made me orthotic inserts for $250. 

After wearing the Chiro orthotic devices for one month, I developed additional forefoot pain but the heel pain subsided greatly. I removed those inserts because it appeared they were the cause of my forefoot pain. Immediately, the forefoot pain was less, but the heel pain came back strongly within one day of not wearing the inserts. Upon my examination, it appeared the arch was too high in the Chiro orthotic inserts, so I went back to the Podiatrist in June 2018 and got the $450 hard plastic 3/4 custom inserts which had a definite lower arch.

I continued to wear the hard custom orthotic inserts and my heel pain completely subsided but the forefoot pain got worse. So I bought a variety of OTC inserts trying to find a solution. I went back to my family doctor who told me I have a mechanical problem, gave me steroid pills and told me to stay off my feet and do contrast therapy. I don't want to keep doing steroids! At that time, I averaged 9 k to 13 k steps a day because I am very active person, so now I have cut back to 6 k-8 k steps daily and try to rest my foot.

After reading several sections of your blog, I have determined I have 2nd metatarsal capsulitis, with beginning hammertoes on digits 2, 3, 4 and a definite Bunion, stage 2-3 on my left foot. I have lost strength in my left foot since June 2018. I can barely spread my toes now and the hallux joint seems 'lax' and does poorly with resistance testing when trying to dorsi-flex the toe. I bought shoes with bigger toe boxes. I bought some Yoga toes but I haven't used much since they hurt my smaller toes. I also have Stage 2 bunion on my right foot, but no issues other than my right foot gets overloaded from compensating for the left foot!

Dr. Blake's comment: Try cutting off the part of the Yoga Toes to the 4th and 5th toes. 

Without actually examining me personally, (I live in Texas), can you at least give me general advice on what I am doing currently? I am attaching a picture of my foot and insert.

I am taping the second digit and sometimes the third digit per your video instructions. This seems to be helping. I am icing the ball of foot 3 times daily for 15-20 minutes. I am doing the alphabet with my foot and rolling my arch on a tennis ball every morning. I am doing your doming exercise 2-3 times daily (10-12 reps) with both feet and place my sock rolled up between Hallux and 2nd digit space to 'straighten' the toe. I have placed a homemade MT pad using felt from Hobby Lobby taped to my insert (I couldn't find anything in stores - I was desperate to relieve the pain!).

Dr. Blake's comment: If you feel better after the icing, continue. If you do not feel better, it may be too long, so reduce the icing to 5-10 minutes. 

Q 1. I notice that after awhile, I will have pain/cramping in the lateral side of my foot (5th MT) even though the 'pebble sensation' in 2nd MT is reduced greatly by the pad and topside swelling has gone down. Yay! Is this pain caused by 'loading pressure' from the arch in the orthotic support? Or from the MT pad? Or both? It seems like one thing fixes one issue, but then causes another issues. Any Ideas? Solutions? So far I am continuing with the pad and dealing with the lateral pain.

Dr. Blake's comment: Yes, probably from orthotic devices, limping, etc. Try to alternate what you have on your foot several times a daily, one being no orthotic devices. 

Q 2. Is it okay to do the doming exercises while dealing with the capsulitis? Will the doming exercises strengthen my Hallux? Any suggestions for getting back strength in that big toe and all my toes of left foot? I continue to try and spread the toes and I also flex the toes after doing the alphabet.

Dr. Blake's comment: As soon as you can do single leg balancing, see the cut out I prescribe for sesamoids so you can do the same idea and float any sore area, you will really start to strengthen your foot and toes. 

Q 3. I tried the gel toe separators for my bunions - they hurt a lot inside my shoe-seemed too hard/big. Suggestions for alternatives and how important is it that technique for me?

Dr. Blake's comment: Not appropriate now while you are dealing with the capsulitis 2nd, too much pressure on the 2nd toe. 

Q 4. Use the Yoga Toes less time until they don't cause pain in the smaller toes?

Dr. Blake's comment: Try my technique for cutting the part that separates the 3rd and 4th toes, and separates the 4th and 5th toes. If still painful, try the less intense Yoga Gems. 

