Bunion Tips on Treatment

I apologize for the low volume, but this was my best video in terms of capturing the power of the ocean. Please read more on non surgical treatments of bunions on my blog. Thanks.Rich

Lisfrancs and Sesamoid Injury: Email Advice

Hi Dr. Blake,

First let me say what an incredible resource your blog has been for me - and how grateful I am that you take the time to advise and treat patients simply because you believe everyone has the right to heal. So thank you.

As for me, I've seen far too many doctors - who all have very different opinions (and seemingly different levels of commitment to my healing). I'm desperately seeking a treatment plan - and some patience with the many questions that I have. 

Now here's my story...

I'm 30 years old and live in New York City. Back in late MARCH, I tripped up (yes UP) the stairs -- and injured my toe/foot. I seemed to only have pain in my big toe (top of my foot) - in the phalange and metatarsal. The first podiatrist I saw didn't catch anything in the x-ray, and believed it was a stress fracture. After 3 weeks of it not seeming to get any better, he still gave me his blessing to go on my 2 week Europe trip. I should have listened to instinct...but alas. I went, wrapped my foot, threw it in a hiking boot, grabbed a cane, and went on my way. The trip was great - but by the last day I couldn't stand. And my foot was purple.

Came home beginning of May - switched doctors. Got an MRI (and another x ray) - and it was confirmed that I have a fractured tibial sesamoid, as well as a lisfranc ligament sprain. The doctor seemed to pay little regard to the lisfranc injury - saying that a sprain isn't serious. 

          Dr Blake' s comment: A Lisfranc injury is one of the most severe foot injuries I treat, 
          with a high  percentage needing surgery.  

Now here's where things get even more complicated. I was heading to Los Angeles for a gig a few days later. The doctor advised me to non weight bear for 3 weeks (in a remove-able walking boot), use a dancers pad, then see another doctor (doctor #3).

I continued to have swelling - but iced and did contrast baths daily. Saw an ortho in Los Angeles - who perhaps due to my desire to be as conservative as possible - decided to keep me non-weightbearing for 8 weeks. The last thing I wanted was to look back and wish I would have committed to more time. He also thought that the bone might be dying, and thought that when I'm back in NYC I should have a CT scan (or bone scan?)

So now...I'm back in NYC. Saw a new Ortho (doc #4). He said that I should start putting weight on it, and to stay in the boot until my next appointment -- in 4 weeks. And he said no CT scan.

Unfortunately I had no advice on how to wean off the crutches - it was implied that it would easy to just start walking. Not really the case for me. So...I started weightbearing while still using the crutches for a few days, then went down to one crutch, and now to a cane. I seem to be doing pretty well -- except that I keep getting a shooting pain in my ankle every time I step a certain way (which isn't that often - but when it happens it HURTS). Been happening now for the last 4 days. The sesamoid, however, seems to be ok. Still a little swollen - but doesn't seem to have very much pain at the fracture site. 

Also my whole body seems pretty out of whack (my hips have a very strange turn out right now...).

          Dr Blake's comment: Typically this out of whack feeling is part of any cast regimen.
           It is helped greatly by using an EvenUp on the side without the cast, 
           and never going to one crutch. It should be 2 
          crutches or no crutches, since one crutch and sometimes canes
          throw your back and pelvic into strange tilts. 

So now that you know my story, I have so many questions...

1. My big toe still feels so strange. Like it weighs 5 pounds. Which is how it felt when I first injured it (why I assumed I broke my toe). I can barely bend it down - and can't bend it up at all. Is this normal? The pain/stiffness/heaviness goes from the joint of my big toe down to the middle of my foot. Often times I have strange twitching there as well...

          Dr Blake's comment: For what I know, this is all normal for your injury and
          being in a cast and non weight bearing for a while. You are gradually
          progressing from the Immobilization Phase of Rehab to 
          the Re-Strengthening Phase. During this phase you need a lot
          of physical therapy guidance to work on the remaining swelling,
          and increase range of motion, strength, flexiblity, and balance. There is a
          lot of hard work ahead.  

2. At this point, should I be forcing my toe to bend? Or is it all still healing that it should still be immobilized most of the time?

          Dr Blake's comment: For these injuries, you never push the toe bending
          part of rehab. You let that 
          come naturally. It is always fun to measure the range of motion 
          with each stage if you have a therapist  you will be working with. 
          Typically you come out of the cast with almost no motion in the motion, you  
          start doing some of the self mobilization movements on my blog
          under Self Mob for Hallux Limitus. You can 20-30 degrees as you 
          begin to walk normally, and another 20 degrees as you begin to run. 
           Keep the joint pain free when you are working on it, you never 
          know if more healing is still going on it there.  

3. What about ankle exercises? Could that also interfere with the healing of the sesamoid/toe? Any physical therapy for the rest of my body? Or should I still wait...

