Nerve Irritation Post Ankle Sprain: Email Advice

Hi Dr. Blake,

I haven't seen you in many years (I think my last visit was around 2004/5 re: my plantar problems while qualifying for the Boston Marathon), and now find your immense blog! Since then, I got married, had 2 kids, and am quasi-coming up for air. Would you please advise me...I hurt my ankle again =(

Late last night, I rolled my left ankle outward while trying to get on a dome-shaped balancing ball at the gym. I heard a popping sound on my way falling down to the floor. I was able to get some ice on my ankle at home. But since then, I've been limping around the house (hardwood floors) and trying to avoid chasing my kids (ages 3 1/2 and 2). My biggest concern is a tingling feeling around the ankle bone that radiates down to my heel and up to my arch area.

I've wrecked this ankle before in a stupid snowboarding accident and have sprained it several other times in my life. But I don't remember the tingling. I'm worried about that because isn't that an indication of nerve damage?

Thanks so much for your advice! I'll call your office to make an appointment if the tingling is still going on. I went to the gym today and worked out my upper body. People thought I was nuts hobbling from machine to machine...

Best regards,

Dr Blake's Response:

Hey Allie (name changed), sorry for the delay. Yes, you must of jerked the nerve real good. It can take a while to calm down. If you have an ankle brace that ties up, that may rest it well. You can also adjust the lacing so that it does not push hard into any sore areas. Continue icing for 96 hours, then begin contrast bathing once daily. See my blog post on how to start contrast bathing. Be good to it and hopefully it will settle down quickly. Rich

http://www.drblakeshealingsole.com/search/label/Contrast%20Bathing

Nerves love non painful massage. And they usually love heat, in general, over ice. Try gentle massage to the swollen areas, and gently move the ankle. I typically teach patients to use their big toe as a paint brush in the warm water of contrast bathing and attempt to paint the alphabet. Also, order a bottle of Neuro-Eze online. It is a good nerve topical medication. You massage a small drop into the area 3 times daily. I sure hope this helps. Rich

Sesamoiditis: Email Advice

Dear Dr Blake,

I am contacting you from Australia as I have been suffering from a particularly persistent case of sesamoiditis for the past 4 months. I read your blog and was hoping you may be able to help as I'm desperate for answers. 

I have tried all methods of conservative treatment, including custom orthodics, 2 cortisone injections (FHL tendon sheath guided by ultrasound) and 1 MTP joint capsule. I had a negative reaction to the second injection, with increasing swelling pain in the 1 MTP. My orthopaedic sports surgeon, decided it was best to have a investigative synovectomy with biopsy carried out to eliminate any potential infection/underlying inflammatory condition that was not appearing on blood tests or MRI. The biopsy yielded no results.

I have also been in a cam walker for almost 3 months, with 2 weeks of crutches included in there post surgery. I have been training in professional football. I am desperate to heal this condition and am reaching out to you for help as I feel my options here in Australia are limited, with little success this far.

I am particularly interested in ESWT and the specific modalities applied so that I may be able to request from a clinic here. I would also be interested to hear your opinion on PRP injections or Augment for bone healing, even though no fractures are present in my case (just a bipartite sesamoid, confirmed via xray and 2 MRI's).

I would greatly appreciate your assistance Dr Blake as I am a very active person and this condition has severely affected my quality of life and aspirations of becoming a punter in the NFL.

Yours sincerely,

Dr Blake's comment: I am honored you have asked me. I have no experience in ESWT or PRP or Augment for this condition, but I think that there is a place for Exogen Bone Stimulation to strengthen the bone. You have been in the Immobilization Phase for typically the time you would for a broken sesamoid, so the question is how to progress you to the Restrengthening and Return To Activity Phases. I am happy to look at any MRIs that you want to send me. The Pacific Ocean is not that big. I would have to assume the length of time is either from inadequate orthotic protection, a misdiagnosed small sesamoid fracture, or pain more from soft tissue with inadequate physical therapy. If everyone is happy that the bone is not broken, find out who makes the best orthotics in town or in the biggest town near you. See if a physio can evaluate you for bone, joint, or soft tissue problems. Ice Pack the area 3 times a day for 15 minutes, and do contrast bath each evening. Buy a roll of 1/8 th inch adhesive felt from Moore Medical (www.mooremedical.com) and with a tennis shoe 1 size bigger, and a good deep toe box, try to design a dancer's pad and arch support that when you walk and run there is no weight on the sesamoid (a slight overcorrection of the foot as a temporary design). Send me photos of your foot, inserts, anything and I can give you advice. Do you have swelling? Does the joint have good range of motion? When does it hurt---with joint motion, or just with pressure? Let's start analyzing. Best to comment on this post, but it you want more confidentiality, email me again. I hope this helps some. Rich

Patient's Response:

Hi Rich,

Thank you so much for your reply.  