Thank you again for reading and answering my email. I was going to donate to your blog and when the site asked me my address, it stated something about contacting you regarding your privacy practices about my address. Can you tell me those or where you have them posted so I can donate with comfort? Thank you again.

Dr. Blake's comment: Thank you for the gesture. That must be a new Pay Pal privacy rule. Your email is never shared with anyone by me. 

Further comments: It is not unusual for a patient to hurt their heal, limp, and then hurt the front of the foot. The inserts, could have been made by anyone, custom or over the counter, probably had a hard spot right under the 2nd metatarsal that bruised the soft tissue. 5 minutes of ice massage is better than just sitting on an ice pack if you know the sport. I have a video on protecting a sore spot that may help you. I do have to say how proud I am of how you are attacking this problem and quite logically. Keep me in the loop. Rich

https://youtu.be/-v9IrSucQpE

Metatarsal Pain: Email Advice

Dr. Blake,


I hope this message finds you well. Thanks for the blog--it’s a great resource, I've been learning a lot from it, and I appreciate your therapeutic approach.


The short version: pain in the area of the right foot MTP joints on the underside of the foot, associated with activity, pretty well under control for now but worried about increasing activity levels in general and hills in particular.


The long version: healthy, active, 25yo male, lifted regularly, walked lots, went for backpacking trips with a heavy pack with no trouble for years, worked part-time in a commercial kitchen, etc. Tried to take up boxing in the summer of 2016, got some small but stubborn tibial stress fractures from skipping rope on concrete, took a lot of time off but gradually resumed activity (lifting, walking, dancing) with no trouble. Incurred some very small fractures in the left metatarsals in a motorcycle accident in March 2017, healed fully, resumed activity. A little pain in the left foot from time to time, but nothing that worried me.


After a couple of brisk hikes in late June/early July, I noticed some unusual pain in about the 3rd-5th MTP joints of the right foot, on the underside of the foot. Not tender to the touch, but a kind of dull throbbing on and off throughout the day. I thought it might be just part of the adaptation process--it had been a while since I had done any serious walking, what with coming back from the broken foot. And I had a short-term job that required a fair bit of loaded hiking (forestry), so I pretty much plowed ahead. The foot didn’t get any better, but it didn’t get dramatically worse, either; I was in stout, supportive boots (albeit possibly too narrow and with too high a heel, see below) during the day, and I noticed some pain when I took them off at night, but nothing crippling.


Still, I figured some time off would do me good, so after the job wrapped up in September I stayed away from running and hiking for a couple of months. The foot calmed down but wasn’t quite back to normal after six weeks off. Pain during everyday life was essentially zero, but eccentric calf raises with the forefoot on a block caused a lot more pain in the right forefoot than I would normally expect, so I saw a primary care doctor who ordered x-rays (attached--let me know if the attachment doesn't work) and referred me to a podiatrist.


The podiatrist diagnosed hallux limitus in the right foot--there was a lot of talk about “degenerative,” “never gets better”, “have you tried swimming, it’s great cardio,” etc. I didn’t care for the sound of this, not wanting to go back to working at a desk, and the podiatrist didn’t strike me as the most competent. So I sought a second opinion from a local AAPSM/ACFAS guy who had a fair bit of running experience (former D1 distance runner). I also began a walking/jogging progression, very conservatively, while avoiding anything I knew aggravated the foot. In particular, I noticed that time on the stairmill and on a steeply inclined treadmill seemed to cause pain out of proportion to impact, and forefoot striking when I ran also made things noticeably worse.


The second podiatrist said that hallux ROM was fine, he didn’t see any swelling, no tenderness to the touch, and encouraged me to experiment with shoes and over-the-counter orthotics and running surfaces and to stop walking around the house barefoot. He didn’t see anything unusual or alarming about my gait, and noted that my feet were a bit flat but not necessarily in need of an orthotic. His diagnosis was “metatarsalgia, like a bruise--not a stress fracture”. This was in about the first week of December.
Dr Blake's comment: This is why I love the AAPSM. Right or wrong, good overall approach. Sounds like nerve to me, and I am glad you had no Hallux limitus. Did he check your achilles for tightness? This is a big reason why patients get metatarsalgia. You work on the 3 causes of pain: mechanical, inflammatory and neuropathic. Mechanical is dropping the heel height, stretch the Achilles tendon, and Hapad longitudinal Metatarsal Arch Pad Small just behind the soreness. Inflammatory with icing or warm water soaks (have to see what feels better). Neuropathic with pain-free massage, Neuro-Eze gel, Neural Flossing three times a day. These at least for what we know now. 