          Dr Blake's comment: Core and other lower extremity strengthening that does
          not hurt the injury can normally be started right after the injury.
          There is benefit to riding a stationary bike with one foot and 
          no tension when you foot is in the boot. There are so many core, hip,
          knee, and ankle movements that you should be doing right now,
          and that is why a PT or Personal Trainer can help. The stronger the 
          core, the normal you are lifted off the foot, and the faster
          the rehabilitation goes.  

4. This lisfranc sprain - is this really something that should be so swept under the rug? I finally researched it and it sounds like it could be a big deal. How do I find out if the sprain has healed? 

          Dr Blake's comment: Lisfranc Injuries are big deals. You need to wait 3
          months from your first MRI  to get a repeat MRI to document healing.
          I treat all Lisfranc Sprains very seriously with a 2 year 
          committment to orthotic devices, arch taping, and a gradual progressive
          re-strengthening program on all the important intrinsic and extrinsic
          muscles/tendons that support the arch.  

The middle of my foot definitely hurts right now - but I assume a lot of it has to do with the fact that I'm putting weight on it for the first time in 8 weeks. I also have a boney bump in the middle of my foot - under the big toe. The doctor assumed it was from the boot. Does that sound right to you - or could it have something to do with this lisfranc thing?

          Dr Blake's comment: Lisfranc's Injuries hurt in the middle of the foot. If you
          are weight bearing, get a orthotic ASAP to stabilize that area and learn to
          tape your arch (I have arch taping videos on this 
          blog). I am not sure what the boney bump is. You could send me
          a photo of you pointing it out, and
          another of the same spot on MRI.  

5. Does walking in the walking boot for 4 weeks after being non weightbearing for 8 (and in a hiking boot for 4 weeks before that) seem like the right treatment course?

          Dr Blake's comment: Yes, but 16 weeks of immobilization means 32
          weeks minimum more to get your foot healthy again. Go slow, go gentle,
          but persist. You are still in the hands of the docs for 
          direction, but PTs and Personal Trainers and Athletic Trainers
          should have the most prominent role in your recovery now.  

6. My left foot has also been hurting quite a bit - since it's been doing most of the work the last couple of months. Is there an insert/insole you can recommend to help this? Mostly the middle of my foot. What about Superfeet?

          Dr Blake's comment: When you get custom made functional foot orthotics from
          a sports podiatrist, they are always made in pairs. Consider seeing Drs Karen
          Langone, Dr Robert Conenello, and Dr 
          David Davidson in New York. You can also see the AAPSM website
          for all the New York 
          members. I am typically safe recommending from that list.  

7. I've been using the bone stimulator twice a day on my sesamoid - which is why I haven't been taping. Should I be taping and just removing it daily?

          Dr Blake's comment: The bone stimulator has a 3 inch penetration. You can aim
          the beam from the top of your foot where you do not have tape, and it 
          will still work. That way you can tape also. This is  at least my understanding
          of the Exogen bone stimulator, but check with the local rep. 

8. I'm not 100% sold on this ortho I'm seeing in NYC. He's just so rushed - in and out in 5 minutes. Do you know a doc (ortho or DPM) here that you would recommend? I had been recommended someone at the hospital for special surgery - but unfortunately they don't take my insurance (GHI/Emblem)

          Dr Blake's comment: See my recommendations above. Even if they are a distance,
          it is worth it. They can refer you to a local PT to do the lion's share of the work.  

9. Would it be possible for me to send you my MRI from beginning of May? I would love to know your thoughts.

          Dr Blake's comment: Yes, Dr Rich Blake, 900 Hyde Street, San Francisco, 
          CA, 94109.  

Thank you so much for taking the time. As I mentioned, I generally need to be on my feet all day (although this last one in LA was thankfully pretty low key). I'm so anxious for my foot to feel normal again, but I'm also committed to recovery and can be as patient as I need to be. However, I just need to feel like I'm doing what's "right". And with so many different doctors over the last few months (all with very different opinions) - I'm left fairly confused and rather discouraged. 

Any thoughts/advice would be so greatly appreciated. 

MANY THANKS,

Jill (name changed)

          Sorry one last question!! 

          I've been using 1/4" adhesive felt applied directly to my foot for the dancers pad. Is this correct for use in             a boot? 
          Dr Blake's comment: See if you can place as an insert in the boot. Somewhere in my blog
          I have an example of this. Get working on your orthotics ASAP and then just
          place that in the boot. I sure hope this 
          helps you. 

          Thanks!!!

         

Common Tips for Toenail Fungus

http://www.drblakeshealingsole.com/2010/10/toenail-fungus-summary-of-various.html

Subtalar Joint Arthritis: Possible Use of Synthetic Cartilage Injections

 To my knowledge, the use of synthetic cartilage injections, are 50% successful in preventing/delaying knee replacement surgery, but has not been FDA approved for the foot or ankle or hip. I know this is coming down the pike, and this article shows the foot is getting some good research in this field. 

