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

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

Sunday's Video of the Week: Introduction to the Bar Method (not the lawyer kind of bar or the Irish Pub!!)

The Bar Method is a form of workout that combines toning exercise with flexibility. It originated in the San Francisco Bay Area and so is very popular. I believe they have developed 4 videos for home use, and I believe it is a great way to condition yourself. Check it out in this weeks: Video of the Week.

Saturday's Exercise of the Week: Metatarsal Doming or Arcing

Metatarsal Doming or Arcing exercises for the foot are perfect for re-strengthening those small intrinsic muscles in our feet. These muscles are not really exercised properly when we stand, walk, or even run. They can slowly weaken with injuries, periods of inactivity, but also shoes and orthotic devices can allow them to stop working. Consider adding Met Doming or Arcing to your daily home or gym workouts and you will feel more power in your feet. A simple set of 10 reps daily can keep these muscles in tone to protect your foot. You can start doing 3 times daily to begin to catch up, then after several months decrease to twice daily, and then in 4 months decrease to once a day. Of course, all exercises are to be done painlessly. 

Friday's Patient Problem of the Week: Narrow Men's Dress Shoes

One of my nice patients today reminded me that he has very narrow and long feet: 11A. He has found that only Alden and Allen Edmond shoes fit him. He does have one pair of Rockport that works okay.

Dr Jane Denton at our office checking out shoe fit and stability.

http://www.aldenshoe.com/DrawProducts.aspx?Action=GetDetails&CategoryID=6&ProductID=94&PageID=8

http://www.allenedmonds.com/aeonline/cati2_Shoes_1_40000000001_-1_____120552____1000_?facet=Width:A

http://www.shoes.com/en-US/Mens/_/Rockport/Casual+Shoes/Width+Narrow_B+or+N/Products.aspx

http://www.onlineshoes.com/mens-shoes-narrow-shop-x-nar-list_ct1,wd4,as54

Thursday's Orthotic Discussion of the Week: Fettig Technique

The Fettig Technique is a specific modification of the Inverted Orthotic Technique designed by Dr Mathias Fettig while practicing in Montana. The classic Inverted Technique ignores the forefoot to rearfoot relationship in preparing the positive cast. Dr Fettig felt for his patients with forefoot valgus/plantarflexed first rays, where he wanted the correction of that everted forefoot deformity, but also wanted the heel inversion, he could combine the 2 techniques. And they have worked well together stabilizing the forefoot and rearfoot components.

All positive casts are poured vertical heel as a reference point no matter what correction you are going to do to the cast. 

Here is an example of a left foot cast that once poured vertical heel so that the top of the cast was parallel with the floor, the cast captured 6 degrees of everted forefoot deformity (inverting the top of the cast 6 degrees).

The front of the cast needs to enclose the first and fifth metatarsals in making what is called the Anterior Platform. 

The first and fifth metatarsals should be marked at their lowest points to the ground, and then a border 10-15 mm proximal to that point marked for the edge of the Anterior Platform. This is due to the need for the plastic to end behind (towards the arch) the weight bearing surface. The 10 to 15 mm leeway is an estimate with longer feet needing more and shorter feet less leeway or clearance. 

Here is a bottom view of the foot with the lines initially drawn between the first and 2nd metatarsals and then the 4th and 5th metatarsals. The low point on the first metatarsal is relatively easy to find with the line towards the arch dropped down the side of the foot and 10-15 mm from that low point. Unless visualization of the 5th metatarsal is obvious, I love to leave this line even with the first metatarsal line. This makes a square and stable leading edge of the orthotic device. 

Here the line for the 5th metatarsal is dropped down. 

Now the fun begins. This image is of the 2 nails needed for the Fettig Modification of the Inverted Orthotic Technique. If the FF Valgus measurement is 6 degrees taken from the top of the cast seen in an earlier image, and 20 degree Inverted Orthotic Technique is necessary for pronation control, then the initial medial nail sets the cast at 26 degrees inverted. The second nail in the fifth metatarsal head then sets the total inversion back to 20 degrees. In essence, we have accomplished a 20 degree Inverted Orthotic with a 6 degree Fettig Modification. 

Once the nails are in place, the plaster to make the Anterior Platform is mixed. I always have 2-3 plaster bowls working, each with different consistencies waiting for one to be the perfect blend of solidity and liquidity to be ready to be used. You can see by this photo that I use color dyes. Also floating in the basin in the back are pieces of wood that I will use to make the anterior platform. These will be placed into the anterior platform under the first metatarsal head, and need to be super saturated with water so not brittle (more the consistency of the plaster). 