From what I have been able to gather in my research, there are two different types of sesamoiditis.  One which is more related to a bony stress response, and the other which is more related to FHB and FHL tendon/ligament inflammation.  I think there's no doubt that initially it was a bony stress response, however I tend to think the sesamoids are now more reactive to the surrounding inflammatory soft tissue.  The MRI's reports detail tenosynovitis to FHB and FHL.

Dr Blake's comment: Tenosynovitis is an advanced, very sore, form of tendinitis and hard to get rid of. 

I was using a personal ultrasound device for a few days (ultrasound pro) which I bought over the internet, which has a low frequency setting.  I was using this around the FHL and FHB area, as well as 1st MTP.  It seemed to aggravate things for a couple of days and then settle down.

Dr Blake's comment: Ultrasound units that you can purchase are either for bone or soft tissue. The soft tissue ones are bad for bone healing, so you need to know which one you are getting. 

  So I have stopped this and am now only using the Melmak bone stimulator which my specialist recommended.  My specialist says its the same as an Exogen 4000.  Here in Australia you can't rent Exogen, you can only buy them for around $1,800.  So I am renting the Melmak for 1 month ($330) and doing 20 min per day treatment as prescribed. 

Dr Blake's comment: Definitely switch to twice a day for the same 20 minutes. 

 I was hesitant to use this as I have been told I don't have a fracture as such and was wondering how much good it will actually do for a "stress reaction" to the sesamoid.  I hope it helps rather then causes a negative reaction.  Do you think these devices help with soft tissue/ligament and tendons? What about 1st MTP swelling?  

Dr Blake's comment: I love this device for building bone strength. A bruised bone would be helped as would a broken bone. For the soft tissue, due regular PT, icing massage, spica taping to limit the motion of the FHL and FHB, and contrast bathing daily for the swelling. 

The 1st MTP is still swollen (6 weeks post synovectomy) and range of motion it limited, although it improving as I'm doing some light rehab like picking up pegs and just ROM exercises.  I'm also doing some heat treatment like hot bath soaks, sauna then swimming pool.  I still haven't had a proper answer from the doctors I have been consulting here as to why I had such a negative reaction to the cortisone injection into the 1st MTP.  I think it was administered incorrectly and have not doubt it set my recovery back significantly.  At the time, the doctor commented - "oh that's good, I got more in than usual there."  I was told he got about 1.5mls into the joint capsule, which from what I can gather was too much.  Also, if there was any bruising of the articular cartilage it can really respond badly.  Would articular bruising show on an MRI?

Dr Blake's comment: Yes, articular bruising shows on MRI. Typically, when my cortisone shots irritate things, for whatever reason, it is 2-4 weeks before we are back to square one. And, in those cases, you never get any benefit from the cortisone, which I do not understand why.

Regarding the orthodics, these have been fitted by one of the best here in Brisbane.  He is the podiatrist for our professional sporting teams, although he didn't employ casts for my high arches.  Techniques include heal cups, posts from 2 to 5, dancers pad and arch support.  I have attached pictures of my inserts for reference.

Dr Blake's comment: Do they or do they not take pressure as you walk off the sesamoid? If not, modify!!!!

I have also contacted the radiologists who took the MRI's.  They are able to set up a web site for you so you can view the images online.  For this option I need to provide them with the following - name, location, provider number, specialty etc). We would then create an account for this doctor so he can log on.  If this doesn't work I can arrange to have the pictures sent via email, although these would be still images.  Would you mind providing the details so I can have QSCAN set up an account on our end?  I will also get copies of the MRI reports to emailed across to you.

Dr Blake's comment: Great, will do in the original email.

I continue to ice each night for 20 minutes which helps.  I have also just started (this last week) getting out of the boot more and back into my trainers with orthodics around the house.  I have also been taking silica as it's supposed to help with connective tissue strengthening (i.e. ligaments and tendons).  I am also taking glucosamine, fish oil, Vit D and calcium supps, in addition to a multi.  I eat a very good diet so I don't think there is anything more I could be doing nutritionally to aid in recovery.

I am seeing my surgeon on Monday (tomorrow) for another post op review and I will request another MRI to see how things are progressing and will keep you posted.

I am happy for you to repost this email on your blog.  Feel free to modify/amend parts as you see necessary.

Thanks again,

Plantar Fasciitis: A.R.T. and Graston to help move out the stubborn scar tissue

For any one that has suffered from plantar fasciitis, there are two important manual techniques that can really help. These techniques are A.R.T.(Active Release Technique) and Graston. These 2 short videos adequately demonstrate the techniques. Most Chiropractors and some PTs are certified in these techniques. So, if the going is slow, consider these techniques, designed to break down chronic scar tissue, as possible help for your sore feet.