I was wondering if you do any hyaleronic acid injections for foot joint OA pain.  Here's a link to a very interesting story:  http://www.news-medical.net/news/20130131/Viscosupplementation-may-relieve-subtalar-osteoarthritis.aspx

Tibial Sesamoid Fracture: Email Advice

     I was diagnosed by xray with tibial sesamoid fracture May 30,2013. I am 36 y/o and healthy, female. Not sure how the injury occurred.

     I am seeing podiatrist, he put me in walking boot for 3 weeks. Repeated xrays showed fracture was worse and no signs of healing. Then he recommended continue with boot, but non weight bearing for 3 more weeks. On July 11th, diagnosed with Non union fracture, still no sign of any healing or improvement. Podiatrist said to allow another 2-3 weeks, but may walk in boot and see how pain tolerance is. If still no improvement then begin cortisone injections. 
Dr Blake's comment: Typical protocol for sesamoid fracture is 3 months removable boot, with 2-6 weeks weaning out of boot maintaining pain free environment.

     I notice burning pain and discomfort after about 5 hours of working, up and down on my foot. He stated that he has seen good success with injections, I just am not sure that is the route I am comfortable with. Do you recommend cortisone injections or are there long term side effects from them?
Dr Blake's comment: Cortisone shots mask pain and slow healing of fracture. Stay away from shots if you are trying to avoid surgical removal. 

     I have read about surgery, but podiatrist only recommends that as a last resort or failed attempts with cortisone. I am a nurse for a busy Family Practice physician and I need (or my boss) needs me to be back at work asap. She is very understanding but this is very frustrating. Its only been 8 weeks! Any suggestions? 
Dr Blake's comments: You need to stay in the boot for the entire 3 months. This is a no brainer to me!!! During the next month have shoe inserts made that take pressure away from the sesamoid. This will speed up your weaning process, and the device will need to be worn for up to 2 years. Get a baseline MRI ASAP to be used to compare your progress in 6 months. You should be able to work with the boot (or well padded surgical shoe!). 

I have not been told of pads to use, can you get them at medical supply store and at my age do you still recommend bone density testing? Thank you for your opinion, any suggestions or help is greatly appreciated.

Dr Blake's comment: You can order a roll of 1/8th adhesive felt at www.mooremedical.com to make your dancer's pads. You really need to read all the posts on sesamoid injuries in this blog (they are plentiful!!), so you and I can be on the same page. There is diet, bone stimulators, icing, contrast bathing, shoe modifications, supplements, spica taping, etc to help you. There is nothing unimportant about this bone, so it is important to save if possible. I hope this helps you some. Rich


     

Melanoma Prevention: Ample Sunscreen on those toes!!! this summer

Shin Splints: Brief Discussion of Syndrome

Shin Splints: Fitness Tips from Personal Trainor Lisa Tonra

The Dreaded Shin Splints (aka, 'This dull, aching in my shins makes me WISH my leg were splinted!)

Runners, basketball/tennis players, even cyclists take note - start your program slowly!

As a new runner or player of sprinting-centric sports (basketball, tennis, etc.), you may be prone to developing pain in the front or inside area of your lower leg. This is very common. After more serious conditions are ruled out by your orthopedist or podiatrist (like a stress fracture), you may receive a diagnosis of 'shin splints.' This is a fancy term for a condition that involves inflammation or tears of the muscles of the shin, or the bone to which those muscles attach. While uncomfortable and activity-limiting, they are very often due to simple over-training and/or muscle imbalances in strength and flexibility between the front and the back of your lower leg and ankle.

After consultation with Dr. Blake (or another sports minded doc) about proper footwear selection and the use of orthotics, the following treatments and exercises will help you manage your current discomfort and help ward off future episodes of The Splints.

1. Ice! Nothing reduces inflammation like icing. Ice for 20 minutes per session, as many times as you can in one day. Another option is to use contrast baths: submerge your affected lower leg up to the knee in ice water for one minute, then follow with immersion in hot water for one minute. Repeat the cycle for 20 minutes total.

2. Cross train!  Use the stationary bike, elliptical machine, rower or swimming pool (anything that reduces the impact of ground forces on the lower leg) in place of your usual running/sprint-centric workout at least once per week. Work at the same level of cardiovascular intensity and you will not lose one scrap of your hard-won fitness gains.

3. Stretch! If the pain is on the INSIDE of your lower leg, stretch your Achilles Tendon. If the pain is on the FRONT of your lower leg, stretch both your Achilles Tendon and your calf muscles. The stretches are similar, and easy to do anywhere. Simply face a wall or other sturdy object (like a counter top). Lean forward slightly from the hips, with hands at waist or shoulder height for support. Place one leg behind you, hip distance apart from the leg in the front. Keeping the knee straight, press the heel of the foot on the back leg into the floor until you feel a vigorous stretch in the back of the lower leg (just above the heel). The muscle being stretched is your gastrocnemius, or large calf muscle. To focus the stretch on the Achilles Tendon, simply BEND the knee of the leg in the back position. You may drop your hips down and forward to deepen the stretch. Hold each stretch for about 30 seconds. Repeat twice.