You can see from the above image that the wooden sticks (parts of wooden tongue blades) are saturated with water before utilizing. They are places into the anterior platform after making and before the plaster dries. Only a small part will be used that goes into the medial arch fill. This is important when pressing with high power presses to avoid breakage of the platform from the medial arch. 

You need to be patient with the plaster as it dries to a certain consistency before making the Anterior Platform. 

Here the plaster is stirred every 2 minutes or so checking on its' consistency. 

Once the plaster is ready, moldable but not runny, it is placed on a small piece of paper.

The positive mold is now placed on the paper in the area of the anterior platform. You place the positive mold with the nails down gently trying not to distort the nails. 

Here, my brother Bob, who is wonderful at designing these molds, works the plaster so that the sides are smoothed. 

Bob is cutting away excess plaster and making the side walls straight on the lateral side and slightly bevelled outward on the medial or arch side. 

The Anterior Platform is applied and the wooden stick to prevent breakage inserted. 

I wanted to show that mistakes are made. I am trying to set this Fettig at 20 Degrees but the placement of the plaster on the mold was checked at 24 degrees. Oh well, do it again!!!!

New plaster applied to make another Platform. 

Measurement shows a perfect 20 degrees. 

The Anterior Platform is roughly squared on all 4 sides.

If you are skilled at orthotic making, you can tell a 6 degree Forefoot Valgus correction (lateral side) and a 20 degree overall inversion have been designed into this Anterior Platform.

Another image of the Fettig Modification capturing all 6 degrees of Forefoot Valgus within the 20 degree Inverted Orthotic Technique. The wooden stick will be cut about 1 and 1/2 inches from the plaster.

The finished positive cast capturing a 6 degree Forefoot Valgus deformity and 20 degree Inverted Technique with the medial and lateral expansions left foot.

Same for the right foot.

Wednesday's Article of the Week: The Inverted Orthotic Technique and Changes in Biomechanics

This is the left foot and 55 Degree Inverted Orthotic that allowed a patient to get the heel centered under the leg. The original problem being treated was severe medial knee pain with over pronated feet. The heel is relaxed position was 13 everted or pronated and the 55 degree correction allowed the patient to get close to 2 everted (vertical). 

The article below highlights the Inverted Orthotic Technique. It is a method of designing the functional foot orthotic to help with foot, ankle, leg, and knee biomechanics. The article emphasizes the positive changes to the lower extremity produced by this technique. I designed the technique in 1981, studied it for 2 years before I first made my observations available, then introduced it in 1984. The cartoon on the home page was drawn by the famous cartoonist Dr Robert Hughes who was at my first presentation. The following are injuries that benefit from this technique over standard orthotic devices:

• Bunion Pain
• Hallux Limitus/Rigidus
• Plantar Fasciitis
• Posterior Tibial and Anterior Tibial Tendinitis
• Achilles Tendinitis
• Shin Splints and Medial Tibial Stress Syndrome
• Medial Knee Pain
• Patello-Femoral Pain
• Piriformis Syndrome

There are many orthotic laboratories that make this device including Allied OSI, Root Functional Orthotic Lab, ProLab USA, and Richey and Company.‎

http://www.researchgate.net/publication/8978040_Effect_of_inverted_orthoses_on_lower-extremity_mechanics_in_runners/file/3deec51891a54ae45e.pdf

Tuesday's Question of the Week: Multiple Pain Syndromes: Email Advice

Dear Dr. Blake, 

I have been following your blog for two years now.  I credit your blog for keeping me walking. The tips and advice I have read have helped me along this far.

I am a 41 year old very healthy female.  Until November of 2009 I was a runner, recreational athlete, and yoga instructor.  I woke up one day in November and noticed my knees were aching.  I had replaced running with using an elliptical trainer due to separating my shoulder 9 months earlier.  I thought maybe the elliptical was causing an imbalance, so I beefed up my hip strengthening at the gym.  My knees continued to hurt.  I saw an orthopaedic surgeon. I had an  Mri of both knees ( 3 times), went to physical therapy.  Physical therapy made things worse.  I developed quad tendonitis.  I could not bend my knees.  Sitting with bent knees was excruciating .  My knees burned and would get very hot and red.  I found a new doctor.  Then another doctor and a chiropractor.  Had RA labs drawn ( 3 times) .  All negative.  Found a biomechanics expert.  Started working with him exclusively. I made a little bit of progress. 