Hallux Limitus: Email Advice

Hi Dr. Blake,

I discovered your web site a few weeks ago and have found it very informative and helpful.

I have had hallux limitus in my left toe for about 6 years and have tried many things to manage it.  These include NSAIDS, steroid injections,

orthotics (OTC such as Superfeet and Sorbothane as well as custom orthotics), carbon plates, stiff shoes.  In the past year or so, I've noted that

stiff-soled shoes don't seem to help as much.  My podiatrist suggested shoes such as Sketchers Shape Ups or MBT--I've tried these but they

seem to rock in the wrong place (still get painful movement in my toe).  On top of this, I'm having pain at the base of my other toes on both feet

(possibly Morton's neuromas?).

I have tried some of the suggestions on your web site with varying degrees of success.  Icing the joint sometimes helps, but at times increases the pain. 

The joint mobilization does help for short periods.  I have tried the spica taping too, but don't think I'm doing it correctly or else I can't limit the motion of the

toe enough.  I bought Yogatoes and find them beneficial.  I use either iboprofen or naproxen for pain when needed.

I would appreciate your input on next steps in managing my condition.  I've been told my surgical option is fusion, and I'm trying to put that off as long as possible

(I'm 53).  I have wondered if things like the dancers' pad you mention may be helpful or if there are other orthotic/shoe options I could discuss with my

podiatrist and perdorthist (I'm in Atlanta, GA area).  With shoes, I'm wondering if I should try a max motion control shoe like the Brooks Beast.  I'm neutral to slightly

overpronating with a moderate arch, but do have a prominent callous on the inside edge of my left toe.  I ask because early in my treatment, I had a perdorthist who put me

in the Brooks Addiction--this helped, but I realized over time I was walking on the outside edges of my feet and thought it may be doing more harm than good.

Thanks so much for your time.

Dr Blake's comment: 

     I agree with your fighting spirit, since undergoing a unreversable fusion seems too much. Glad you have found some things to help. Perhaps we can arrange that  you send your MRI, so I can see that if surgery is needed, perhaps cheilectomy or joint implant should be considered. These are not permanent, and can get you many years of a more comfortable joint if you are a candidate. Let me know what the dorsiflexion range of motion you have in this joint compared to the other foot. Since the same person measures it, the difference is almost as important as the overal amount. It is important to continue to perfect each technique. Try 3M Nexcare Waterproof tape for more support while spica taping. Definitely start using dancer's pads (get a roll of 1/8th inch adhesive felt from Moore Medical) in all your shoes. If you have stable orthotics, they can be added to the orthotic devices. Definitely ice for 10 minutes 3 times a day the top of the joint. Definitely go to the Brooks Beast for stability. In a month, let me know if this is helping. You can simply add a comment to this post. I hope it helps. Rich

Plantar Plate Tear of the 2nd MTP: Email Advice

Hi Dr Blake,

I'm desperate for advice.

 I'm 17 wks pregnant and after 10 mos of misdiagnosis and on/off pain, I was informally diagnosed with plantar plate tear of 2nd MT.

 My MD said since the pain has been present for 10 mos, the likelihood of it healing on its own is slim.  The joint is more lax dorsally than the uninvolved side and I have a mild hammer toe deformity. I started wearing a walking boot a week ago, and it provides almost complete pain relief.

 I am a physical therapist. Really want to avoid surgery. Does this sound like it could repair itself? Does it sound like a grade 2 or 3 tear?  Will have to wait to get MRI until after pregnancy. Thank you!

Alice (name changed)

Dr Blake's comment: 

     Sorry for your problem, and congratulations on the pregnancy. I have 2 wonderful unbelievable boys, and can not image life without them. You have a wonderful journey ahead. They will grow, but you also. 

     Only an MRI will tell us grade 2 or 3, with grade 3 being a complete tear of the plantar plate. Unfortunately, due to your pregnancy, you must wait. The walking boot is now your gold standard. It has proven you can produce a pain free environment for healing. You must use it on and off for 3 months, unless you can find a shoe that gives you just as much pain relief. Consider looking into hike and bike cycling shoes with rigid soles, or hiking boots, or getting a Bock carbon graphite shoe insole and see if it works in your athletic shoes. But, whatever you are walking in, we must create a pain free environment over the next 3 months to try to create a great healing environment. During that time, you ice pack the area from the bottom 3 times a day for 15-20 minutes. This daily program reduces the inflammation, both the acute (daily), and the chronic (built up over the last 10 months). Begin to experiment with Budin splints to get the right tension and decide if you put over the 2nd toe only or both the second and third toes. Sometimes, I will use the double Budin splint and place over the 2nd and 4th toes with the two loops. You will be wearing the Budin splint while you strengthen the area for 2 years. Some of my patients run marathons in these splints. 