4. 'Pre-habilitate!' Developing good strength in your shin muscles and the muscles of your feet and toes will go a long way toward warding off future bouts of The Splints. Here are a couple of good ones to try:

     a.  While sitting with feet flat, trace the alphabet on the floor with your toes. You can also try picking up marbles or a towel using your toes. Try 2-3 rounds of 60 seconds each.

     b. Walk on your heels (with toes pointed up towards your shins) for 30 seconds. Rest for one minute, then repeat. Do 2-3 cycles of heel walking.

You can also ask your Dr. Blake about taping the lower leg, if you simply must continue to run. A good taping job will help hold the tendons of the muscles of your shins against the shin bone itself to prevent additional stress on the area.

Remember, increasing your mileage slowly (no more than 10% per week), actively cross-training  and avoiding excessively hard running and playing surfaces will go far in preventing future episodes of shin splints. Because no one likes to be sidelined from their favorite sport!

Good Luck!

About Lisa: 


Lisa Tonra, a twenty-year veteran of the fitness/wellness business, holds credentials from ACSM, NASM, and BASI Pilates and is currently a Physical Therapy graduate student. She specializes in injury 'pre-habilitation,' prevention and recovery for all sports-related and overuse conditions. Lisa can also design, implement, coach and monitor fitness routines for all recreational athletes, fitness enthusiasts and beginning exercisers. Her philosophy is a simple one: "There is a (sometimes hidden) fitness enthusiast in all of us! It’s good to set a short-term fitness, health or lifestyle goal to get yourself up and moving, but challenge yourself to take the longer view of 'training for life.' What are Your Body Goals? I can help you achieve and maintain them, and do it injury-free!" 

Visit Lisa's personal website here: http://yourbodygoals.com

How To Tell If Your Running Shoes Are Worn Out: Excellent Video Dr Jenny Sanders

Posterior Tibial Tendon Surgery with Gastroc Recession

Hi Dr Blake
     I am interested in your advice...I was a very active runner until I began having lots of issues with my posterior tibial tendon and eventually, after about a year of non-surgical treatment, I was diagnosed with a navicular accessory bone.  

     I had it removed 5 months ago, along with a gastroc recession.
Dr Blake's comment: 
     The restrengthening progress of surgical procedures to arguably the 2 most important muscle/tendons in your foot and ankle can be a 1 to 2 year progress. That does not mean it will take you that long to get back most of your power within a year. Typically, 30% improvement is seen by 3 months post surgery. The 3 to 9 month period is slow with gradually improvements up to 60-70%. Then, the 9-15 month part of the rehab is where the true power comes back as the internal scar tissue is finished it's long course of remodeling and thinning out. This, of course, is predated on a physical therapist who knows how to rehab this successfully, and you patiently go through the Phases of Rehabilitation correctly---Immobilization, Restrengthening, and Return to Activity. 

 My question is about how long it should take to recover?
Dr Blake's comment: So, at 5 months, you should be out on any immobilization devices like removable casts, you should be in orthotic devices and taping your arch daily, you should be increasing your walking, and perhaps started on a Walk/Run Program (although that can take up to 9 months to start). The restrengthening should be well underway with toe raises, posterior tibial theraband work, single leg balancing, and core strength workouts. As much biking, elliptical, and swimming the better as long as nothing causes limping. Read my post on "Good Pain vs Bad Pain" and do not drift into the Bad pain that often. Recovery is always a Bell Shape Curve, with some faster than others. There are so many variables at play. However, monthly you should be progressing, and keeping that 0-2 pain level Painfree environment while you get stronger. July 2013 should have more time on the bike, more toe raises, 5 more reps of theraband, easier time at doing the Single Leg Balancing, etc. than June was. You are in a time of plateaus. 3 to 9 months post surgery can go slow. With each 2 week or month plateau, it is up to the doc and PT to decide if normal, or if changes in your program are necessary. 


 I saw the surgeon at 4 months and he was very vague,and while I can do a bit more than I could Prior to surgery (cycling, some elliptical, bit of walking) it still gets quite sore.
Dr Blake's comment: To really see where you are at, you need to stay in the 0-2 pain level Good Pain Side of Rehab on a day to day basis. That is really where you are at. Find what limitations you have in attempting to maintain this level, which honors your tissue's ability to take stress, and write those down. It will take you 2-3 weeks to get a feel of really where you are at and then you can compare July accurately with August, and August with September, etc. Remember pain leads to swelling and scar tissue, and we need to reduce build up daily.

