Sesamoid Pain: Primary or Secondary to Swelling

This MRI image of the ball of the foot highlights swelling under the first metatarsal produced by a joint sprain but causing palpable soreness on the sesamoid bones. The xrays showed a possible fracture of the tibial sesamoid and surgery was being considered. The MRI clearly shows that both sesamoids are fine (to the left and right of the arrow under the first metatarsal head). This patient actually sprained the 3rd metatarsal phalangeal joint (see the reactive swelling or whiteness) and was favoring that area placing weight abnormally on the big toe joint. 

Achilles Tendon Partial Tear MRI Images

This patient presented with a 9 month history of pain in the achilles tendon area. There was no incident of acute pain, however the pain did come on during a long run. The patient continued to finish the 10 mile run, but knew that the achilles was a problem. The MRI (now 9 months post injury) shows surrounding swelling (white regions) and over 50% of the body of the tendon showing changes. The achilles tendon should be solid black, if healthy, in this imaging like the less than 50% on the right side. Within the injured part of the tendon, while the healing goes on, the tendon is part swelling, part tendon, part scar tissue, part stuff that makes it take on an irregular appearance. It is 50% unhealthy. 

A different image of the above tendon which does not highlight swelling. In this image the tendon does not look as bad. This is a T1 image where the above is a T2 image. 

There the side view of a T2 image showing the body of the tendon looking unhealthy (you want solid black). 

Another side view of the achilles with T2 weighting showing the area of partial rupture and the healing process. The central area would look very white if this image was within 2 weeks of the actual injury.

A final side view through the more normal 50% of the tendon showing swelling in front of the tendon, a little tear within the tendon, but overall a very healthy part of the tendon. The swelling in front of the achilles is called a retrocalcaneal bursitis.

Heel Pain: Email Advice

Dear Dr. Blake,

I am so grateful to your writing this wonderful blog. Thank you!

For about 12 month I have severe, debilitating heel pain, very similar to plantar fasciitis. I do not have any first step pain and my pain gets progressively worse over the course of the day. 

Dr Blake's comment: Without the am soreness, we are probably not dealing with plantar fasciitis. 

In addition, I experience a burning pain that feels like nerve pain.

Dr Blake's comment: Here is my original video on the differential of heel pain. See if it makes sense that you have plantar fasciitis or another problem. The hardest to diagnosis is nerve entrapment. 

 I am able to only stand or walk for about 3-5 minutes. The inside of my heel is tender if pressed and my heel is painful upon percussion.
Dr Blake's comment: This sounds like possible calcaneal (heel) stress fracture/bone reaction. This diagnosis is only made by MRI or bone scan. 

 Over the past few months, we have ruled out plantar fasciitis, as well as nerve root compression originating from L5/ S1. As a treatment I had received a steroid injection into the plantar fascia, as well as an epidural steroid injection. These treatments have not produced any results. I try to stay very active: I do yoga, Pilates, I walk on a de-weighed treadmill, and I work out on a stationary bike in a tireless attempt to get better. I so hope to be able to take a walk with my children again.
Dr Blake's comment: Even though your workup sounds good, why has there not been an MRI or bone scan? You can have nerve pain from the swelling produced from a calcaneal fracture. So get one of those 2 scans. 

Recently, someone suggested to me that I had Baxter’s neuritis. From the literature that I was able to find, this diagnosis seems to fit my symptoms exactly. I do feel a lot of sensation and pain along the course of the first branch of the lateral plantar nerve. What would be the treatment for this?
I am wondering if I should immobilize my foot instead of stretching it and mobilizing it.
I would be most grateful for a reply.
Kind regards,
Dr Blake's comment: Baxter's neuritis can be a cause, but impossible to diagnosis. It is always a possibility in recalcitrant heel pain. You need to rule out bone issues and then inject the lateral plantar nerve with long acting local anesthetic to see if that helps. If it does, try several cortisone shots into the same area, and consider surgery only if the shots give you temporary but great responses. I hope this helps. Rich

Partial Rupture Achilles Tendon

Partial Rupture Achilles Tendon

3rd Metatarsal Capsulitis: Email Advice

Hello there,

I tried to send this message via the link on your blog but it seem to get stalled so I have no idea if you will have received this message.

I am a very active person so my feet do get a good workout (ballet, hiking, fieldwork research in mountains etc.). Quite suddenly (no warning), I had intense pain in the ball of my foot (pain when walking) and went to doctor right away. My regular doctor did not seem overly worried about it although I did have an x ray that showed nothing wrong. I had no referral at this stage. I knew something needed to heal so I stopped my regular activities, kept off the foot as much as possible, and wore flat shoes. Within a few weeks, I began to walk almost pain-free in flat shoes - just a minor sensation when stepping.

Dr Blake's comment: Excellent job immediately acting on the problem. X rays are notorious for false negatives. 

