Peroneal Tendinitis: Email Correspondance

 I have been suffering from peroneal tendonitis for four years now and I'm hoping you can shed some insight on how I can kick this thing for good! Originally, my podiatrist recommended motion control shoes to control the torque in my ankle: that was a complete failure. I rolled both my good and bad ankle twice in a matter of hours.
Dr Blake's comment: Wow, that was bad luck. Peroneal tendonitis stands be more from over supination (aka under pronation) than over pronation, so I am not sure why the motion control. Neutral, and some stability shoes, are great for this problem. My favorites are the Saucony Triumph and Brooks Ghost right now. 

After this my local running store recommended a support shoe instead. These shoes are usually fine for a few weeks, but as soon as they start to break in the underpronation gets worse and worse. It's a weird combination of feelings: like the arch support is so heavy that my feet aren't touching the ground on the inside, but also that the heel has worn out so quickly that I feels like it isn't touching the ground either. 
Dr Blake's comment: Look at the posts on lateral shoe wedging (which may be crucial), and common modifications of supination control. You can even power lace for supination protection. 

http://www.drblakeshealingsole.com/2011/08/supinators-orthotic-modifications-to.html

http://www.drblakeshealingsole.com/2012/10/shoe-wedging-to-stop-supination.html

I recently switched to a neutral shoe after the owner at another local running store was horrified that I was literally walking on the edges of my feet (and I have the ugly calluses along the entire edge to prove it). The neutral shoe has helped greatly. I feel significantly less later calf pain, but I can feel the tendonitis creep back in. It almost feels as though my feet slide from one side of the shoe to the other while I'm underpronating, and no amount of lacing can keep them in place. When I strike the ground evenly I have no pain, but when the edge of my foot hits the ground I can feel it right up the tendon.
Dr Blake's comment: This is why are supinators fall in love with shoe wedging and inserts that correct. Over supination is the most unstable and dangerous biomechanical problem I treat on a regular basis. You can even purchase some Red Sole Inserts from REI and other stores, and use masking tape and/or duct tape along the lateral under surface border, to straighten your foot until you get some professional help. When dealing with injuries, finding the mechanics that are causing or aggravating the problem, is vital. Or the problem is a repeating issue. 

I've also tried a lateral heel wedge to no avail, and a full over the counter lateral insole. Are there any other options or am I doomed to pain? I can't understand how one ankle sprain 4 years ago has led to such significant change in my mechanics, I always just grabbed any old shoe and had no problems before. 
Dr Blake's comment: Ankle sprains, where there is loss of ligament stability, can cause subtle and not so subtle instabilities that the body has to deal with. Besides the info above, start doing your Single Leg Balancing nightly (for it will take 1-2 years to get super strong in the protection of your ankle and probably now is a good enough time to start). 

http://www.drblakeshealingsole.com/2010/08/video-flatfooted-balancing-exercises.html

Friday's Patient Problem of the Week:Supination and ankle problems

Good Evening Dr. Blake 

    I am a 33 year old  young man living in Los Angeles CA. I have been having ankle inflammation in my right ankle which started about 1 year and 7 months ago. It was a pretty simple episode that I got ankle cramp and I manipulated my ankle with my finger and got inflamed for over 8 months.

Dr Blake's comment: Inflammation in the ankle in somehow who stands like you do is very very common. It normally is a combination of muscle fatigue and mechanical stresses (flat feet, high arches, loose ligaments, tight muscles, etc). Typically, you place yourself into some logical problem of rest, bracing, anti-inflammatory, and stretching and strengthening. The rest part is activity modification where you try to sit more at work, or at least get a soft mat to stand on, and use weekends (days off) to recover. 

   During this time,  I was trying to not put pressure on my right ankle so I was putting my body pressure on the left foot. The inflammation was not going down with taking lots of Ibuprofen 800 mg twice to 3 times daily. I was having burning sensation and warmth feeling around my ankle all the way down towards my heel.

Dr Blake's comment:Burning can be from a lot of causes---neurological coming from local or as high as your spine, vascular with poor circulation, and inflammatory with marked swelling. Unless there is more swelling than you describe, this burning may be from some stress on the nerves, however could be from swelling deep within the ankle joint.

    I have high uric acid level which is approximately around 9.2 or little less over the past 12 years, and while suffering from burning and discomfort,  my ankle would get a warmth feeling when I was wearing shoes. I saw couple of podiatrists where one gave me lidocaine injection to increase blood flow to reduce the inflammation, but it did not help me. 

Dr Blake's comment: Nothing in the history you give sounds like gout, although there is mild versions of it. Typical Gout is red, hot, and swollen area, where you worry that there could be an infection in your workup. The high uric acid blood test could have just been a red herring. 

   Over the phase of 1 year I received 3 cortisone shots in my right ankle that it finally helped with the inflammation going down. When my ankle was inflamed, I was experiencing tingling sensation around my ankle which the tingling would be less when I was laying down on my bed.

 Dr Blake's comment: So, your tingling was probably from deep swelling putting stress on the tarsal tunnel nerves. Nerve pain is so debilitating, and your body goes quickly into a self preservation mode to relieve it. However, this preservation mode normally produces way too much muscle atrophy and severe weakness settles in. 

   After about 1 year my left foot started burning around the ankle and I have changed many shoes but I would feel the burning getting worse as I wore every shoes. My wife noticed that I walked not straight and she brought it up to me every time I walked. After reading and doing a lot of research online, I came to conclusion that I have severe supination and I still have a little inflammation on the right ankle with the burning sensation and tingling.

Dr Blake's comment: Best to send me a photo of you standing, barefoot and in shoes, from the back of the heels. The photo should be from 2-3 feet behind you in good lighting. This will help me understand the severity of your severe supination. Supination, with the lateral instability it causes your ankle, could explain all of your symptoms. That would be nice. 

http://youtu.be/bc2PRrtwemM



http://youtu.be/hxsNaBXT_ug

    I have been seeing physical therapy for couple of sessions and they have gave me stretches and some work out but I need your help Dr. Blake. Please respond back and try to eliminate my pain and suffering that I am having for the past 1 year and 7 months. My job is a Pharmacist and I stand on my feet over 8 hours. Please please get back to me to find a solution to my suffering. I would really appreciate your concern and attention Dr. Blake if you can make my wishes of walking normal without any pain. GOD may bless you and your family for helping a young married man gain back his strength and be pain free.

my cell phone number is XXXXXXXXX  please contact me if you have to and please help me with all my suffering.

Dr Blake's response:

     Thank you so very much for your email. I have tried to give it some attention. I am glad you are going to the Physical Therapist since they can be my eyes in my attempt to help some. 

The questions I would have from them:

1. Are you excessively supinating and, if so, can they design an inserts that completely eliminates that stress?

2. Do they think you have inflammatory pain or neuropathic pain? Neuropathic pain is true suffering. Ask them to teach you neural flossing and test for low back involvement. 

http://youtu.be/Xs8Cl39LXQg

3. Can they give you an Air Cast Ankle Brace for more stability but not a lot of compression?

http://www.betterbraces.com/aircast-sport-stirrup-1

4. If it is neurological, you should have a doc involved that can give you oral meds, topical medications, and be able to order MRIs, EMGs, etc as indicated. All your pain can be coming from the low back because it is so hard to stand in spine neutral constantly in your job.

http://youtu.be/E0E60NpOSHg



5. Ask the  physical therapist if an ergonomic evaluation of your work place can be done to make sure you know all the tricks at keeping your ankles and back healthy and minimally stressed. 

I sure hope this helps you some.