 I am doing several strengthening exercises and calf stretches, and back off when the pain gets worse but in the last few weeks I don’t feel I’ve made that much progress. Is this normal and when do you think I should expect to be able to start running?
Dr Blake's comment: When can you run? The answer is typically easy and that is when you can walk for 30 minutes at a normal pace without increasing in pain above 0-2, then you can be started on a 30 minute Walk Run Program. I have that program in this blog. 30 minute Walk Run Program has 10 levels that you progress through slowly and carefully, and you are only starting with 3 minutes running. I hope this all makes sense. Listen to your body. If you do not have help from a PT, get some if possible to give you guidelines on how to progress over the next 4-6 months carefully. Good Luck!! Rich
Ciara (name changed due to Witness Protection)

5 Mechanical Causes of Injuries and Pain Syndromes: Video Intro

Plantar Fasciitis: Educational Video on Basics of Treatment

I hope you enjoy my first attempt with this wonderful program called PowToon to make educational videos.

Plantar Fascial Stretches For Central Heel Pain??

Will these stretches assist with pain that i'm finding in the center of the heel? I know that Plantar Fasciitis is typically at the base of the heel, closest to the arch, however I can press the center of my heel pad and feel pain. Thanks

Dr Blake's comment: 

Thanks for the comment. Typically, the stretches help some, but ice massage on a frozen sports bottle for 5 minutes 3 times a day works the best. The center of the heel pain is typically bursitis pain, more than fasciitis pain. Hope this helps you. Rich

http://www.drblakeshealingsole.com/2010/05/quick-tip-7-rolling-ice-stretch-for.html

For Heel Bursitis, massage under the heel itself, in that 2 inch wide area, for 5 minutes  three times per day.

Nerve Symptoms: Start with Neuro-Eze but Evaluate the Cause

After several months trying to heal my sesamoiditis I started getting sporadic tingling sensations all over my foot, and a numb feeling around the sesamoid and along the inside of my big toe. After reading this post I subsequently bought neuro-eze with the hope that it would alleviate these symptoms. However, I have been hesitant to use it because the description on the bottle says that it helps with neuropathic pain, and I do not have any nerve pain and I'm not entirely sure if what I have would be defined as neuropathy. Would you still recommend to using it for my symptoms of tingling and numbness?


Dr Blake' s comment: 

   Yes, it is a good starting point for the neuropathy (abnormal nerve sensations). Patients with neuropathy get just numbness/tingling, just pain, or a combination of the 2, but it is still neuropathy. Neuro-Eze in my experience works on 50% of those cases. That being said, please have a neurologist or physiatrist look into the cause of this problem. Is it coming from your back because you limped for a while? Did the swelling around the sesamoid trigger some excitable nervous activity that now needs to calm down? Is it a totally separate problem called peripheral neuropathy related to pre-Diabetes, Vit B12 deficiency, osteopenia, etc? I hope this helps you. Rich

Fitness Tidbit of the Day from Lisa Tonra

Fitness tidbit of the day:

Gals: are your thirties well behind you? (I'm right there with you!) Have you noticed that your knees seem to be moving a bit more towards each other, perhaps even looking somewhat knock-kneed? You might 'need' to look a bit more south, towards your feet! It's always wise to check with your podiatrist to rule out more serious conditions and those requiring orthotics or other external support, but a few simple exercises performed in bare feet can make all the difference in knee health. Try this simple routine:

1. Warm-up: While standing, lift all ten toes off the ground and lower them. Now lift all ten toes off the ground and spread them as far apart as possible. Finish with lifting one heel off the floor at a time, rolling from one side to the other. Repeat each move for 12 repetitions.

2. Heel Raises: Standing on both feet, raise your right heel and then set it down. Do the same with the left heel. Now holding onto a firm surface, such as a counter top or chair back, rise up onto both heels simultaneously. Do one set of each movement for 12 repetitions.

3. 'Domers': Standing with feet flat on the floor, lengthen toes along the floor as broadly as possible, then pull them inwards towards you while keeping them on the floor. Try to keep your toes straight rather than curling them under your foot. Return toes to starting position and repeat 12 times.

Strengthening these small-but-mighty muscles of the feet will help increase your foot and lower leg strength, enhance your awareness of foot mechanics and give your knees a big positioning boost! Good luck!


About Lisa:

Lisa Tonra, a twenty-year veteran of the fitness/wellness business, holds credentials from ACSM, NASM, and BASI Pilates and is currently a Physical Therapy graduate student. She specializes in injury 'pre-habilitation,' prevention and recovery for all sports-related and overuse conditions. Lisa can also design, implement, coach and monitor fitness routines for all recreational athletes, fitness enthusiasts and beginning exercisers. Her philosophy is a simple one: "There is a (sometimes hidden) fitness enthusiast in all of us! It’s good to set a short-term fitness, health or lifestyle goal to get yourself up and moving, but challenge yourself to take the longer view of 'training for life.' What are Your Body Goals? I can help you achieve and maintain them, and do it injury-free!" 