Things continued to improve. About a month afterwards, I felt almost no pain (just an awareness of that part of foot but not really pain) at regular walking in regular flat shoes or barefoot at home, so I thought I was getting somewhere in healing. But things reached a standstill for many more weeks (same awareness of foot, but I was hesitant to re-attempt anything more active than walking lest I create a setback). So I went back to doctor to get a referral to a podiatrist. He diagnosed "capsulitis" and said something about ligament tears around the 3rd metatarsal joint. No further screening, but I have a referral to get orthotics and some type of shoe (I was rushed out of there as he must have been behind schedule, so I have no idea if these are orthotic shoes for regular use or a special shoe for healing period). It did hurt when he pushed hard on that joint, but walking is almost pain-free - same mild awareness of that area of foot.

Dr Blake's comment: When you do activities that vigorously involve the ball of your foot, capsulitis or the 2nd and 3rd joints are common, along with sesamoid injuries under the big toe joint, and nerve pain from trauma to the superficial nerves. Look into getting small longitudinal medial arch Hapads and Budin splints. I have ample information on the blog on purchasing and positioning. Email me again if you have questions. Also with capsulitis you need to be doing metatarsal doming 3 times a day (pain free) and icing for 10 minutes 2-3 times per day. 

Questions:

(1) Anyhow, given that I am at about 9 weeks after the pain started and there has been improvement (even if slow), what should I do next (other than the orthotics and possible shoe etc that was prescribed)? I am headed in the right direction but not ready to resume activity yet. Perhaps physiotherapy, and more vigilant icing 3x a day (no one ever told me to do this)? Do I need some type of stabilizing boot or not if I don't feel noticeable pain in regular flat shoes?

Dr Blake's comment: Yes, icing, and no special boot other than the orthotics. Make sure that the orthotic devices really protect the area when you go up on the ball of the foot. If the orthotics have an irritative met pad, have it removed and use the budin splint with the orthotic instead. I love PT for this. You go 2 times weekly and they can act help you increase activity. You are leaving the Immobilization Phase of Rehabilitation and entering the Restrengthening and Return to Activity Phases. 

(2) What do you think of the healing progress so far? Given what I've read, these injuries are slow to heal so maybe the healing time for my issue is normal and on track. How does one gauge when one can resume a bit more activity?

Dr Blake's comment: Everything sounds fine and on track. You should be congratulated for acting on it quickly. Once you get the orthotics and splints, gradually increase walking but do not emphasize a pushoff. The PT will help. You can do mat exercises for ballet, but wait at least until your ballet shoes are padded with metatarsal pads before you start floor exercises. Do you have someone to help you with ballet slippers? 

Any advice would be appreciated as this podiatrist did not seem inclined to sit down and talk to me about a thorough game-plan for how to proceed. And given how important my activities are to me, I want to do the right things. 

Thank you,

Everyone Should Know The Batkid Story

http://wapc.mlb.com/cutfour/2013/11/15/63957512/batkid-saves-lou-seal-and-san-francisco-from-the-penguin

Tarsal Tunnel Syndrome: MRI crucial to look for Inflammatory Causes

If you are suffering from tarsal tunnel syndrome, you really want an MRI like this. This MRI shows inflammation of all three tendons that run within the tarsal tunnel on the medial side of the ankle. This inflammation places pressure on the posterior tibial nerve that runs within the tunnel causing nerve symptoms of pain, numbness, electric shocks, etc. If you can reduce the inflammation, create a pain free environment, and calm the nerve sensitivity down, the symptoms should get better. 

Artificial Leg: This will bring a smile to your face!!!

http://metro.co.uk/2013/11/08/bionic-tortoise-with-amputated-leg-walks-again-thanks-to-lego-wheel-4178973/

Varus Wedging for Excellent Pronation Control

Tailor's Bunion: You Tube comment

Hello Dr Blake,  I finally broke down and saw a pedorthist last night and we're starting with a simple adhesive foam insert located down from the tailor's bunion and under the 5th metatarsal. I went running this morning and within a 1/2 mile I was fairly used to the lump in my shoe. I went about 3 miles with hardly any pain. What we discovered as well was I was buying corrective running shoes for my pronation. I switched back to an older less structural shoe and let my pronation go for the run and felt better as well. While I'm trying to relieve the bunionette he recommended I stay way away from shoes that force me to put pressure back towards my 5th metatarsal. Once the pain pain is lessened then I can start back with the corrective shoes. Dr Blake's comment: I think this is a great observation. Too many times in correcting pronation the orthotic and shoe combination put too much weight laterally on the 5th metatarsal. One possible outcome would be the development or worsening of a tailor's bunion or bunionette,

Plantar Fasciitis: Key Points

Double Crush: Back to Foot Connection

Dr. Blake,

I found your blog and need some advice if you have a minute.

I have pretty bad lumbar back problems. MRI has shown lots of problems from L3 down to S1. I was referred to a pain doc for 3 rounds of steroid shots. She took new pictures and said it was time for me to see a surgeon.

At the same time I have numbness in my feet. Bad in the right. Swelling/pain in ankle, etc. Went to foot doc and was diagnosed with tarsal tunnel and neuroma. Have this in both feet, bad in right, left is manageable. He said my shoes were to narrow causing the neuroma and my high arches were falling causing the tarsal tunnel.