Two years later my left foot started to hurt and my entire lower leg. Then both feet and lower legs started to hurt.  Peroneals, post tib, calves, the ball of my foot. I could no longer stand barefoot ever. I wear shoes in the shower. I started going to podiatrists after ten days of unexplained pain.  I went to five different doctors in my area.  All found nothing.  All insisted I did not need orthotics. One went so far as to say he wished he had my feet. He said he thought I had fibro. He said orthotics are golden arches and to not to come back unless I broke my foot.   I had previously visited a physiatrist at University of Florida who ruled out Fibromyalgia. 

Dr Blake's comment: If you have pain in your foot, some form of orthotic device can help. There is a infinite range of devices to work with and all the variations of support and cushion and off weight bearing. 

I found your blog.  You advised a reader to look into Barry University.  I found a doctor a few hours from where I live.  The minute they looked at my feet I knew something was wrong.  They could not believe the atrophy of the balls of my feet for my age. They recommended orthotics.  Another option was sculptra injections in the balls of my feet.  My first pair of orthotics were made of hard plastic and the heel cup was too small.  I walked around on those orthotics for 3 months, then my heel fat pads started to thin, but my knees started to get better!   Orthotics were sent back and I was referred to another doctor to start sculptra injections.  New doctor made softer orthotics and injected sculptra.  The sculptra helps a lot.  It did take about 18months and several rounds to get to this level of comfort.  Sculptra is very expensive and does not last more than 6-7 months. The balls of my feet still get hot every night and sore.  I still have to where soft orthotics and soft tennis shoes.  I no longer hard limp all day which is a miracle. My knees no loner hurt every day.  Just every now and then. 

Dr Blake's comment: I am so proud of you for not giving up. If your doctor can send me a cast of your foot, I will make a Hannaford for you. But, I need a doctor/pedorthist to dispense/adjust. Hannafords would be the best design for your feet. 

http://www.manhattanfootcare.com/2013/03/sculptra-derma-fillers-for-treatment-of-foot-conditions/

http://www.drblakeshealingsole.com/2010/12/top-100-biomechanical-guidelines-31.html

My heel pads have started to thin again. I can feel the bones easily when I palpate my heels.  It hurts along the outer rim and along the back of heels.  It feels like I always have a blister when I do not have one. Hurts a lot.  Gets red and hot every night.  I use ice packs a few times a day, every day. I have to sleep with my heels off of the bed, because the pressure hurts.

Dr Blake's comment: Here is the links to two products you should buy.

https://www.mooremedical.com/index.cfm?/Achilles-Heel-Pad%E2%84%A2/&PG=CTL&CS=HOM&FN=ProductDetail&PID=166&spx=1

http://www.alimed.com/stay-on-heel-protector.html

 The orthotics I am wearing are slow recovery poron with spenco on top.  This worked for about a year. I have currently stuck a thin gel sheet over the heel portion.  Not perfect but helps. Thinking of buying J gel.  In October the spenco was replaced but not the slow recovery poron.  Spenco bottomed out in a few weeks.  Heels hurt.  the physician I currently see always keeps my orthotics for 4-6 months before I get them back. I never leave my current pair .  The adjustments have to be made when I am in the office.  I have been waiting for my new pair since October.  When they do come back the lab has usually botched them.  I have become my own pedorthist.    I have a dremel tool.  I make my own met pads . I add cushioning to my orthotics.  I wear my orthotics at all times,  except in the shower. 

Dr Blake's comment: Sounds like you deserve at least a honorary Podiatry degree. This is why I make my own orthotics. If only my patients really understood my dedication. Partially LOL!!!

I  need orthotics that will help my very boney feet to stop hurting so much.  I think that the right orthotics will keep my feet protected and comfortable and keep my knees happy.I worry that if my feet are this bad now, what will happen in the future?  I can come to California if needed to see you.  My exercise physiologist said I have 20 year old bones and 80 year old fat pads.  It would be wonderful to  get my life back.   So many doctors have turned me away.  I want to know if you believe you can help me? 

Thank you, 

Dr Blake's comment: I have since communicated with the patient and sending her a size 10 (her size) Hannaford. The wonderful part of a Hannaford is what you get back from the lab is just a little more than an insert with your foot length and width. The Hannaford is multi layers of memory foam and you do the molding during your first 30 hours of wear. They feel like walking on a cloud, but need big enough athletic shoes to fit them. If you are looking into Hannafords, I am happy to work with doctors and labs to learn how to make them. Read all the posts previously on Hannaford orthotic devices. 

http://www.drblakeshealingsole.com/2013/01/grinding-hannaford-orthotic-you-tube.html