I ended up in the Altra Olympus, very happy with them for walking and running, and somewhat happy with Altra’s desert boots for casual wear. (I tried Hokas, but even their wide sizes were a touch narrow in the forefoot for me.). A felt metatarsal pad on the stock insole (for both feet) also helped a good deal. I found that easy running on grass with a heel strike and a high cadence didn’t seem to make things any worse, and got a pair of cushioned flip-flops for walking around the house.
Dr. Blake's comment: You are doing everything right. For those that do not know Altra shoes, they are all zero drop, meaning no heel lift to put pressure on the front of your foot. I love the big Hapads to spread the force. You may have to thin out. The small size is usually perfect. 

Hapads on top of Orthotic Device with various pads under forefoot to accommodate or cushion

Since then, I’ve been titrating up the jogging, taking it easy and staying on grass, adding 5 minutes here and an extra session there, and I still seem to tolerate it pretty well, so that’s all to the good. I’m down about 5 pounds from 200 in December to 195 now and plan to drop another 5-10 in the coming months, which should also help. I’ve been supplementing D3 and K2 for years and have continued to do so, along with milk, yogurt, and a calcium/magnesium supplement. I've also been lifting and it doesn't seem to cause any pain. Two things have given me cause for concern.


The first was a hike I took on December 26 or 27. About 11 miles round trip with ~3000 feet of elevation gain, a big day out but the sort of thing I would have done without a thought before the motorcycle accident. I was in Asolo TPS 535 boots with Sole orthotics, a combination that had never given me any trouble on backpacking trips and big hikes before forefoot problems started. (Different pair of boots from the ones I had worn over the summer--I hadn’t really worn these for any major hiking since the forefoot problems had started.). By the time we got back to the car, my feet were in quite a lot of pain--both feet, dull throbbing pain pretty much all across the MTP joints, and also some “spiky” pain in the area of the right sesamoids. Outside of the 0-2 range, definitely not the normal soreness I would have expected after an unusually big hike. The pain was probably 90% back to normal and back to normal within a week, where “normal” means “maybe a little sensitive in the right 3rd-5th MTP joints with occasional fleeting mild soreness here and there, but essentially no pain and no discernable pain with everyday activity.”
Dr. Blake's comment: The problem was the new unbroken-into shoe, and a more then what you were used to hiking. It sounds reasonable it should have flared up with the shoe was not flexible enough at that moment allowing more stress to the tissue. Glad it calmed down. 


The second was a few days ago when I tried to stretch my calves by standing on a block with my heel hanging off and letting the heel drop. Felt fine at the time, but about three hours later, I noticed a dull throbbing pain from the right 3rd-5th MTP joints, which came and went periodically for the next 24 hours or so. I’ve been icing for 10 minutes 1-2x/day for the last few days as per your blog--too soon to tell whether it makes a long-term difference, but it sure seems to help acutely. I'm also going to start contrast therapy. Again, the pain was pretty much back to normal (so, a little “sensitive” or “tender” but essentially zero real, consistent pain with everyday activity and jogging on grass) within about three days.
Dr. Blake's comment: This is called placing your foot in a negative heel position and all the weight on the forefoot. Another unusual stress that irritated things. These are benchmarks for what you can and can not do this month. Typically they are not permanent in any way, but you are not ready for that for the next 3 months. Then you can test it again. Were you doing it single leg or double? Less stress with double. 