     As the pain calms down, and you get into more normal shoes, if the Budin splint is not enough protection, then you need to experiment with Hapad Longitudinal Medial Arch Pads. 

The most important thing to do right now, and for the next 3-4 years is daily Metatarsal Doming Exercises. This will strengthen the bottom muscles probably 3 times more than they were, but it is important not to curl the toes. It can take the next 1-2 months just developing the ability to keep the toes straight before you actually dome. 

     Good luck and congratulations. Rich

Back and Foot Correction: Email Correspondance

This is an email from a patient whom has done well with her orthotic devices to stabilize her lower extremity, but now seem to be having problems. 

I have recently had an odd thing happen with my feet/orthotics. Over the last several months I have had increasing problems with my right hip/ITB. Rolling on the styrofoam roller helps but won't get rid of it. Used trigger point therapy in upper quads; that helped  but didn't get rid of it. Ended up with very sore muscle around fascea lata (sp?). Then hip itself got sore. Found that if I went barefoot, it went away. Did that (as much as I could) for a few days. Noticed that my left achilles was very tight and sore...maybe got stretched too much going flat-footed?

Of course I had to wear shoes but did better wearing the sandals, without orthotics.

A couple days ago, my lower back started to hurt so I tried to wear orthotics more.  In my work, I am on my feet for up to two hours at a time; sometimes it's only once a day but other days I do it a couple times, but with breaks in between. Yesterday, I hit a wall. My hips were so sore and then my left medial gastroc muscle started spasming. It  also seemed to come from the crease in my knee in the back. This feels a lot like what happened initially (which included my popliteus muscle), many years ago in my right leg, that lead to my plantar fasciitis. Which my orthotics seemed to cure.

Problem now is that if I wear any shoes at all, it is painful/difficult to walk using the affected leg, left one. Orthotics in tennis shoes of course are worse than wearing my sandals which have fairly good arch support but less than orthotics. But even the sandals make that muscle cramp. 

I am taking it easy, both with my back and my feet....using ice and naproxen.

The only other thing I had been doing differently just before this calf muscle event was trying to stay aware of not locking my knees. I thought I had licked this one years ago but last week a Pilates coach said I was still doing it. So I have been trying to keep knees slightly bent when I think of it.

I remember once you told me that my feet sometimes hurt, (it feels like the arch in my orthotic seems too high) because my back is shifting and there is something wrong up there, rather than my feet being the cause of that kind of pain.

I am wondering if you have any insights as to why I might be currently experiencing this increase of pain in my calf when I use any kind of arch support? 

Thanks

Hey Tina, sorry for your dilemma. One possible cause is that a branch of the sciatic nerve, coming off your back, going behind the knee into the calf, and finally the arch is irritated. You may have been slightly irritating with the knee hyperextension, and perhaps you have a slightly bulging disc.When these nerves hurt, it is hard to wear arch support which presses into them. I would see a physiatrist, like Dr Irene Minkowsky, to look at the whole neurological chain from spine to toes and see if there is a simple place to start treatment. I hope this helps. Rich

Hallux Rigidus: Email Advice

Dear Dr. Blake,  How very kind of you to give of your time and knowledge on your blog and actually answer all of us poor folk!

I will be brief.  I crushed my foot June, this year.  5 bones have healed, but I am not quite weight bearing yet, due to the trauma to nerves, tissue.  No bones were broken in my big toe but it is stiff even after several weeks of physical therapy.  My surgeon says it is HR and showed me a bone spur on top in x-ray which is, he says, the cause of the lack of motion.  The joint looks OK.  I have read that these spurs can result from trauma which it must have because I had full use of my toe before the accident.  The Dr. wants to remove the spur and some of the bone beneath it to give room for the toe to bend up.  If he sees that the joint is not in fact good when he does the surgery he would then do a joint replacement. 
1.   Is that the only way to remove this spur?  Is this a reasonable solution?

Dr Blake's comment: From trauma to surgery, this is too fast a progression. I would wait one year minimum before entertaining a surgical approach, unless the pain was out of control, and/or you have more information for me other then a bone spur and stiffness. Have the physical therapist continue to work on it pain free. Start doing the joint mob on the video below twice daily. Let me know how painful the joint is, and we can discuss spica taping, orthotics, shoe selection, Flector patches, PT modalities, topical meds, injections, dancer's pads, etc. 

2.  I will ask the Dr. and PT, but would like your opinion.  Am I making the spur worse working at increasing the motion with physical therapy, forcing the toe to bend more?  