Monday's Image of the Week: Temporary Kirby Skive for Pronation Control

This photo above is the left foot orthotic device of a patient that pronates excessively. Many times when I am dispensing orthotic devices, I fall short in controlling the excessive pronation enough based on stability required or continued symptoms. I have added in this image a 1/4 inch beveled wedge in the medial heel area of the left foot orthotic device on top of the plastic.I call this a Temporary Kirby Skive. It will give me more correction temporarily to the orthotic device in controlling pronation motion. Eventually I may decide to place that Kirby Skive into the plastic itself. The typical material used for this wedge is Korex, grinding rubber, or EVA. The top cover in the right of the image will be glued back on.

http://www.parisorthotics.com/hcp_lectures/STJA%20Loc%20and%20Rot%20Equil%20Theory_PAC2001.pdf

Recent Fibular Sesamoid Removal: Email Advice

I had a fibular sesamoidectomy 4 weeks ago and I am still having a ton of pain in the big toe joint. It is actually worse than before the surgery. My surgeon never taught me how to properly tape the area and I was wondering what the best way to support the toe was. Also what exercises could I be doing to help the area. I still don't have full range of motion.

Thank you for your help.

Dr Blake's Response:

     You are in the 3 month zone of the surgeon's responsibility before they release their patients back to people like me who will rehabilitate. Everything I discuss has to be discussed and agreed upon by your surgeon who has ultimate responsibility and first hand knowledge. My primary goal here will be to give your some normal guidelines on what happens and can be done. 

     After you leave the hospital or surgical center, you will have bandages and stitches and post op shoes/boots, and crutches. These will all be in part of your life until 2 or 3 weeks when the wound has healed and your stitches can come out. The joint is sore, swollen, very limited range of motion, and basically non functional at this point. The next 10-12 weeks you have to reverse all the swelling accumulation with icing twice daily, NSAIDs, contrast bathing each evening, and 2-3 times per week physical therapy. This is where you are at right now. Your goal the next 8-10 weeks is to reduce swelling, but get strong. 

     So, during this next 8-10 weeks, use crutches, removable boots, post op shoes, big tennis shoes and orthotics, whatever it takes to minimize the day to day irritation that will keep aggravating the swelling. You want 2 months from now to be in a great position to re-strengthen the foot and leg. The Immobilization Phase (now for you) lasts typically 3 months, and the Restrengthening Phase until your 1 year Anniversary. Don't let the inflammation linger into the 4th month by pushing it too much now. 

     The physical therapist goal in seeing you is to reduce inflammation, gradually increase range of motion, gradually teach you how to strengthen your whole lower extremity progressively, sometimes design dancer's pads and/or orthotics, make recommendations to the surgeon on your progress and changes in treatment, etc. 

After the 12th week post operatively, typically the swelling is down, the range of motion is better, and the Restrengthening and Return to Activity Phases are gradually blended. Some activities will take you 1 full year to get back to like cutting hard in basketball, whereas running with off weighting orthotic devices can be started at 3-6 months. Depends on the force needed for the activity. 

     It is important to understand about scar tissue maturation. At 9 months, the scar tissue produced by the surgery will begin to thin, and cause less interference with normal motion. By 12 months, the scar tissue is typically no longer a problem restricting motion and causing pain. Some activities require this normal scar maturation process to occur before they are comfortable. 

     So, in my practice, you would have the stitches removed, you would have little to no pain because you would be using crutches, removable boots, etc, whatever is needed, you would be icing 2 times a day, contrast bathing once daily, you would be going to PT 2-3 times weekly, you would have a healthy diet, you would be getting soft based orthotics (like Hannafords) to protect the joint, using dancer's pads (1/8th adhesive felt from mooremedical.com),  you would use spica taping when you feel you need it, you would be using the Blaine Scar Kit for twice daily massage, and the physical therapist would definitely have you on the stationary bike (arch on the pedal), swimming/running in place in the pool, taking NSAIDs orally or topically, doing Hallux Limitus Self Mob if allowed twice daily, walking progressively more and more, not trying to manually increase normal joint motion, and using intelligent activity modification principles. Memorize my post on Good vs Bad Pain. 

     I sure hope this helps some. Rich 

Knee and Foot Surgery Questions: Email Advice

Dear Dr. Blake:

I have a too short first metatarsal on my right foot and walking on this too short metatarsal for over 7 years has also damaged my knee.

Questions for you:

If I have the knee surgery first, will I need to be on antibiotics the whole time that I recover from my foot surgery if there are pins sticking out of my 2nd and 3rd toes, since these need to be shortened too?   Does having a total knee replacement with a metal implant complicate in any way a future foot surgery on the  on the same leg?  Are most knees able to tolerate a Rollabout after knee surgery?
Many thanks for the information.  Your blog is great!