Basically, I'm a mess and in pain all the time. Lower back and ankles/feet. Hard to stand for very long.

I was googling and found "Double Crush" which links the lower back problems and the tarsal tunnel problems.

I need advice because I don't know how to proceed. I've tried everything, shoes, expensive orthotics, compression socks, stretching, exercises, chiropractic, massage, and others. I was prescribed shoes, orthotics, compression socks by foot doc. I was prescribed drugs (They want me to take Lyrica) by the neuro sergeon. 

I'm frustrated and frightened because I'm just turning 50 and I concerned this is only getting worse. I don't know if I should see another foot doc or another back doc or what to do. I need my foot doc to talk to my back doc and discuss this problem together because my reading indicates they are related.

I'm also confused on the orthotics because some of my research shows, yes do them, other reading indicates they may be causing some of the problem and I need to go natural. I believe there is a connection and my alignment from my feet up to my back is out of wack and I don't know were to turn.

Any advice?

Frustrated and in Pain from San Antonio, TX

Dr Blake's response:

     Thank you so very much for your email. Lower Back irritation to the nerves that go to the foot are unfortunately very common. I am a biomechanics expert. I need to see if I am dealing with a musculo-skeletal problem, or a neurological one, since the treatments may vary at times.

     You want to try to avoid foot surgery, if suggested for neuroma or tarsal tunnel, until the low back component has been worked on considerably. But, you still need to treat the foot locally.
Golden Rule of Foot: Treat the Low Back Nerve Component First to see what the Role in the Foot Pain.

     You are so right to want a team approach. Typically, this is a physiatrist, who can work with the medicine/epidural side, but knows what the podiatrist is doing, and what the neurosurgeon has to offer.

     You are in a nervous system overload right now. You should maximize support to the foot and low back (orthotics, foot strengthening/taping, core strengthening, back braces), and ways to minimize nervous irritability (oral meds, topical meds, warm soaks, neural flossing,etc.). I never recommend avoiding medications in this scenario, since you have to get the nervous system calmed down, and it can take a long while, getting the medications right. 

     Definitely, the role of orthotic devices to stabilize your lower extremity, and lifts if you have a short leg, are a no-brainer to me. Find out who makes the best orthotics in your area. Have your doc prescribe a Standing AP Pelvic Xray to document the leg length difference standing (I have some posts in my blog on this). Treatment of a short leg is Back Pain 101 to me. Most definitely recommend surgery for the back if the nerve injury is causing weakness in your legs, but waiting a month or two to get orthotics that make your feet function symmetrically and lifts for any short leg make help considerably. 

     I sure hope this helps somewhat. Rich

     

Tarsal Tunnel Syndrome after Big Toe Joint Injury: Email Advice

Dear Dr. Blake,

I have been dealing with sharp/shooting pain and tingling in my foot since January (I was originally diagnosed and treated for stress reactions in the metatarsals, then sesamoiditis, and for the past few months, tarsal tunnel.)  The tarsal tunnel syndrome was confirmed with a NCV/EMG test, however, despite 3 months of physical therapy, surgical shoe bracing, and a 200mg daily dose of Lyrica, the pain, tingling, and numbness in my foot and ankle have grown worse.  I had a recent MRI (I attached some images.).  Do you see anything abnormal which could be contributing to the problem?  I am about to get a second opinion for surgery.  Do you have any other suggestions?

Thank you,
Cindy (name changed)

Dr Blake's response (after the patient sent FedEx the CD with images and reports):

Hey Cindy,

 I am so sorry about your situation. Hopefully, you can get this resolved without surgery. From what I gather from looking at your MRIs and reports, you injured the tibial sesamoid under the big toe joint 10 months plus ago. This caused swelling in the big toe joint, and this still exists to be worked on, since it can continue to be a trigger for nerve pain. I think the big toe joint injury still has a little healing to go, and you must daily try to protect with dancer's pads/orthotics, reduce the inflammation, and allow weight bearing since you are showing signs of some demineralization in that area. Make sure your Calcium and Vit D3 are good--typically 1500 mg calcium and 1000 units Vit D3 daily. 

     The nerve pain can be from many sources and normally is a combination of things. The tendon that goes under the big toe joint was still inflamed back in the ankle and probably has caused pressure on the tarsal tunnel nerves. Any limping that causes you to supinate (walk on the outside of your foot) can also be an irritant to the tarsal tunnel. You have some low back dysfunction, even if mild, but can still cause some hypersensitivity to the nervous system. L5 nerve root affects many nerves under the middle of your foot. The removable boot, even if you use an EvenUp (hopefully you did!!) can tweak the low back or hyper-extend the knee causing neural tension.