Visit Lisa's personal website here: http://yourbodygoals.com

Peroneal Subluxation/Dislocation Syndrome: Video Presentation

Video on Importance of HbA1c Test for Diabetes and Stability of Diabetes

Morton's Neuromas: Success with Alcohol Shots

Excellent article about Morton's neuroma which has plagued me for six years. Had some success with alcohol injections, but my podiatrist moved to Kansas before completing series of shots. Replacement podiatrist doesn't believe in their value. Can you recommend another doctor in Wilmington, NC? The pain is severe after 45 minutes of hiking which is my passion.  Prefer NO surgery.  Also, your search function on my iPad keeps taking me back to the same article when I try to access potential treatments you recommend.  Thank you for any help with identifying a doctor who,shares your values and expertise.  

Dr Blake's response:

     There are the podiatrists in North Carolina from our national Sports Medicine Academy--AAPSM. They are normally the best place to start.  

Christopher J. Gauland, DPM		2140 West Arlington Blvd. Ste. D	Greenville	NC	27834
William J. Johncock, DPM - Fellow	828-327-3029	419-B 2nd St. N.W.	Hickory	NC	28601
Robb A. Mothershed, DPM		3057 Trenwest Dr.	Winston Salem	NC	27104
Jeremy Thomas, DPM Website	919-851-3435	204 Ashville Ave Ste 40	Cary	NC	27518

There are some of the other articles on Morton's Neuromas, but many more throughout the blog. Sure hope this helps. Rich

http://www.drblakeshealingsole.com/2010/08/mortons-neuromas-which-shots-to-get.html

http://www.drblakeshealingsole.com/2011/05/evaluation-of-possible-mortons-neuromas.html

http://www.drblakeshealingsole.com/2010/08/mortons-neuroma-treatment-options.html

Foot Possible Stress Fractures: Email Advice

hi doc,

i'm a former patient (i can't remember when exactly, but it has been a while). at the time i was seeing you, i had problems w/ stress fractures in both feet (revealed via MRI). you had me do contrast baths, taping, wearing orthotics and i had to wear a walking boot at one time or another on either foot.

during a recent tennis match, i was forced to make a shot which had me land a bit awkwardly on my left foot. i felt "something" right away, but it wasn't enough to prohibit me from playing the remainder of the match. since then, i've felt some things that make me think (more like know) that my left foot is broken. i've had the same type of throbbing at night that has kept me awake at night on the top and bottom of the ball area of the foot. there is no swelling, only slight discomfort when walking - pain in the 3-4 range that varies during the day - and the pain is not constant.

i've been able to play tennis, but i've been taping my foot (amazing how i remembered to do it just like that!) for support.

think it's best to actually come in or do you think i can just tape and immobilize for a while to see if that has any positive effect (or possibly no effect)?


very truly yours,

Dr Blake's comment:

     Ralph (name changed), thanks for the email. It is so difficult to play tennis (or most sports) with a stress fracture, that you either have a small one, or just a sprain of the ligaments. I agree that it sounds like a stress fracture however by how sudden it came on. These scenarios are always stress fractures until proven otherwise. Stress fractures always give swelling, but with some of the deep ones, you can never see the deep swelling. Small stress fractures, if given time to heal, normally take 3 months to heal. So, you can wait the 3 months, and if you are not appreciably better, than let's take some xrays. Read my blog post on Good vs Bad Pain, and avoid bad pain. No limping or sharp pain while playing or you will hurt something worse like your knee. If wearing the old removable boot during the work day makes it feel a lot better, I would do that (even for 4 hour periods can rest the area and help healing). Remember to get 1500 mg Calcium and 1000 units Vit D, check the foods you eat for average amounts and supplement if you have to. If tape helps, tape daily for 2 weeks longer than you think you need too. 3 times daily work on the inflammation with 10 minute ice packs and/or contrast baths. I sure hope this helps. Rich

Hallux Rigidus: Email Advice

Hi Dr. Blake




I'm an active 52 year old female with end stage hallux rigidus. My condition was caused 27 years ago when my big toe was jammed into the joint playing soccer.



Each year I would assign a percentage to inconvenience the pain disrupted my daily life. Once the bump appeared about 2 years ago the percentage went up to 90%.



In the past 6 months I've had 3 opinions. Podiatrist wants to clean the joint then a joint replacement in 10 years, orthopedic 1 wants a fusion, orthopedic 2 (top doc in major east coast city) said joint destroyed and severely arthritic. Fusion is my only option.



Your blog is incredible and helped me ask great questions. No one offered spica taping which I just tried a few days ago with great pain relief.