Dr Blake's Response:

Thanks for the questions and the compliment. Definitely you need the knee surgery first, since it changes how you walk and may change the foot correction given. Typically there is a 3, but preferrably 6 month wait between surgery. Yes, the knee must be able to take the stress placed by the Roll aBout, so it is the physical therapist more than anyone that says it is time for the foot surgery. You should have a month practicing on the Roll aBout with good success before you undergo surgery. You do not need more than a peri-operative antibiotic (at the time of the surgery) for the foot surgery in general. However, the orthopedist in charge of your knee health, may think otherwise. I would be surprised if you had more than a 2 week course of antibiotics with the foot surgery. Have the 2 doctors talk, or consult an infectitious disease specialist prior to the foot surgery to have them discuss things and come up with a plan. The bacteria is stirred up at the time of the surgery and the skin is typically completely healed at 2 weeks. Topical antibiotics are placed over the pin exit wounds. Hope this helps. Rich Blake

Sesamoid Injury: Email Advice

Dr. Blake,

I am a 50-year-old woman and I work out 5 times a week. I run on the tredmill for 20 minutes each day and then end my workout lifting weights. I used to be a gymnast and 24 years ago broke a sesamoid bone in my left foot. After several trials of everything, I ended up having surgery removing the broken bone. Following my surgery I developed RSD. To remedy this I had daily injections as an epidural for a week. I haven't had any trouble with that foot since.

In October I noticed my right foot started hurting in a similar way as my left foot did. I have a high tolerance for pain and continued running on it, not to mention, wearing pumps and boots with a higher heel. It got to the point where I just couldn't take it anymore, so I went to a local podiatrist in Factoria, WA. He briefly looked at my foot, took a xray, and told me my sesamoid bone was broke into two pieces and was splintered pretty good. He put me in an air cast and scheduled a follow up to evaluate whether surgery would be required.

After that appointment, I just didn't feel confident in the diagnosis, so I decided to go to a top rated podiatrist in Bellevue, WA. Before I went I requested a copy of my xray from the previous doctor, but when I got to my second opinion appointment, no one in the office could open the xray on the CD. Having said that, the doctor had to take another xray. He gave me pads to wear and discussed surgery and available dates. I put my aircast back on and left. On the way home, the second opinion doctor called me and said he looked at my xray as well as his partner and did not see any break whatsoever or any splintering like the first doctor claimed. I have been back for a follow up with the second opinion doctor and have another appointment on Jan. 6th 2013 for a possible cortisone shot. The second opinion doctor doesn't have a clue what it could be causing my pain. 
Dr Blake's comment: This is why you get 2nd opinions to make sure surgery is necessary, but the difference is so enormous, you now need a 3rd. I once had 6 opinions on a personal health issue, and I am very happy I did. Is the Aircast a brace or removable boot? If it is a boot, and if it is not comfortable, use 1/4 inch adhesive felt from www.mooremedical.com to design a dancer's pad for the inside of the boot. 

Sesamoid pad to float the sore area placed into the removable boot. 

My foot still hurts off and on...more on than off. I have also noticed than when I cross my right leg over my left, the bad foot tingles terribly. I had a pedicure before Christmas and the girl working on me massaged my feet and pulled on my toes. It did feel quite a bit better after that, but a couple days ago the pain flared up again.

Today I downloaded a program (OmniVue) that allowed me to open the first doctor's xray. I now have a copy of both doctor's xrays. I compared the two and really don't know what I am looking at. I was able to export the first doctor's xray and save it as an image. Would you be willing to allow me to email the image to you so I can get your opinion on all of this? If so, I would certainly appreciate it.

We are meeting with the first doctor on Jan. 3rd to give him an opportunity to explain himself. I don't want any trouble. I just want to know if my foot is broke or not. My biggest concern is nerve damage and the possibility of developing RSD once again.

Thanks in advance.

Dr Blake's comment:

Thank you so very much for the comment. You can take photos of the xray images (as big as possible) and email to me at drblakeshealingsole@gmail.com.

 You should however not get a shot unless you have an MRI which is the best definitive test. You can send me the CD of the MRI and I will be happy to look at.

 If you can not get an MRI, and the xrays not are that definite, I would follow the protocol for a fractured sesamoid which includes 3 months in a removable boot, and a bone stimulator. 