     All this being said, you have many reasons, non-serious that could have (and still are) stirred up your nervous system. You have had all the right tests, but now you need to find someone to calm down your nervous system. Addressing the possible triggers are important, so decreasing inflammation in the big toe joint makes sense, making sure you are not walking to the outside of your foot, making sure you are not hyper-extending your knee, making sure your gait is centered (not dominant to one side which is always bad from the spine), and perfecting all the ways to calm down the nervous hypersensitivity. I have many posts on my blog that can help you, but you need someone in pain management that can help with Rxs,etc. Medicine seems good at evaluating and treating damaged nerves, not hypersensitive nerves. 

     To help you get started, work daily icing and contrast bathing for the big toe joint. Weight bear to tolerance if possible gradually improving duration. See a physical therapist to find out how to protect the sciatic nerve, and keep your spine neutral when you do activities, and outline a plan to increase activities. You might need an epidural injection to calm down the nervous system, and if you have any sympathetic signs (skin discoloration, changes in sweating, etc), also need a sympathetic block. I had to have both after a back injury, but they were done at the same time. Treatment to the foot/ankle has to be gentle due to the nerve hypersensitivity without injections (unless you are calmed down). Deep massage should also be avoided. You need to be doing non painful strengthening of your foot, and typically swimming or stationary bike are used for cardio (this is where the physical therapist can help). Hypersensitive nerves love gentle motion, heat, gentle massage. Learn what is neural flossing so that someone can show you if appropriate. Easy to do multiple times a day. 

     In terms of medicine, stay on 200 mg Lyrica right now, and add Cymbalta or Elavil at bedtime. These changes are common to begin to get ahead of the symptoms and necessary since you are increasing in symptoms. Have a RX for Lidoderm patches and a compounding medication for nerve pain (you could start using the OTC Neuro-Eze and find where you can massage without increasing pain). I have patients who can not massage due to the pain, but a compounding spray is given which helps.

     There are 2 types of physical therapy--musculo-skeletal and neurological. You need neuro based physical therapy right now. There is a daily, sometimes hourly, distinction to be learned about Honoring your Pain vs Working Through your Pain. It is an important skill to learn.

     Cindy, I hope this helps you somewhat. Keep me in the loop. Rich

Lateral Knee Compartment Disease: Varus Wedging seems to be a good aspect of treatment

As a podiatrist, I team up with orthopedists to treat many knee conditions. One of the most gratifying is the treatment of lateral knee compartment disease. In attempt to avoid complete or partial knee replacements, I am asked to varus or medial wedge them to open up the lateral joint line. I can not tell you how successful it is, but I have many very happy patients. The treatments are always teamed with a variety of other treatments, including synthetic cartilage injections, knee braces, knee strengthening, shoes selection, icing, and some cortisone shots. I have enough very happy patients who presently are avoiding surgery, and love their wedges, that I thought I would share this video with you. 

Negative Impression Casting: A Start towards Making Great Orthotic Devices

My true love in podiatry is helping people. Making the best orthotic devices I can do is a vital part of my and most podiatry practices. I hope this esoteric presentation on the nature of taking an impression cast of the foot, called the "negative cast", will give you some insight into the workings of making good orthotic devices. It starts here with me. 

Hallux Limitus/Rigidus Examination with Self Mobilization Technique

This video below discusses the measurement required to make the diagnosis of Hallux Limitus vs Hallux Rigidus along with the self mobilization techniques to improve your range of motion. Please enjoy!!

Sesamoidectomy: Patient Comments

Dr Blake,

I just wanted to send you a note to say thank you so much for taking the time to write your blog. It has been a huge help to me over the last year as I've gone through the drama of a sesamoid fracture. I thought I'd share my story with you. I'm sure you've heard plenty that are similar, but I hope you don't mind adding one more to the list. 

I fractured my lateral sesamoid (I think - it's the one closest to my 2nd metatarsal) July 2012. I was referred to a podiatrist, and at my first appointment she diagnosed me with a stress fracture of the 2nd metatarsal even though I kept saying that the source of the pain was right around that sesamoid. Nothing was showing up on xrays at this point so she told me that it had to be the 2nd metatarsal and that the pain was just deflecting for some reason. 

I was put in a walking boot for 6 weeks, which I diligently wore until I was told I could start to wean myself out of it. A week after I was finally out of the boot completely the podiatrist told me I could start a walk/run routine and build up slowly, as well as slowly begin swing dancing again (a hobby that my husband and I do together). I danced for a total of 30 minutes in 1 week and my foot ended up swollen and in more pain than before. I couldn't get in to my podiatrist for a week, so I put myself on crutches, ice, and elevation until I could get in to her. By the time we got to do an MRI a week after the swelling, I had managed to get all the inflammation down, but could not get comfortable in the walking boot again. So the podiatrist suggested spica taping and a dancers pad in walking shoes. The MRI also showed a fracture on the sesamoid at this point but nothing wrong with my 2nd metatarsal. So, I started doing my research online and found your blog, watched your videos to learn how to tape, and went from there. I used your taping method and a dancer's pad for 6 months straight while I went through the rest of my story. 

Dr Blake's comment: A bone stimulator would have been great at this point, and some discussion of dietary calcium and Vit D3, and the use of icing and contrast bathing daily (my favorites). 