I haven't seen much on what the risks would be if no action is taken. I understand the disease is progressive. Can the joint break.
Dr Blake's comment: No the joint can not break. It is gradually self fusing, but that produces both bone and soft tissue inflammation. The soft tissue inflammation can be controlled with icing 2-3 times per day, occasional cortisone shot or oral cortisone burst, contrast baths 3-4 times per week, spica taping to limit the bend of the joint, NSAIDs occasionally, bouts of PT or acupuncture, and activity modification. 
The bone inflammation is also helped by contrasts baths, possible off label use of a bone stimulator, physical therapy, off weighting the joint with orthotics and dancer pads, and occasionally use of removable boot, stiff hiking boots, carbon graphite plates. Hang in there and see if the above can help you get this calmed down. You were good to get the opinions, of course, if you have any surgery, you would have to get an MRI and possibly CT Scan to analyze the present situation better. Rich



I'm very hesitant to fuse. Although I was told its self fusing. Is it ok to let the body self fuse. I can tolerate the daily pain for the most part.



Thank you for dedicating your time to helping those of us living with this crazy condition.

When Working Out: Understand the Laws of the Environment You are In

When you are feeling rushed and in a hurry,  maybe it is time to stop and appreciate the wonder all around you. These photos are from Centurion in Pilanesberg Game Reserve, South Africa . The guy in the car was honking, trying to get past the elephant.                                                                          Road rage, it affects us all...

Should we Cool Downafter Exercise?

New York Times article on whether or not we need to cool down after exercise sent by one of my patients. 

http://well.blogs.nytimes.com/2013/04/24/do-we-have-to-cool-down-after-exercise/?hp&_r=0

Cipro and Prednisone's Negative Impact on Tendons

Hi Rich,




A friend said I should tell you I'm finishing cipro (for stomach bug) and was on prednisone recently (related to shingles) in case that makes me more prone to a tear or injury. I guess that happens with some corticosteroids and antibiotics.



I'm taking it easy. Let me know if this changes anything.



Thanks very much.   Dr Blake's comment:   Hey Nakima (name changed), You are suspectible for 2 weeks after stopping Cipro to injury tendons. Please finish the medications, wait 2 weeks, and then increase activity and exercises. You have a double whamy with both those meds. Lucky you. rich

Achilles Tendinitis: Avoid Cortisone Injections

This was a comment posted today on 6/28/13.

First I want to say that I've had Achilles tendonitis in both ankles for the past 5 years. I've had cortisone injections every 6 months for the first 2 years from my local Doctor then went to a Physiotherapist and had 6 months of Shock Wave treatments that didn't help.

Dr Blake's comment: Please try to avoid any type of cortisone injection around the achilles tendon. I am so hopeful that ultrasound guided injections will be the wave of the future, but it will take many years to prove that any injection of cortisone around the achilles tendon is not potentially dangerous. Remember health care providers: do no harm. Use physical therapy, acupuncture, body work, orthotics, stretching, strengthening, etc to help the achilles. 

 I then went to a Specialist and received more injections which only helped for about a month each time and then I was back again for more. Then on the 24th September 2011 I sprained my ankle as I was getting out of bed - yes, before I even touched the floor with my foot. I heard a very loud crack and it hurt really bad - even my husband heard it! It started swelling and aggravated my Achilles tendonitis to the point where I couldn't wear my shoes.

Dr Blake's comment: This is probably a partial tear of the tendon causes or aggravated by the cortisone. 

 I had to buy a pair the next size up if I wanted to go somewhere. It stayed very sore and swollen for months until I had a intensive set of cortisone injections in February 2012. It helped (until now) and the ankle swelling and tendonitis went away but I still have a strange swelling on the top of my foot. It starts where my toes join and then goes up the foot almost to my ankle. It swells and hurts more if I'm on my feet a lot or even just a few hours so I'm going to try your hot and cold bath method to see if it helps.

Dr Blake's comment: This was a comment from the contrast bathing post.

I still have the Achilles tendonitis (in both ankles now again) and was referred back to a different Physiotherapist. After 5 treatments he said I had too much inflammation in my body and couldn't treat me - the more he and I worked on it, the worse it got. The strange thing is, all my doctors etc. have told me doing The Negative Heel Stretch is the only way it will help it but in one of your videos, you say they should be avoided.

Dr Blake's comment: Here is the video associated to that comment.

 I've tried doing them (because my doctors have told me) but I had excruciating pain and had to stop. It only makes my problems worse and for some reason they don't believe me. Anyway, I'm going to follow your advice with the calf, ankle and foot stretching instead and hope it works.

Dr Blake's comment: Definitely push to get an MRI so that we can analyze the 3D of the tendons. Please stay away from cortisone and let the MRI put us into a specific direction. 

Surgery of the Future??

My wonderful friend Kenn sent me this great video highlighting one Israeli company and there great advances in non invasive surgery. I love the Star Trek reference, because this is what I dream about for the surgery of the future!!!