Dr Blake's comment: Yes, gradually increase ROM pain free. If there was just scar tissue, PTs are wonderful at pushing through pain to achieve better motion. But spurs imply subtle cartilage damage, and need a more gentle approach. In this scenario, I never recommend pushing through pain (although I am sure that there are skilled practitioners who can do it). 

3.  Is there more a podiatrist can do for me? 

Dr Blake's comment: See my comments above on taping etc. The best you can do is gently get the joint moving, while creating more and more activity painlessly which will stretch out the soft tissue. Gradually advance your activity from walking to running etc. As you attempt more activity, treatment options come up from your podiatrist, PT, etc as you try to do the activity and not produce a pain response over level 2 on the pain scale. You are advancing from the Immobilization Phase of Rehabilitation, through the ReStrengthening Phase, into the Return To Activity Phase, and this all takes good individualized thoughts to help you through. I sure hope this helps you. Rich

Thank you,  Jill (name changed)

Coalition: Painful Problem poses Difficult Decisions

Dear Dr Blake

I have a calcaneo-navicular coalition that has caused me pain over the past 6 months. I am 32 years old, and up until 6 months ago have never had an issue with my feet, despite being an avid gymnast, and then runner. I used to do upwards of 50 kms per week.

Since March 2013 I have stopped running – there was one day where I was walking around barefoot all day, without my orthotics/supportive shoes  (I have had orthotics all my life). Woke up the next day and was in pain.   Since March I have had pain when walking. 

I had an MRI and bone scan, and they revealed there is a coalition with some irritation of the bone at the site of the coalition. I had a cortisone shot nearly 2 weeks ago and it has taken away a significant chunk of the pain but I can still feel the stiffness. 

Thank you for your blog –I am currently icing my foot now after reading it. 

My question is – I would be happy to take another 6 weeks off running if I had a 2^nd shot – just to put this whole thing to bed.  Do you think that is a good option?

The other option according to my surgeon is resecting the coalition but he thought the cortisone would work.

Thank you

Dr Blake's comments:

     Thank you so very much for the email. I think you are doing well, and would limit the cortisone shots as much as possible. If you need them to avoid surgery, go for it. You would do another cortisone shot to reduce to the pain to between 0-2, and this has already been done. There is no reason to do more now. There is no reason to consider surgery either, for this may be an isolated incident. Typically, orthotic devices do well for CN Coalitions, so I would see how the next 6 months to a year goes. I like my patients to be able handle reflares when they occur. If this area flares in 2 or 3 months, you will be very discouraged, if you do not have a plan to reduce the pain quickly. Typically this means removable boot, icing, taping, activity modification and NSAIDs. Do you have all this? Do you know how to do a great low dye? You need to be a great foot taper!! See the videos below. I hope this helps. Please give me some followup. Rich

Ankle Pain Unknown Diagnosis: Email Correspondance

Dr. Blake,

Over 2 months ago I started experiencing some pain in my left ankle after yoga. Got it checked out. I was told tendonitis/sprain. I did RICE for 4 weeks. Then put it in a boot for 2 weeks. But it still didn't heal.

About a week ago, a new doctor told me I have posterior tibial tendon insufficiency. My pain is also in the surrounding areas, on both sides of my ankle. She told me to get some shoes (I used to wear flip flops 99% of the time) and I also got an orthodic inside (New Balance). 

http://www.drblakeshealingsole.com/search/label/Posterior%20Tibial%20Dysfunction

I'm 23 years old, relatively healthy and fit, and haven't been able to workout in over 2+ months. Now, after doing the smallest things (i.e. driving, stairs, etc) my ankles start hurting. Both my left and right hurt now.

I am confused and frustrated, and don't know where to turn next. I've seen 3 doctors and the pain still isn't gone. Can you give me some advice? I'm happy to return the favor in anyway I can, please help me, this has me really down, please e-mail me back.

Thanks,

Dr Blake's comment: 

    First of all, you need to verify the diagnosis. MRI is a useful tool to help in that direction. I am hopeful you just bruised the back of the ankle, or something else minor, that may take time but will heal completely. Without the MRI, there are too many possibilities to give this much further direction. You are still in Phase I of Rehabilitation without a solid diagnosis. Phase I is the Immobilization/Anti-Inflammatory stage. Use ice twice daily around your ankle for 15 minutes and do one formal contrast bath every evening. Place yourself back in the boot, you may need a lot for the next 3 months, for any situation that produces over level 2 pain. Remember to create a pain free environment as best you can keeping the pain between levels 0-2. Read my blog post on Good vs Bad Pain and memorize. I hope this helps. Rich

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

ABEO Sandal: A Great Recommendation from a Trusted Foot Patient

This recommendation gets one or two more stars in quality since the patients has been suffering with terrible nerve pain for a long time. 