By January 2013, my husband and I had to move to a new city for work, so my podiatrist sent me on my way with a referral to a PT for 6 weeks to try and get my foot healed completely in our new location. Four weeks into PT, the PT told me she thought I still had a fracture based off of my reaction to ultrasound therapy, and sent me for more xrays/MRI and suggested I go to a new podiatrist. My regular doctor also sent me to an orthopedic surgeon for another opinion. 

These xrays and MRI showed the fracture had not healed, the bone was fragmented, and there was signs of necrosis. 

Dr Blake's comment: Necrosis alone can be treated with bone stimulator, necrosis with bone fragmentation sounds surgical to me. 

The orthopedic wanted me to just stay off of my foot for another 9 months and see what happens. Just taping and a dancer's pad was all he wanted (oh, and he said soft-soled shoes, which I found really bizarre after reading your blog). I wasn't happy with a wait-and-see solution, as I had pretty much done that for 9 months already and couldn't understand how another 9 months would help. The new podiatrist, on the other hand, felt that with the state of my sesamoid it would be wisest to remove it. He said he didn't see much hope in it healing considering the damage he was seeing, and that we were at the stage of last resort. Normally I do not jump on the surgery band wagon quickly, but I didn't see much of an alternative either. Even the orthopedic had given the same diagnosis on my bone, he just wasn't willing to cut it and was hoping for a miracle. I queried e-stem but the podiatrist said I probably had about a 30% chance of that working, and considering I had just found out I was pregnant he didn't think the crutches for 9 months would be a safe idea. 

Dr Blake's comment: Congratulations!!!!!

So we waited until I was in my second trimester, got my midwife and an OB to both approve the surgery (they also felt it was better to take the bone out before baby was born so I had more time to heal before caring for a newborn), and made a plan with an anesthesiologist to do the whole surgery with a block instead of a general anesthetic. I took the brave step and had the sesamoidectomy 2 weeks ago, 13 months after this whole thing started. The good news is that the bone ended up not necrotic or fragmented when they got into my foot. It came out all at once, but either tissue or cartilage (the doctor said he'd have to order a lot of labwork to tell) had grown into the fracture, so the podiatrist said that it never would have healed properly and it was probably good we took it out (I hope this sounds right. It was a little overwhelming to hear right after surgery). 

Dr Blake's comment: I hate MRIs for the read of avascular necrosis. It scares many patients into unnecessary surgery when bone stimulators can help. I am unclear however how the bone fragmentation was not fragmented. I think MRIs show more internal disarray that we read as external disarray (ie. fragmented). But, soft tissue in the fracture would mean it could not heal. So, let's accept that as fact. 

Although I'm only 2 weeks out, and still non-weight bearing (I go for my 2nd post-op appointment this afternoon to see if I'm ready to start moving into weight bearing), I'm amazed at the difference I already feel. I used to get sesamoid pain even sitting on the couch or lying in bed, and now I don't. I haven't really needed any pain killers except for maybe a couple of times in the last 2 weeks. Normally the pain is staying below a 2 (yay good pain!), and icing the back of my knee (a trick one of the OR nurses taught me in recovery) reduces the swelling enough to lower the pain if it gets any higher. I have a little bit of weird nerve sensation in my big toe, but I see from some others on your blog that this seems to be a fairly common feeling post-surgery. 

Again, I just wanted to thank you for your blog. Your different posts on this issue has been helpful to read and has made it much easier for me to know what to ask and what to expect. I'm hoping that my foot continues to feel as good as it does now, but I'll admit I'm slightly nervous for the weight-bearing stage. 

Fingers crossed! 

Dr Blake's comment: The love this patient is really pouring out to anyone of you with sesamoid problems is easily felt. Thank you for your real time experience and honesty, something I can not give the reader. It is immensely vital. Keep me in the loop and to a gradual but easy healing!!! Rich

Achilles Tendon Flexibility Measurement and Strength Daily Routine

I hope you enjoy my new video on the Achilles Tendon

Post Sesamoid Surgery: Email Advice

I am a Detective and in an office setting most days but of course have to be 'fit for duty' with the ability to run, chase and fight at a moments notice. I had a sesamoid bone removed 072913 (i broke it in two after chasing a bad guy in May 2012 and the doctor let me walk around it until 07/2013) and have been home since.

 I had one post surgery visit and he said "start putting weight on your heel" so I did that. 6 weeks later I went for my second post surgery visit and I cant bend my toes without pain, there is a burning sensation on the top of my big toe and at the bottom of my incision scar is a "lump" that is very painful. I think it is scar tissue and when I touch it, it is very sensitive. I still can not put my weight on this area therefore I am walking on the outside of my foot (according to my tennis shoes) and not putting any weight on the inside ball of my foot because of the pain.