Anyway, what these two incidents (together with my earlier experiences with the stairmill and inclined treadmill) suggest to me is that even though I can run a bit on the flat, hills may be a problem. But I’d like to work in forestry again this summer, and walking up hills is a pretty central job requirement. And it’s been six months now, including two months more or less completely off--seems like a long time for this not to heal, given the circumstances.
Dr. Blake's comment: Please experiment when you are doing at risk things only either the double loop Budin splint (loops on the 2nd and 4th toes) and a carbon graphite plate under the insert you are wearing. These are only for the times you feel you should have the extra protection. 


So: any recommendations for reintroducing hills? Any suggestions for thinking about how much heel my work boots should have, other than trying various different things and seeing what’s comfortable? (For reference: high heel like what I wore last season, lower heel.). Anything I should be thinking about that I’m not? Anything I shouldn’t be thinking about that I am? Should I worry more, less, or exactly as much as I am that this is the first inkling of a degenerative condition that will lock me into a desk job forever, or at least for next season?
Dr. Blake's comment: Your thought process is wonderful, and we are dealing with some many variables: heel height, stiffness or lack of flexibility more like, tightness of shoe. The tissue is stressed by holding the stretch for a long time, like the negative heel stretch, making it too hard to bend through (like with the new shoe), explosive actions, high impact. Try several shoes and pick the one with some flexibility but some cushion (not weighted heavily on either side). Try to be mindful to reduce stress in your actions, whether that is slower, or gentler, or using your arms more to push you up. Do not favor or something else will go wrong. Ice daily whether you think you need to. Experiment with the plates and Budin splints or hapads, but try to change the environment. Work through times that get sore even if you thought you were getting it right. Healing should occur, even with these ups and downs. Good luck Rich


I think that’s about everything I wanted to ask, together with all the relevant information. If there’s anything else that would help you give an informed answer, feel free to ask. Thanks for reading, and thank you for your time.


Best,

Oofos: A Soft Sandal for Heel or Ball of Foot Conditions

Oofos is a very cushioned sandal that many of my patients with heel or metatarsal area pain are raving about. They will not replace a removable boot and/or crutches when you need those, but they can help if you are in a more chronic stage. I am really not sure if there is a difference between them and the softness of crocs, but they have various styles to at least experiment with. If I have taught anything on this blog, I hope I have imparted the need for experimentation to help with foot problems. 

https://www.oofos.com/  

Metatarsal Pain (including Morton's Neuroma) Taping with Pad

This is a simple, but often effective, wrap for various forms of metatarsal pain including Morton's Neuroma. Readily available 2 inch Kinesiotape or Rocktape, and small Hapad metatarsal pads can be used. Purchase Kinesiotape from Amazon and go to www.hapad.com. Hope it helps you. Rich

Bunion/Metatarsal Help with Hapads

Please send me more info on your felt pads for arch support to aid bunions. Thank you 

Regards,

http://www.drblakeshealingsole.com/2010/07/arch-support-with-otc-hapads-help-for.html

Nerve Pain: What to do next?

Hey Dr. Blake, 

I keep up with your blog and I'm so sorry for your recent losses. Hope you are ok. I'm having trouble with my foot again and wanted to ask your advice, if you are up to it. If not, I understand. In case you ARE up to it, here's what's going on...

I can't get the pinched nerve (the Big X in the pics below) to calm down. I've had it padded a million ways (not sure I'm padding it properly either) and when I take the pads off and take a full step, it's zinging me just as strong as when it first started. I have been able to walk on the foot with the pads but I'm starting to get blisters and callouses on the side of my big toe from walking all weird from the padding and trying to avoid zinging myself by stepping on the pinched nerve. I did not and do not ice like you suggested (3x a day). I can but I don't because...I don't know why. Lazy, too busy, etc. So if that's what I need to do before anything else, I will make it happen. 

Thanks, 

Terry (name changed)

Dr Blake's response:

Hey Terry (you know who you are!! LOL),

     Thank you for the concern. I have been in a fog, but trying to help you and others does help get me centered. Thank you very much.