Hey Dr Blake:

 A couple things you might want to keep in your bag of tricks if ever you run into another person like me, who has done everything and tried it all.....and still had pain that is impacting their life.  Also, a person who doesn’t do well with pills.  I bought 3 new shoes which have helped with the comfort and pain a lot.  The brand is ABEO and they are available at the WalkingCompany.  There is one on College in Berkeley and many elsewhere.  They have a squishy but moldable footbed and have been a godsend.  I went back and bought these....which I am walking the dog in pretty well. http://www.thewalkingcompany.com/abeo-capistrano-neutral-grey/25431  I still use my tennis shoes and your HANDMADE WITH CARE orthotics for my Reservoir adventures.

Heel Pain: Early Signs of Developing Plantar Fasciitis

Richard 

 I hope this email finds you well.  I have  foot question.  I am having sharp pain in my left heel upon getting out of bed barefoot  in the morning. It improves once I put on shoes and the day progresses.  Is this an immediate ah ha moment for you as a podiatrist and is it simply fixed?  thanks 

Hey Barbara (name changed),

 That is normally the start of plantar fasciitis. I will send you a link on stretching 5-10 times per day, and 2 times a day roll your foot on a frozen sports bottle. You are catching it early. Rich

http://www.drblakeshealingsole.com/2013/07/plantar-fasciitis-educational-video-on.html

Hallux Rigidus: Great Comments from patient after Joint Fusion

Male, early 40s and I take exception with opinions above steering people away from certain treatment. I started in orthotics for a while, then bilateral chielectomy in 1999 for Hallux Limitus, eventually progressed to minor Hallux Rigidus. Again, chielectomy got me by for 2 years before little was left for joint space, along with arthritic bone surfaces.

Tried arthroplasty on left instead of fusion. It failed due to quick return to arthritic bone surface that shredded the tissue. Fused shortly after, then once that was stable enough, fused the right at the end of 2012.

This year I've had a sesamoid removed in the right, opted to increase the angle of the fusion in left due to some hip/back pain and general discomfort of the toe in shoes. I'm weaning out of the walking boot now, but showing signs of sesamoiditis already. My guess is I'll just have that removed and not drag out the process any further.


I've had 9 surgeries, and I will state with extreme confidence that if you take the usual 7-10 initial days of recovery IN BED with foot up, you'll be far better off. Toughing it out or playing hero by going back to work in 3 days, slows healing and greatly increases risk of infection and injury of vulnerable foot... won't fool your doc at all either. They know when you push it.

I was a U.S. Marine... I can push myself physically and mentally. But I know enough NOT to push. What's the benefit of pushing? None... except maybe to your employer. It's NEVER acceptable for your health to be less than top priority for you and even your employer when you end up in surgery again... less productivity long-term, etc. Of the 7 my current surgeon has done, he called me out on #4. I went back to work at 6 days, 3 days sooner than any other and he knew it before I said a word. 

I have no hesitation about surgery if needed. I have a fantastic surgeon, ask every question I can think of and accept answers I may not want to hear. Consider your situation honestly and do what is recommended by the doctors. The recommendations aren't guesswork. 

I suggest the opposite of a gal above. DO consider fusion or other procedures, but only a good fit for your condition, your surgeon's preferred course and all post-op aspects of the process. Ask about what's next after surgery. What option are if something doesn't go as planned. It can and does happen, and having a plan you and your doc agree upon is vital. Don't focus on future problems, but do talk about the possibility. Non-union of a fusion after you went out golfing on day 4 is on you and if you have a plan for complications, everyone moves forward. My surgeon actually had such a patient. Next initial post-op visit, I walked in using a 3-iron as a mock cane. :)

Oh, and shoes are often a question here, as well. For me, hands-down, New Balance with plenty of width. Do not skimp on width! You'll get used to and treasure it very quickly. Even then, the exact same model/size can differ between pairs. Finding what works consistently does take time, and likely won't be a $29 pair of cheapo shoes. Pain relief is worth time and money for me, though. 

The local New Balance store lets me mix and match from boxes of same size/model and gives me 7 days to walk in them because they know I'll be back next time. Even a 1/8" tilt difference due to slight tweak during manufacturing of two otherwise identical shoes makes all the difference in knee/hip/back soreness. As shoes age, they stretch in different places, as well. Do not discount this aspect of your treatment and recovery... you do so at your peril.

I'm a lurker, but a fan, Dr. Blake... keep up the great work, and your participation in discussions here is valued far more than you realize! Without it, the site is just a place for you to opine and others to talk about you, usually in the negative, benefiting nobody. Because of your willingness to be involved, I have sent two your way, one a happy cured patient, the other currnet and they are very pleased, as well.