 Last week I was released to "light duty" with restrictions of no more than 15 min walking or standing an hour.... is this normal?
Dr Blake's comment: This sounds like the surgeon's mantra: "To cut is to cure". Surgery is really just the start (normally a good start) towards being well again. This is the hope of every patient when they go to surgery. And with sesamoid surgeries, this is what you should expect. It is hard to know what is going on right now. Are you just more painful than most, or is this a complication? You really have to create a pain free environment with a removable boot, orthotics, dancer's pads, stiff sole shoes, etc. Whatever it takes, and with whatever combination it takes. You are the surgeon's responsibility so have a heart to heart conversation. You should be icing twice daily with 10 minute ice pack, and doing a 20 minute contrast bath each evening. Read my posts on sesamoid fractures which talk about how to protect the sesamoid. 

Should I get a second opinion because I don't feel my surgeon "cares" now that I am back to work and I am in pain still. I have began to take my hydrocodones at evening time again and my foot is so sore on the top (tarsals) I think because I am walking wrong.

Dr Blake's comment: You really need to talk to the surgeon. Say you need advice because you think you have more pain then you should. Find if he/she believes physical therapy would help you. Physical therapists see you typically after the stitches come out, and you are ready to get the joint calmed down, un swollen, and moving again. Ask the surgeon if the Blaine scar kit is appropriate. Ask if an agent like Neuro-Eze would help reduce the pain and allow you to massage the injured area. Pain free self massage is always good to a painful area. Tells the brain to not be so hyper about it. 

What do I do? Should I be home letting this heal properly? Should I anticipate additional surgery to eliminate this pain? Is this amount of pain normal?

Dr Blake's comment: This could be where a second opinion comes in. Not to transfer care, because that would be hard to advise from afar, but just to say yes or no to some of these questions. Second surgeries are rare post sesamoidectomies, but secondary problems because you are not doing a good post operative program are not uncommon. Good luck, and please keep me in the loop. 

Thanks for your reply and assistance.

Hammertoes: Cause and Treatment

Please enjoy my new video on hammertoes and their treatment. Rich

Movement: Simple or Extreme: Is a Vital Part of Living

When I treat injured patients, who come in with pain, crutches, limping, boots, etc, the immediate goal we have is to get normal motion back. Because movement is vital to life. When lost, devastating. This is sent by my friend Kenn. Thank you for thrilling with movement. Simple movements, complex movements, and scary movements. Movement defines our health, gives us vitality, gives us a sense of well being. We need to never stop moving when life allows us to keep on going. 

Hang on to your seat, and turn up the sound!

 

Things I'm sure I can't do, maybe you can't either. 

Although, I might still be able to do the last one!

 

https://www.youtube.com/watch_popup?v=A6XUVjK9W4o

Ball of the Foot Pain: Email Advice

Hi Dr.Blake,

 I have been diagnosed with sesamoiditis and have had this foot pain for over a year now. It is beginning to develop in my other foot as well.

 I have tried almost everything imaginable: two different orthotics, cortisone injection, active release, had a chiropractor tape the joint with kinesio tape and even one of those electric wave machines.

 I really do not know what else to do the pain keeps getting worse. Do you have any other suggestions? I am extremely desperate. - Thanks, Ann (name changed)

Dr Blake's comment: 

     All we know from what you have said is that you have pain under the ball of your foot, that no one feels is broken or arthritic, and the pain is not getting better with people doing things to you. So, I would begin to be more active in your approach (very sports medicine) and begin to see what happens. Take this one month at a time and you can give me a followup 30-40 days from now. So, what can be done:

1. Attempt some form of better diagnosis (xrays, etc).
2. Ice pack the area for 15 minutes twice daily.
3. If swelling or stiffness noted, do contrast bathing once daily or once every other day.
4. Find a shoe that works best whether it is padding or stiff or flat, etc. Try to decide what is best.
5. Put your self in the Immobilization Phase I of Injury Rehabilitation by staying in an Anklizer removable boot or Ovation Medical Boot with EvenUp on the other side.
6. Spica tape your toe daily.
7. See if your doc will prescribe voltaren gel or flector patches for you (at least for when you sleep).
8. Figure out if either of the two pairs of orthotics actually do protect the ball of the foot (we need function not number of). 
9. To specifically deal with the pain, see a pain specialist. Avoid NSAIDs since you could have a bone injury.
10. See if any other activities you are doing daily is irritating things and make some change. 
11. Apply Neuro-Eze to the sore area 3 times daily (buy online).
12. Do Metatarsal Doming and Single Leg Balancing daily to keep some strength in the foot (painlessly). 

I hope this gets you started in a good direction. Rich

Tailor's Bunion Pain or Is it?