Make sure you are doing well with Calcium and Vit D3 and icing twice daily with contrast bathing once daily. Hope this helps for now. Rich

Morton's Neuroma: Successful Surgery after conservative therapy failed

This was a wonderful comment to my post below on Morton's Neuromas and their Treatment Options. Thank you to the young man who wrote this. It does not change my mind on being conservative, but I do not think his first 2 podiatrists gave him an option of surgery. I do not do surgery, but we have 2 highly trained surgeons in the office who I consult frequently. If you have a solid diagnosis of Morton's Neuroma, you must be informed of your options, for it is the only way to make the best decision for you. You are the one feeling the pain, the doctors can not, but the doctors should help you stay objective and help you work through the treatment. 

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

I had MN in my right foot. I visited three podiatrists before finding one who was willing to perform the surgery - and he changed my life by doing so. I had orthotics, splints, injections - everything - over a 12 month period. Nothing helped and I woke one day wanting to cut off my foot (seriously, that is what I told my wife).

After changing from a PPO to Kaiser, I once again visited the Podiatrist. The doctor immediately said, "If you've tried other remedies, then you need surgery." I had the surgery two weeks later, and was walking with a padded covering the next day. The difference almost brought tears to my eyes.

I know of two others (also runners) who have had MN and the only remedy was surgery. The podiatrists I fired were all unable to perform the surgery, so they tried to offer every remedy under the sun except the only one that would help. Makes me angry even typing this.

I now have MN in my other foot (presumably years of running and years of marching are taking their toll). I see my doctor next week and I am quite certain that he will go back and pull the nerve. IT IS THE ONLY TRUE REMEDY IF YOU ARE IN PAIN.

Dr. Blake - saying that only 5% require surgery simply cannot be true and is certainly misleading to the patients seeking comfort in a very painful foot. I fear that they will follow the guidance and try to seek comfort with other treatments for at least one year (as you suggest) like I did. For the third of sufferers who have the pain in their foot, especially at the 8-10 on the pain scale, they will not be cured with orthotics, therapy, injections, etc. Surgery is their only cure.

Dr Blake's Response:

Thank you so very much for your heart felt comment. Most of my patients who have surgery for Morton's Neuroma feel the same way. When you need surgery for Morton's Neuroma, you should have it. This does not however mean that conservative treatments should not be tried before. 

There is typically a 3 month window of time after the patient first presents with MN pain that 2 things happen: A) an attempt at conservative treatment is initiated, and B) MRI documentation along with an evaluation of other causes of nerve pain. If by the end of the first 3 months, the conservative treatment is not working well, the MRI documents a MN, and other forms of nerve pain (like low back referred pain are ruled out), surgery is recommended. 

The gray areas come from patients where the pain is manageable, the MRIs are inconclusive, and there is some suggestion of low back involvement. 

So, I am very happy for you. I am biased to avoid surgery when possible, and that bias does come across strongly. I always feel bad when the patient and I work hard together to avoid surgery, but in the end surgery is needed. But, my patients know that if conservative treatment fails, surgery is our last resort option. How does conservative treatment fail? One way is that the pain level is not managed in the 0-2 range (Good Pain). During the first few months, while conservative treatment is being explored, it is imperative to do whatever to get the pain under control. This is more true for nerves than any other structure. Dr Rich Blake

Injury Rehabilitation: The Magical 80% Rule

80% is not 100% or 99% or 95%, but is the most talked about number in sports rehabilitation. Why? When you look at the pain scale, the numbers are graded from 0 to 10, with 10 being agonizing pain and 0 no pain. With most injuries, it takes 20% of the overall rehabilitation to reduce the symptoms 80% (normally between 0 and 2), and another 80% of the overall rehabilitation to knock out that remaining 20% (to daily 0 with no reflares). Therefore, sports medicine providers attempt with most injuries to reduce the symptoms to between 0-2 (80% better) and hold the symptoms there for a long time. The patient still has some symptoms as they get back into activity. It can be quite unnerving to some patients to still be experiencing pain while re-attempting to participate in an activity. However, since it takes 20% of the overall rehabilitation to get there, and for simplicity let us say it took 2 months to reduce the pain from 8-10 down to 0-2, then it will take 80% of the time (8 more months) to completely eliminate all the pain. If we wait for no pain to begin activity, the wait is much longer than necessary, and the body gets stiffer, weaker, more deconditioned, and overall, more vulnerable to re-injury when starting up again. So, 80% reduction in symptoms down to levels 0 to 2 pain is considered the gold standard in treating injuries. Golden Rule of Foot: When 80% of symptoms are reduced, and normal walking occurs without limping, a return to activity program can be initiated. This is the 80% related to the pain scale.