Golden Rule of Foot: Keep It Simple Stupid

Golden Rule of Foot: Keep It Simple Stupid

     Yes, the famous KISS principle applies here as in most aspects of life. So, it is a great start to the Golden Rules of Foot that podiatrists live by. For every treatment plan, there are simpler and more complex modalities. Patients can help you decide if you go for the big guns or start slowly. I make mistakes all the time being too simple when more complexity is needed, and too complex when simple will do. So, I allow my patients a vital role as we discuss options. It is the nature of a sports medicine practice anyway for the doctor/therapist and patient to team up to work together on the problem(s) at hand.

     One of my patients today just injured her posterior tibial tendon. Because of many factors, including the fact that she ruptured the other posterior tibial tendon 15 years ago, I immediately ordered an MRI to know what direction to go towards. This would be considered a more complex approach, instead of a more simple xray, with course of icing, anti-inflammatory medication, and ankle brace. But, the seriousness of possible missing a tear and immediately treatment thus I could not take a chance. The more one uses an MRI you see when and where it really makes a difference. No KISS Principle today.

     One of my new patients today was in for a second opinion regarding big toe joint surgery. Very serious stuff, but her conservative care was very lacking, and the surgery suggested very complex with joint replacement. I started her icing 3 times daily, spica taping to hold the joint still, Cluffy wedge to place weight on the first toe, and dancer's pads to further off weight the big toe joint. Simple stuff to start for a serious problem. She is to call or email in a month and also send me her MRI done 6 months ago. Here I am starting with the KISS principle since it seems helpful and direct.

     One of the interesting factoids I have learned is that complex is exciting, interesting, and seemingly professional to most doctors, therapists, and doctors. They expect treatments to be something the patient do not do on their own. Add a laser into the discussion and everyone gets excited. Medical schools and seminars emphasize complex treatments and testing. And this is how the KISS Principle gets ignored, violated, battered, and destroyed daily in most medical practices. Students who rotate occasionally through our office seem bored with simple solutions and definitely are not taught this stuff. I rarely see a bunion patient with toe separators by their podiatrist as an example.

     I am internationally known for my orthotic designs, yet I use OTC orthotics routinely when KISS applies. I always prefer icing and contrasts to oral medications or injections. If a patient said that they would rather have surgery than to ice 2 times a day for the rest of their life, I would have a vigorous discussion of why that may not be prudent. The KISS principle can be boring, time consuming, and non-flashy, but 90% of the chronic pain patients I see have a very inadequate KISS based conservative program of treatment when I first see them. These are patients that have seen up to a dozen of health care providers. I also give credit for this dilemma to the patients for not following through on simple treatments, or implying to the health care provider that it sounds too simple (the provider hears that as an attack that they are "simple minded.") How often are simple treatments ended because they only gave 20% pain relief when 5 simple treatments additively could give 100% pain relief.

     When you are going through treatments, find what works even partially, and stick to them for 2 months longer than you need to due to pain. Make your treatments additive (One from Column A, One from Column B, etc). Add complexity when needed, but if the treatment complexity seems more than the seriousness of the injury, ask questions. And if the treatment simplicity seems not enough for the seriousness of the problem, ask more questions. I sure hope this thought process is helpful. Dr Blake
   
     

Smart Socks: They are on their way to Help Athletes and Diabetics

I am so excited about the future. These two videos give a little look into why I am so Happy!! Socks to help me treat my runners and socks to help me treat my Diabetics. 

First Metatarsal Position: Important to Know with Metatarsal Problems

One important measurement that bio mechanic specialists evaluate is the relationship of the first metatarsal to the second metatarsal head. The foot should be centered under the ankle joint (therefore not pronated or supinated). One thumb on bottom and index finger on top grab the second metatarsal head and stabilize it. This will be the reference point. With the other hand, grab the first metatarsal head also from top and bottom. See where the first metatarsal head lies in relation to the second metatarsal head when the thumb fingernails are parallel. Then move the first metatarsal head up and down noting the overall motion and position. The motion is ideally 5 mm up and 5 mm down. In this patient, the left first metatarsal moved only 2 mm total (4 mm down and -2 mm up). This is called a stable plantar flexed first ray. Ideally the first and fifth metatarsal heads are lower than their adjacent metatarsals.

On this patient's right foot, the first metatarsal rested 3 mm above the second metatarsal. The overall motion with 6 mm (6 mm up and 0 mm down). This is called an elevated first ray or metatarsus primus elevatus (I love to talk like I am smart!!) This is an unstable first metatarsal that will not hold up the arch, and causes instability in the foot. It can be the cause of bunions or produced by the formation of a bunion. When recognized, orthotic modifications like the Cluffy Wedge or Morton's Extension  can be used, and if surgery is being done, corrections for the elevated bone can be done. With an elevated first metatarsal, the weight goes more to the second and sometimes third metatarsals leading to pain syndromes like metatarsalgia, capsulitis, neuromas, and hammertoes.