     First of all nerve pain/abnormal nerve sensations can forget to shut off even when you protect them for extended periods of time like you have. The old saying is that "if you look at a nerve funny it will hurt for 9 months" is fairly true. When treating nerves should be addressing 4 areas---mechanics (which you seem to have mastered), anti-inflammatory (and ice 3 times daily is the easiest), nerve hypersensitivity (oral meds, topical meds, neural flossing, injections), and diagnostics (MRI with contrast, Nerve Conduction tests, etc). 

Please email me back on what areas you have done and could do in each of these 4 areas. Rich

And the response:

Thanks for the response! Wow, I had no idea nerves could take so long to calm down. 

Mechanics - I think I am doing this right if that means not feeling the pinched nerve "activate" while I have the padding on. Most of the time I don't. This past week I feel it even with the padding on. For the last 3 weeks, I have been extra active and on my feet for much longer each day than normal. 

Anti-inflammatory - I am not doing any at all. So I can begin icing 3x per day. Any other ways?? 

Nerve hypersensitivity - not doing anything at all. What should I do?? 

Diagnostics -I never had the swelling or the level of pain for this nerve that I did for the original injury so I haven't done any new diagnostics. I just have the old MRI and X-rays that were done before this new pain started. I am not able to get a new MRI right now due to financial constraints and a super high deductible. 

Dr Blake's comments:

     Mechanics: So right now stay where you are at and avoid barefoot if that is irritating you. Some of my patients during flares will go into already tested removable boots or hike and bike shoes, or something that always works, and stay in it for a 2 week period.

     Anti-inflammatory: Definitely we need to see how 10 minute ice pack on the bottom of your foot works first 3 times a day. You can add 2 advil or 1 aleve occasionally. You can also massage into the area arnica or traumeel. 

     Nerve Hypersensitivity: Go online and purchase Neuro-Eze and massage into the area 3-4 times a day for one month. Also, look at the blog for the video on neural flossing  (aka neural gliding). Do that 3 times a day. 

     Diagnostics:Remind me what the old MRI showed since this is the best test. However, getting a neurological examination to look at the whole sciatic nerve (even the spine up to the neck) to have see if you are getting neural tension anywhere. Simply having a PT evaluate how you sit and lift, etc, to give you tips on posture and how to minimize the day to day stresses on the sciatic nerve can be helpful. 

     Please give me feedback. Thanks Rich

The patient's response:

Ok, thanks!! I will begin all of these suggestions ASAP. (I am icing as I type this!!) 

Here are the MRI results. The MRI was about 2 months before I started feeling this nerve pitch. Nothing particular happened that I am aware of that caused it. I was doing well and recovering from the original injury. But as you can see from the pics, this nerve pinching that's bothering me now seems to be right in a line up my foot from the original injury. 

MRI FINDINGS: Dorsally located subcutaneous nonspecific edema of the forefoot is noted. No stress fracture is currently noted. There are bursal effusions especially between the 2nd and 3rd, 3rd and 4th and to a lesser extent 4th and 5th metatarsal phalangeal joint. Subtle flexor tendon is noted third ray. These findings are compatible with bursitis, synovitis, and mild tenosynovitis without associated stress fracture. Phalangeal sesamoid ligaments appear unremarkable. 

IMPRESSION: 1. MULTIFOCAL BURSITIS, nonspecific soft tissue edema with no stress fracture noted. 

2. The Lis Franc ligament is intact. 

Dr Blake's response:

    All of the original MRI findings indicate inflammation, but does not rule out inflamed nerves (they can be hard to see, especially with the bursitis inflammation). If we get another MRI down the line, then the expensive one, the one with contrasts, should be done since it can give more information. Ask your doc about a 8 day Prednisone Burst to jump start the anti-inflammatory attack. Rich

Tuesday's Question of the Week: How to deal with Metatarsal Pain

Hey Dr. Blake!  Hope 2014 has been good for you so far.

So I was doing really well with my recovery (after another foot injury),  but I may have tried to do too much too soon. I have a new issue with my RIGHT foot (first injury was on this foot) and something going on with my LEFT foot now too! I attached a pics (RIGHT foot is BLUE marker, LEFT foot is red marker). 