Functions for Foot Orthotic Devices which Influence Design

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)

Rheumatoid Arthritis: Email Advice

Hi Dr. -

      I have RA which have mostly affected my knees. I had a synovectomy on my left knee and do not have full extension or flexion in either. I saw my knee doctor today and asked if seeing a podiatrist for some shoe/ feet advice would be a good idea. He said yes. 

     My questions: would orthotics help my situation, I'm somewhat flat footed and knock kneed as well (awesome right?) I would like to be able to walk 30 minutes a day for exercise but have found in the past that I get foot pain. I know this is mostly due to my awkward gait caused by knee issues.

Dr Blake's comment: Definitely, I always recommend trying to make patients more stable. The health provider whom designs the orthotics will have to decide on full foot correction only, full knee correction, or a compromise between the 2. Sometimes I will make one version, see how it works, and then rework if the foot or knee is not getting the relief I want. 

     Are there certain brands of shoes you can recommend? Especially for walking but casual shoes as well.

Dr Blake's comment: Typically, I start with a bigger more supportive orthotic that works in SAS, Brooks Addiction Walker or Asics 2170 type shoe. Then, if this works, I can make a more scaled down version sacrificing some support for shoe fit. 

 I've tried the as seen on tv inserts, happy feet, none of those seem to help, in fact I think they hurt. I feel like a soft but firm support would be awesome, but what do I know. I would be so stoked if you respond to this and more them willing to come see you if you think you ca offer me some help and direction. I hope you're having a great day/evening and thank you for your time.

:) Karen (name changed due to witness protection)

Regards,

Sesamoid Fracture: Email Advice

Dear Dr. Blake,

First, thank you so much for being available for patients and allowing patients to contact you with all their concerns. I feel so much at ease simply knowing the fact that I will be heard! 

Here's a brief history of my sesamoid injury.

Last year in May 2012, I had missed a step while climbing up a staircase and because of that I hit my right foot on the edge of this sharp step. However, that entire day I walked around bearing the pain and only a day later I found out about the fracture on my sesamoid bone. Photo-1 (attached) shows my fracture.

The fracture line is clearly seen in the medial or tibial sesamoid. 

 My doctor asked me to take care and wear good shoes and also gave me some oral medication. I went regularly..And by August 2012, he said I am all good now since I experienced no more pain on the area under my foot.

So I got back to wearing slippers, trendy sandals n high-heeled shoes, walking barefoot at home, gym-ing, running etc. However, there were sometimes when I noticed some discomfort but it didn't last too long and so I forgot all about it.

It was only two days back (Sept-2013, a year later) that I noticed some weird pain and I got concerned since its been a year and I still notice discomfort there. So i got an Xray done (Attached: Photo-2) and I was taken aback when I saw that the sesamoid bone is in two separate pieces now. I went to the same doctor and he said he'd have to put me on a 3-week medication (since i'm leaving for a trip next tuesday) and he said we'll check how you are once you get back. Else we'll have to get it operated (removed).

Here the sesamoid fracture appears widened. The first and second x rays are 15 months or so apart and there has been relatively little pain in this. 

-

Now Dr. Blake, I'm concerned. I don't feel good knowing the fact that I'm going to be walking around with a broken bone in my foot. What do i do? Can the bone ever get healed without having to remove it? And am i placed with a certain level of disability for life?

Please give me your advise on this since I'm leaving on a trip as well and I'd be exploring places on foot! Now I'm very worried about having a fun trip and a walk-stress-free life ahead!

Awaiting your reply.

Thanks and kind regards,

Paula (name changed)

Dr Blake's comments:

     First of all, x rays are the worse form of followup on these problems. The bone can look irregular due to increased water content across the fracture, but internally can be really solid. So, relax for now. If you read all my blog posts on sesamoid injuries you will realize you have a lot you can do to help your self. Here are my suggestions to work on over the next 4 months. 

#1 Get a baseline MRI
#2 Make sure bone density is good
#3 Make sure Vit D3 levels are good
#4 Make sure your diet is good with daily 1500 mg Calcium and 1000 units VitD
#5 Ice pack bottom of foot for 15 minutes once daily and also as needed
#6. Learn to spica tape of increased activities
#7 Learn to make dancer's pads to off weight the sesamoids even in heels
#8 Have custom orthotics designed to off weight the area
#9 Use common sense in avoiding activities you know will bother you. 

I hope this helps you get moving in the right direction. Do not be concerned over your new x ray for it does not tell how strong the bone actually is. Rich

The Patient's initial response:

Thank you so much, Dr. Blake!