This was a comment on my tailor's bunion video on my youtube channel also entitled  drblakeshealingsole.  To:Richard Blake I have a question about the tailor bunion...does this seem to come on suddenly and feel as if one is stepping on a rock? I did so much googling on internet for days and could not find anything for the longest time. The location of my foot problem is in the tailor bunion area. But it seems I have other symptoms that don't match. About 4 months ago I stepped out of the pool and felt like I had a rock stuck in my foot but nothing was there! Hurt sooo bad. It seemed to be slightly red/bruised..it was exactly where I have a mildish callous on the bottom of foot below pinky toe. It went away after a while and I forgot all about it. Then a couple of days ago..boom out of nowhere it happened again! (walking in my kitchen minding my own biz). I took a closer look with flashlight and the area (on bottom of foot where callous was) was a little red and when I put pressure on it I could see a sort of star shaped white-ish area inside below the skin...did not have that on the other foot. (it's not a plantar's wart). So I pushed on it for a while and took some pics of it. About five hours later it was all bruised up (but maybe that is because I was manipulating it so much). Also when standing only, the bone below the toe on the top of my foot appeared to be protruding more so than the other foot..I really freaked out about that but concluded it was from the area being swollen. I really don't think it is broken. I can move my toes and everything just fine. Does this sound like tailor bunion? I have pictures... I'm so bummed because I've been slacking in exercise and was planning to start walking/jogging again. Dr Blake's comment:      Tailor's bunions are very gradually changes to the fifth metatarsal which develop over years as the foot spreads out. The pain you are having could be a bone bruise from walking on the cement around and in a pool, or a simple corn that can slowly develop under the tailor's bunion and one day hit critical mass and really hurt. Simple corns can bring big strong people to their knees. Corns are actually just dead skin accumulations and should not hurt to debride them. If they hurt and bleed, you may be dealing with a wart which may just be in the area of the tailor' bunion. The star shaped whitish area is probably the central core of a corn, and this central core dives deep irritating the nerves. I doubt it is broken also. Try the lip stick technique where you mark alittle lipstick on the sore area and place it barefoot in your shoe that has an insert. Walk around alittle and see where the lipstick rubs off. Cut a hole in this area and/or build up the area around it with other pads from old shoes. I hope this helps you. Rich

Kinesiotaping for Plantar Fasciitis: Patient Recommendation

I typically show my patients with plantar fasciitis some simple and more complex ways to tape their arch. Recently, one of my patients has been using this technique with great results. 

Foot Numbness: Email Advice

Hi

I have read some of the posts on your blog, but not seemed to find the correct answer to my problem;

Last winter I walked with Ice Traction Cleats for a long time. 1 hour every day for 4 months at least. After that I one day suddenly felt numbness of the ball of my left foot.  I tried talking to a chiropractor who believed there was a problem with the piriformis because I take B12 shots near to this muscle and the piriformis might have been hit.  

I have tried to stretch this muscle, but no relief.  

I have also talked to my doctor who did not believe in the piriformis theory and found nothing after MR.  

The numbness is still the same after 7-8 months and has also occurred in my right foot, but not as strongly. I feel the numbness all the time, but  sometimes it gets worse.  I am not diabetic.

Looking forward to suggestions.  Thanks!

Dr Blake found a video that may show a similar type cleat. 

Dr Blake's comment: 

     First of all, no matter what the cause start massaging Neuro-Eze into the area 3 times daily. Neuro-Eze is a homeopathic topical that concentrates an amino acid L-Arginine. It works on over 50% of my patients with your symptoms. One bottle will last about one month and it is helps keep going. If it does not help, ask your podiatrist, or primary care, to give you an Rx on a compounding nerve lotion or gel. 

     Piriformis syndrome was a good thought since the motion of telemarking, like a ballerina's turnout, overuses the piriformis and can cause irritation to the sciatic nerve there. I am not sure exactly how you moved, but it probably was differently than you walk normally.  But, you can also irritate the same nerve at the low back, in the spine itself to the neck, in the hamstrings, behind the knee, in the calf, and on the inside of the ankle. There are many choices you have. Typically you seek a physiatrist or neurologist to help you sort out where the nerve is being irritated, while you start treatment on the symptoms. 

     Many would also start you on an evening dose of nerve meds like gabapentin, lyrica, or elavil to help calm the nerve down. The faster you act on an upset nerve the better!!

Border to Border Run: My Past

During my second year of podiatric residency, I joined with 9 other runners and 4 alternates to run from Oregon to Mexico as a Publicity Stunt for the California Podiatry Association. I am right between the R of the first Border and the TO (rather dorky looking) in the first row---always got to be in the spot light. It will always be the most unbelievable endurance event in my life. I ran 125 miles in 7 days!  I ran from Feb to early May building my mileage from 0 to 70 miles per week. My weight went from 236 (Medical Residents eat not exercise!!) to 184 during my training, and then to 174 by the end of the week. 

We started at the Oregon Border with 2 vans--5 runners and 2 alternates in each. The 2 alternates were in charge of every detail besides running. We had 10 hours to run 70 miles, yes averaging 7 minute miles, and then transferred the baton to the next van while we were supposed to drive 70 miles down the course, ate and sleep. We had some much PR work to do (radio, newspaper, and TV interviews) that 8 hours of sleep typically became 5 or 6. We went down the state on 101 then over to Sacramento through Clearlake. After Sacramento, we ran down to San Francisco, and through the peninsula to Pacheco's Pass. We ran day and night, 24/7, with each group sharing some of the most dangerous sections. The entire course was pre-approved by the Highway Patrol. 