RIGHT: Big X is new pain (the dot is the old, original injury). New pain feels like a sharp electric shock on one particular nerve every time I put pressure on the area (i.e taking a step, pressing on it). It's a tiny bit swollen. I don't feel any pain when there's no pressure on it. It started one day when I took a step. Nothing happened at that moment, no quick move or anything that I would connect to an injury. It was very faint at first. Then as time went on, it felt "stronger."  In the weeks BEFORE I felt it, I was recovering from the first injury (blue dot). I was increasing my walking time/distance, experimenting with shoes other than sneakers (some high heels) around the house. The foot felt great, but weak. Then this new "zinging" little pain thing!! I tried to ignore it but I can't, hurts too much. After much experimentation and remodels, I have rigged a gel insert to support the area all around the Blue X. Problem is, my old injury (blue dot) is starting to hurt again, maybe from wearing this new rigged padding. I attached a pic of the rigged padding. 
Dr Blake's comment: yes, you must have the original area "dot" within the hole also.

On my LEFT foot: attached pic to show you where it's bothering me. It feels sore. And very rarely, a few "zings" too. I've been wearing a pad for this too. Pic attached. This came on very slowly, then one day just felt too sore to walk on it without padding. My left foot took a beating throughout the whole time my right foot was useless (from beginning August until October) 

The pain of all this new stuff in NOTHING compared to the first injury. However, I still can't walk properly so I can't ignore it. I had been doing the ankle and foot rehab at least 3x per week until last week when my right foot hurt more than normal. I would like to know what you think. I may be in your area of Cali soon and if I am, I hope to come see you. Until then, we have email and attachments :) 

Dr Blake's comment: When making an accommodation or float for the bottom of the foot, always go with the horseshoe concept like with right foot. The hole technique can make the swelling much worse as the swelling does into the hole and has no room to escape. 

Thanks, 

Hey Sam, Definitely try to get the pad on the right to float the small blue dot also. Definitely sounds like you pinched a nerve, and try to ice 3 times daily for 10 minutes for the next 10 days. Try to use the same horseshoe pattern on the left, the donut holes can make the swelling worse since the swelling is trapped in the hole. Rich

Monday's Image of the Week: Accommodation Par Excellence!!!

Pain in the Metatarsal area is a prime location to try various off weighting pads. These vary from metatarsal pads to dancer's pads to toe pads. Here is a great example of one of my patient's very successful attempts at off weighting the sore area of both feet. I gave her the 1/8 inch adhesive felt from www.mooremedical.com and she found a metatarsal pad. By pointing her in the right direction, and her spending time at home placing pads in various positions, she is feeling better than she has felt in several years. Bet you can tell where she is sore by the pattern of the padding!! 

Metatarsal Pain with Possible Plantar Plate Tear: Email Advice

Hi Dr. Blake,

 I'm all the way over here in Northern Virginia but found you while researching plantar plate tears. I think I might have one near my 4th metatarsal. I injured my right foot 8 weeks ago, was horribly misdiagnosed by a "top" ortho-foot surgeon here and am now looking for someone who can help me figure out what's really going on. 

Do you do consults with non-local patients? 

Dr Blake's comment: I have provided email/mail consultations, and I am happy to review things for you. The distance is always a problem, and I never feel that I am really doing a good job in this area. I am my own worse critic however. It is so important to find someone closer to you that you trust. You can check the AAPSM website for qualified sports medicine podiatrists nearer you. 

I have X-rays, no MRI yet but can get it.

Dr Blake's comment: This is definitely an MRI diagnosis!!

 I can not put any weight on my foot at all without pain. I can not walk or drive.

Dr Blake's comment: This is not unusual for undiagnosed plantar plate tears, metatarsal stress fractures, etc. Get that MRI. Please purchase an Anklizer Removable Boot and EvenUp and start creating that pain free environment. Ice for 10 minutes 3 times a day if you can tolerate the cold. Should feel better. 

 I'm 39, very active (lifting, dancing, lots of walking, biking, etc). I will do whatever it takes to walk without pain again. Thanks for reading this and thank you SO MUCH for this blog. It's helped me stave off some seriously depressing thoughts in the middle of the night!!

Dr Blake's comment: Thank you.