But, what about the 80% related to activity. 80% better for function is when you can start running again. Running is the basis of almost all athletic endeavors. The way I look at and discuss with patients the function scale is:

0 to 20% bed ridden,or non weight bearing on crutches or Roll-A-Bout
20 to 40% from beginning to bear weight to off crutches (normally needs removable boot/cast)
40 to 60% Gradually feeling less pain with walking with or without boot
60 to 80% Walking with increased speed with mild symptoms, beginning to do sports specific activities like volleying in tennis, or shooting around in basketball
80% Passed the 30 minute hard walk test without set back, can begin a walk/run program, can begin to play sport with some idea of gradation back into full activity.

It is the magical merging of these two 80% scales that will allow the patient to begin their sport at a high level and begin to feel normal again psychologically. Many patients the scales don't match for a while and the health care provider must have them wait. For example, many patients have 80% pain relief by icing, medications, activity modification, braces, orthotic devices, etc, but when they attempt to walk hard for 30 minutes (standard test), or attempt sport specific activities like solo volleying in a squash court, they have definite increase in symptoms. They are still in the 60-80% range of function. This is the time that physical therapy, injections, changes in orthotic devices, chiropractic, accupuncture, etc, is utilized to get their function off this plateau and onto the 80-100% plateau where they can dramatically increase their activities. A good sports medicine provider is very skilled at this task of raising the plateau. Since the 80-100% plateau can be filled with reflares, minor setbacks, and many good pain/bad pain decisions, it can be the most difficult and challenging time in treating active patients. It is in this time period that most treatment of all the possible causes of the problem occur---short legs, flat feet, lordosis, weak muscles, tight muscles, dietary, etc, etc, etc. It is the fun part of rehabilitation.

I hope this post explaining the magical 80% rule used by most in the rehabilitation world has been helpful. Do not wait until you have no pain to begin to exercise you love, but there is so much thought on how to return to activity during this 80-100% prolonged plateau safely. Good luck!!

Foot Pain: Dilemma of Good vs Bad Pain

This is the Post all my athletes need to read.

For the athlete dealing with a painful situation, coming to a useful understanding of what is good and bad pain becomes crucial to speedy rehabilitation. Good pain is discomfort that is appropriate to work out through, or to feel afterwards. Bad pain is discomfort that must be stopped, the breeding ground for setbacks and flare-ups.

Varying pain thresholds in athletes can greatly complicate matters. Some athletes with a high pain threshold can train through a more serious injury believing that they are doing no harm, only to find that the injury has greatly worsened. In this case, their body’s own feedback mechanisms have let them down. Something in their head is yelling “No Pain, No Gain,” in probably several languages. They can participate at very high levels with pain, hoping that they can work through it. Sometimes they can, but many times they can not and the injury gets worse. Most of these athletes need the outside help of coaches and personal trainers, doctors and physical therapists, to help set some limits. Their own “self-preservation” mechanism is not working properly. Evolution to better body awareness can occur with good coaching. There is hope for this group.

For other athletes, including myself, with low pain thresholds, all pain is bad and can not be tolerated. This group may actually learn to accept some pain as okay, or good pain. They can also evolve.

Besides varying pain thresholds, there are many physiological reasons that the exact same injury can hurt a lot more for one athlete than another. The closer an injury is to a nerve, the more it hurts. The more your body swells with any injury, the more you hurt. If the injury is on the outside of your foot, and you walk/run on the outside of your foot, you will hurt more than another patient who walks/runs on the inside or the middle of their foot. The weaker the area is before you are injured, the more you will hurt after the injury since it will take longer to get the area strong. These factors are just a few.

Remember, injuries first heal and then double heal. Some bones like your metatarsals may get approximately twice as thick during the total healing process. This is why tendon and ligament injuries can heal with scar tissue that leaves the tissue twice as thick. So, even when an injury is completely healed, more healing may occur for several more months possibly producing noticeable symptoms to the athlete. Healing always produces some level of pain with swelling, muscle tightness for protection, scar tissue breakdown, etc. This can be good pain. So, how do we make some sense with this?

4 Golden Foot Rules may give us some focus.

• Golden Rule of Foot: Never push through pain that is sharp and produces limping.

• Golden Rule of Foot: Never mask pain with pre-activity drugs, including ibuprofen, aspirin, etc.

• Golden Rule of Foot: 80% of healing occurs in 20% of the overall time, with the remaining 20% taking 80% of the total time.

• Golden Rule of Foot: Good pain normally dwells in the 0 to 3 pain level (scale 0 to 10).