We ran on to Fresno for more PR opportunities and then back to San Luis Obispo. I was so sick by then that one of my fellow runners, Matt Fettig, ran 4 of my miles for me!! I was upset since that meant I would only do 121 miles that week. From there we headed now the coast to San Diego, finishing actually 7 days from when we started. From then, I started my podiatry practice one month later. 

I have so many memories of that event, and have had so many inspirations from this group. Closest to me are Dr Jane Denton (female on the lower right) who has her elbows on Dr Chris Yee (Hawaii) and Dr Dave Hannaford (Marin County and famous for the Hannaford Orthotic). Dr Jane Denton has been my podiatric partner now for 30 years, and one of my best friends. Between me and Dr Yee is the true mastermind of this adventure, Dr John Colson. John practiced in San Diego, and was on the committee that agreed with this scheme. John and I were best friends, and with my being at the California College of Podiatric Medicine, called and see if I could round up 8 other runners. They were easy to find in podiatry school. In 1981, Podiatry was truly at the forefront of sports medicine with biomechanics, and students filled the schools (like me) hoping to have a sports medicine practice.

Next to me to the left is Dr Pamela Sisney who practices in Cincinati. Next to her to the far lower left is Dr Kevin Kirby, whom sent me this photo, and is the biomechanics guru of our time in podiatry. Dr Kirby (I refer frequently to the Kirby Skive) practices in Sacramento, California, and lectures around the world on biomechanics. Holding the sign, next to Dr Kirby, and obviously not a runner (but a good friend) is Dr Richard Green who practices in San Diego. Dr David Laha (whom we called Layaway) is in the upper right and practices in Kansas, and in the upper left holding his hands out is Dr Steven Palladino whom practices in Santa Rosa. Dr Robert Eckles and Dr Matt Fettig are next to and under him respectively. Dr Paul Resignato stands in the upper middle with his cool bandana!!

Thanks for letting me relax and remember times that I didn't sit so much!!! 

Preparing for Long Distance Hiking: Email Advice

Hi Dr. Blake,

Thank you for creating and maintaining your blog!  It is a great read and full of incredibly useful information.

Dr Blake's comment: Thank you so very much!!

I recently completed a thru-hike of the John Muir Trail, and my Achilles tendon was very tight and sore for the last five days.  At the time, I did not know how to stretch or tape it so as to reduce pain and the risk of injury.

How do you recommend I prepare my feet prior to long-distance hiking and walking?  And how do you recommend caring for your feet during the hike?  I am doing a 700 mile trek next Spring, and I would like to avoid any complications.

Thanks!

Dr Blake's Response:

     The main areas of concern with events like that are:

1. Foot and Ankle Strength
2. Achilles and Plantar Fascial Flexibility
3. Supportive and Padded Socks
4. Broken In Boots that are the right style for the terrain you are on
5. First Aide Kits for Blisters, Cuts, etc
6. Knowledge (some expertise) in toe, arch, ankle taping
7. Excellent training with weekend long walks/hikes to rebuild endurance

I have some of this on my blog. You can review the videos on strengthening of the foot and ankle, and flexibility of the achilles and plantar fascia. Go to a store like REI for advice on socks and boots. Prepare a first aid kit with Body Glide for blisters, big and small bandaids, antibiotic ointment, and coban tape. Check the blog also for the videos on toe, arch, ankle, achilles tapings. Check with a PT or Podiatrist if you think you have areas of weakness, like the achilles, that may need some individual advice. Get down to basics and make sure you are cutting your nails correctly (typically straight across). Buy boots at the end of the day when your feet may be slightly swollen, and wear the socks you will be hiking in when the shoes are fit. I hope this helps you. Please email with other questions and I will try to put on this same post. Good luck and happy hiking!!! Rich

Lower Diabetic Foot Ulcerations with Orthotic Devices: Article

http://lowerextremityreview.com/issues/august/amputation-reulceration-rates-fall-after-two-years-of-orthotic-therapy

Obamacare: Thoughts from the Prestigious AMA

AMA Insight, No matter which side you are on.

The American Medical Association has weighed in on Obama's new health care package. The Allergists were in favor of scratching it, but the Dermatologists advised not to make any rash moves. The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the Administration had a lot of nerve. Meanwhile, Obstetricians felt certain everyone was laboring under a misconception, while the Ophthalmologists considered the idea shortsighted.

Pathologists yelled, "Over my dead body!" while the Pediatricians said, "Oh, grow up!" The Psychiatrists thought the whole idea was madness, while the Radiologists could see right through it. Surgeons decided to wash their hands of the whole thing and the Internists claimed it would indeed be a bitter pill to swallow. The Plastic Surgeons opined that this proposal would "put a whole new face on the matter". The Podiatrists thought it was a step forward, but the Urologists were pissed off at the whole idea. Anesthesiologists thought the whole idea was a gas, and those lofty Cardiologists didn't have the heart to say no.

In the end, the Proctologists won out, leaving the entire decision up to the assholes in Washington.