Regards,
Annie (name changed)

Budin Splint Modifications for Sore Toes/Metatarsals

Hi Dr. Blake and I hope you are staying dry!

You asked that I email you with how I’m doing. We met on Tuesday, November 6^th regarding pain on my right foot at the base of the second toe.  You prescribed a pad with an elastic loop to wear around the second toe along with some stretching and icing.

It’s now been 11 days and I can’t say I’m felling much different. The pad is irritating to wear with sneakers or boots because when I slip my foot into the shoe, the elastic loop gets pulled down and irritates the skin at the base of the toe. Sometimes I have to take it off for a while.

 I find that when I wear my clogs with an open heel, however, it is much more comfortable.  I don’t usually wear clogs but it’s the only shoe that I can wear the pad pretty much all day without discomfort. I’ve been pretty religious about wearing the pad regardless.

I’ve been bad about the icing. I’ve only iced twice since seeing you.

I do the stretches but not daily.

So I haven’t been the perfect patient.

What do you suggest?

Thank you.

Dr Blake's Response: 

Hey Alicia (name change), Thanks for the update. Try getting a digital gel pad at the Sports Shop to put under the splint. It is a long finger looking structure, that you can cut into 3rds to place over the one toe. I have also attached the link to Silipos company that makes these things.  Then you can put the splint on tighter even. You can also use paper tape on the top of your foot to tape the splint down so it will move less. Attached is the note I wrote. Definitely ice twice daily, since the pain you are feeling is inflammation. Remember to stretch and perhaps buy some Yoga Toes so that we can begin to introduce them. Sure hope this helps. Rich PS If the icing does not bring down the inflammation along, then we can have you ice and go to PT. They would love to work on your foot. 

Budin Splint is a powerful stabilizer of the toe joints. When the elastic band is irritative, a digital gel pad can be used initially over the toe, or just tape to hold down the band and prevent it from moving. 

Alicia is a return patient I have not seen for about 4 years. Nancy has pain in her right foot and second toe area for about 6 months. Her pain level on a scale of 0 to 10 is about 4 or 5. She is taking some Advil for the pain. Has 2 pairs of orthotics which both have reverse Morton's extensions made by Dr. David Hannaford. She is a 59-year-old. She is 5 feet, 128 pounds. Her activities that she likes are West Coast Swing, water aerobics, Zumba and dance aerobics. She would like to enjoy them without discomfort are her main goals.

SHE HAS NO KNOWN DRUG ALLERGIES.

Medicines she takes a regular basis include
1. Valtrex.
2. Calcium.
3. Vitamin C.
4. Vitamin D.
5. DHA.

She has had no past hospitalizations or surgery. She is on no special diet.

On my examination, I found someone who had pain in the 2nd metatarsophalangeal joint plantarly. It is sore on maximum plantar flexion of the joint, not dorsiflexion. She has full range of motion. There is no evidence of instability. She has always had a short second toe and I think that short second toe may be raising up just a little bit or the 1st and 3rd toes may be going under it. In either case it would trap the second metatarsal head against the ground and cause irritation. If you couple that with her reverse Morton's or dancer's pad, that puts the weight off the first and onto the second, so as part of her treatment I reduced the padding under the 2nd metatarsal head.

Alicia's 2nd toe is much like this. When the toe is being held up in the air by being above other toes, and can not physically get down to it's normal level, pain develops under the metatarsal toe joint. The pressure at push off stays too long in the one place. The splint is designed to pull the toe down into more normal alignment. 

DIAGNOSES:
1. Capsulitis symptoms, right 2nd metatarsophalangeal joint, 726.90.
2. Right hammertoe deformity, 735.4.

PLAN: So today orthotic devices were evaluated and on the right side the area under the 2nd metatarsal head of the reverse Morton's extension was removed. I encouraged her to ice twice a day, encouraged her to stretch the toe in a plantigrade direction without pain. I may go to YogaToes once it is less painful. I gave her a prescription for 2 Budin splints and this will be designed to hold the toe down. She is advised that she can easily adjust the bottom if there is any pressure.

http://www.silipos.com/products/orthopedics/Digital-Care