Let us focus on these 4 rules.
When an athlete asks if they can participate in their activity, there is no breaking of the rule of sharp pain and limping. Good pain may be at the start of a workout, then eases up. If the pain comes back in the middle of a workout, this is bad pain and it is best to stop. Participating with a team activity that is semi-dependent on you is tough as you ease yourself back into activity. But you must be clear from the start of the activity that you may need to stop if pain develops. Ask your co-participants to tell you if you are limping. Sometimes they see it before you feel it. Limping throws the entire body off, risking other injuries. Sharp pain normally produces limping, but limping can also occur as you transfer weight to avoid pain or if a body part is too stiff to bend properly.

Drugs, as simple as aspirin, ibuprofen, etc, can mask little to significant pain. Never take these drugs before participation, only after if allowed. In general, 6 hours before an event is permitted. Many of the anti-inflammatory drugs also inhibit bone healing, so are contra-indicated in bone injuries entirely.

Healing can take a long time to completely occur with any injury. The job of the doctor, therapist, and patient is to try not to repeatedly get in the way of the healing process. But even with our best efforts, we tend to take two steps forward, one back, then two forward, then three back, and so on. I am happy to say in following injuries for more years than most of my readers have existed on this earth, injuries do heal. People do forget what ankle they sprained in 2004, and what heel got plantar fasciitis in 2007. Yet, most healing occurs in 20% of the time, with the remaining 10-20% healing occurring in 80% of the time. When you are 80% better, level 1 or 2 pain still may exist, but you can do everything athletically your heart desires. But, it can take months and months of icing, stretching, strengthening, occasional flare-ups, to get rid of the last 20% of symptoms. It is considered the realm of good pain, but it can wear thin on our nerves and patience.

Good pain is pain/discomfort/soreness/tenderness/dolor that does not have to interfere with activity. Listen to your body. Does the pain cause limping? Is the pain sharp in intensity? Does the pain come on in the middle of an activity? Does the pain come on after an activity and hurt then for several days? Does the pain come with increased swelling? These are all signs of bad pain. Good pain stays in the 0 to 3 range, no matter what your pain threshold is. Good pain is normally gone the next day, so there are no residuals. Good pain does not cause limping, and is not sharp. Good pain, is not perfect, but your daily reminder to keep icing, stretching, strengthening, and listening to your body. Good pain can be a good guide to allow you to work an injury to complete healing.

But, you may ask, why not just wait until you have no pain before you go back to activity? The more inactivity, the more deconditioned you become, and the longer the return to activity process will actually take. So, it is better to try to discover the difference between good and bad pain. The better you become, the better decisions you will make in your athletic life, and the longer you will be an athlete. The better you become, the better prepared you will be for the next injury. An important medical decision may be made based on your knowledge of good and bad pain. If all pain is bad, you will have a less active life and may seek surgical intervention as a quick fix. If you still believe "No Pain, No Gain", I can not wait to see you at our sports medicine clinic as a regular customer. Learn about your body through this process. It has prevented 3 surgeries for me. And the same rules can apply to anyone recovering from any type of injury, not just athletics. Good Luck!!

Ball of the Foot Pain: Email Advice with MRI Images

This nice patient mailed me her CD from New Zealand. She is suffering from pain under and in the big toe joint from many years. This is my report to her.

Image of Tibial Sesamoid under the first metatarsal showing irregularities within the bone. The bone does not look totally healthy, but is not fractured or fragmented.

A slightly different image of the tibial sesamoid. The fibular sesamoid looked healthier. This can simply be from favoring her foot with some demineralization of the bone.

Here a large bursae or ganglion cyst is seen under the tibial sesamoid.  Sesamoid Fractures are often diagnosed when, in fact, the source of pain is in the soft tissue swelling under the sesamoid

Another image of the soft tissue swelling with some swelling in the tibial sesamoid (very slight).

Here we are at the joint level with our slice. The irregular white areas can be also seen below in the next image. This abnormal tissue arises from the plantar (bottom) medial side of the joint (arch side). This tissue, referred to as chronic synovitis, can get trapped in the joint and constantly irritated. Again, since it is on the tibial sesamoid side, it is often misdiagnosed.

Here the irregular soft tissue appears to be coming from the side of the joint. 

Another image of the same soft tissue swelling. When it arises from a joint, it is called a ganglion cyst. This may need surgery to remove the sac of tissue and tie off the stalk where it comes off the joint. 

Great image of this soft tissue mass causing so much problems.

These sacs can be injected with cortisone, not into the joint, to see if they will reduce. If not, they are removed.

Another side image of this mass.

From this view, and others, we know the cyst is filled with fluid. The problem with cortisone is not to inject other than the cyst which is quite small. If your doc feels uneasy about injecting, he/she may recommend surgical removal as a safer approach. Cortisone placed in the wrong spot can be dangerous.