Your responses have helped me understand my situation better! In fact I feel a lot better, too. I will keep all those points in check. As of this Tuesday, I'm leaving for Europe and I plan to get myself good shoes first and get regular with all the other points.

Thank you again!

Much regards,

Nerve Pain: Email Advice

Hi Dr. Blake,

I have been following your posts for months now.  Hope you can help in even giving me direction and whether seeing you or a different kind of doc would be best next step.

Out of the blue in Jan., I noticed a constant nagging sensation like my sock was uneven on bottom of left foot/big toe and irritating it.  When I took off sock, the foot was bright red, swollen and painful to touch esp. in the metatarsal area and more so on middle joint of big toe.  There also seem to be a lump on that joint and when I even lightly touched it, would send a radiating pain up my leg, into my back and up the right side into my neck.
Dr Blake's comment: You are talking about the femoral nerve which has a branch to the big toe and can radiate like that. I am assuming that something from that joint irritated the nerve causing the nervous system breakdown. 

And once the pain was activated, my entire central nervous system went into hyper gear and it was impossible for me to bring it down -- with many different supplements, topicals, even meditation, etc.  The other piece that went hand in hand were areas on ball of foot and around the big and second toe that were blue and even pieces of vein protruding that were the most painful areas.
Dr Blake's comment: This is sounding like RSD, which stands for Reflex Sympathetic Dystrophy.

Most of the acute symptoms have improved or disappeared since then although still some lingering issues that prevent me from going on a walk or doing even simple activities.
Dr Blake's comment: Sounds like you managed to create a nice pain free healing environment that is so important when the nervous system is barking soooo much!!

Since Jan. I have gone to a couple of different chiropractors who not only use activator, they also use techniques to break down fascia issues.  One thought that the major issue on big toe might have been capsulitis which also might be putting pressure on nerve.  I also went to osteopath.  He thought it was bursitis on big toe creating all the problems.  Also went to 2 different individuals that specialize in chiropractor neurology.  Their exam showed that the constant radiating pain had to do with pain center in brain not shutting off pain signals and my central nervous system had a hard time shifting to parasympathetic system.  Also X-ray of foot and back where taken.  No fractures in foot.  I have spinal stenosis I believe at L4/5 which I understand can trigger pain in first/second toe(???).  Also I do have a flat arch in the problem (left) foot.
Dr Blake's comment: This is helping with the whole picture. The L4 nerve root goes to the big toe. If this nerve is irritated at the back, and then irritated at the foot, a "double crush syndrome" occurs and the nervous system is very unhappy.

Practicing natural healing for decades, I have also done lots of remedies -- including vit. c, msm, an anti-inflammatory supplement with proteolitic enzymes, vit. B, B12, lion's man (medicinal mushroom for regrowing nerves), calc/mag + magnesium chloride (liquid and gel), comfrey compresses, castor oil compresses and the list goes on. I have also worked with feldenkrais practitioner and also try to stretch when id does not aggravate pain.
Dr Blake's comment: Neural Flossing or Gliding is great and relatively new to physical therapy world. It is a gentle way to stretch the involved nerves, not allowing scar tissue or swelling to collect around them. On my blog I have a video of one sciatic nerve flossing technique. 

Since Jan. I have not been able to use my customized orthotics, as areas where raised, trigger pain so I have gotten a cushy "not customized" orthotic from Walking Shoe Company that molds to foot and provides arch support.  That seems to work for now and does not trigger pain.
Dr Blake's comment: This a great idea, you have to remove any abnormal nerve stimulation.

I tried walking about 12 min. on dirt on Sunday (first time I tried to go for short walk) and couples of hours later I felt increased pain sensitivity.  Not unbearable,  rather a reminder something is still going on and simple activities still problematic. In Jan. pain level and intensity were probably a solid 10. now about 2-3 as long as I keep walking to minimum and not engage any other activities to aggravate it.

Sorry about long email.  Final comment .... being self employed, I have a very high deductible which essential means all of my medical expenses are paid out of my pocket.  Unfortunately, that piece does enter the equation of what I can do.

Thanks,
Deb (name changed)

Dear Deb,

     Thank you so very much for the email. You sound like you are at where one of my patients is right now: Wanting to remove the source since it could trigger it all over again. I do not blame you. You may have to save up your money so when you feel free to spend through your deductible (next year???) you can get the MRI or CT scan to identify the lump in your foot, and treat it. At the same time, you need to work on your back to get that as stable as possible (less chance irritating the L4 nerve root. All this can easily max a high deductible quickly, leaving 11 months to have the insurance doing the rest of the paying. I am so proud of how you dealt with the initial flare of RSD. Please send me 5-10 bullet points on the key things you felt were crucial getting this to 0-2 pain. Rich