Foot Pain and A Higher Source

    I am having foot pain only. It may be from higher up. I feel it in my buttock too and some faint pain sometimes in my leg. I have a clean back MRI, though. Is it possible the L5 nerve impingement causing foot pain can be found in the hip/glute muscles instead

1. Dr Blake's comment: 
2. 
   

   For sure, you should read about piriformis syndrome, but the sciatic nerve can also get hanged up in the hamstrings or behind the knee. Rich

http://www.drblakeshealingsole.com/2013/12/sciatica-and-piriformis-syndrome.html

Sinus Tarsi Syndrome: Email Advice

The sinus tarsi is a canal that runs within the subtalar joint between the talus and calcaneus. It can give symptoms below the ankle in any of the 4 directions: back, inside, outside or top of the foot (this being the least). An injection of local anesthetic can be a diagnostic tool to locate the source of the pain. When the doctor feels confident in that diagnosis, they may combine cortisone with the local to get longer lasting relief. This patient seems to have gotten the diagnostic part with the initial pain relief post shot, so the source of the pain seems to be likely from the subtalar joint. 


Hey Dr. Blake I wanted to ask. I had experienced some strain on my left foot and saw a podiatrist today. According to the doctor it was deemed a congenital left sinus tarsi syndrome. I had been experiencing a strange pain on that area for 2 weeks. Its like tender muscle which wouldn't go away and hurt with my work shoes which are slip-resistant rubber-soled shoes provided by the company. I have a job that consists me of being on my feet a lot. I know for a fact that the work shoes I had 2 weeks ago on a Tuesday was the cause of the strain on my left foot and that weird pain because the shoe got wet by the rain and the work shoe I had was of the steeled-toe kind which is a bit heavy. I hadn't had my superfeet inserts in them because I hadn't gotten pain before only when the shoe got wet. I initially had seen a general doctor 2 weeks ago and was given a ankle boot, a soft shoe and 800 mg ibupropen to be taken 3 times daily as needed with pain. Still the pain came. So now today Friday 10/2/15 I was able to land an appt with a podiatrist to get a thorough observation. She gave me a cortizone shot which at first relieved me of the pain when I walked but in the afternoon around 3pmish, I felt my left foot inflamed due to the shot I think. I even had lunch and took one tablet of ibupropen and I still feel it. I had tried to ice the area for 10 min and I still have it. I was told I'd be fine to return to work normally but I feel like the shot made it worse seeing that it feels more painful to walk. I was also given a new ankle brace to wear to replace the old one, but again feels like I can't walk a normal stride on that left foot. Do you have any recommendations? I did email the doctor about this too. Thanks. 

Dr Blake's comment:

It can take the cortisone up to 2 weeks to really work (if given in the right spot). Unfortunately, the shot can be irritative and cause more pain for awhile (typically only 4 days). Ice for 4 days post shot, and see how the symptoms go. By the time you read this you should be at the 2 week point, so I hope you are doing much better. Sinus tarsi is a pronation produced problem, and many braces are actually designed to pronate us. So, if the brace does not feel great, remove, and find another or just limit your activities. Hope this helps some. Rich

Accessory Navicular: Email Advice

Dear Dr Blake:

I strained my accessory naviular syndosmosis 8 months ago. MRI showed no PTT tears and very minimal bone oedema. I am in orthotics and some days are pain free but some days I get an ache around the area or more proximally up the PTT, pain 1-2/10 max. I can cross train, row and cycle but am doing no impact activity. My orthopaedic surgeon told me that if it was going to settle it would have done by now and that the next step to consider is surgery (he recommended a Kinder procedure). Given how much better it has got and fairly positive MRI results I would like to think that conservative treatment could work for me but lack guidance as to how to go about it. Should I be considering surgery at this point? Can delaying surgery affect how successful the outcome is? Many thanks in advance. 

Dr Blake's response:

     Doing surgery now is like recommending preventative surgery. I have not heard you talk about strengthening exercises. You need to gradually, and pain free, strengthen the PT tendon, and other tendons/muscles that support your arch. You need to maximize the amount of arch support you get from your othotic devices. You need to do posterior tibial taping for all your athletic activities. Hope this helps. Rich 

http://www.drblakeshealingsole.com/2012/11/posterior-tibial-tendon-dysfunction.html

Achilles Tendon: Cortisone Shots Near Them are Risky

Hi Dr. Blake,

I am hoping you can give me some advice: 

I was training to do an ironman triathlon this year. Last year I did my first ironman and I have done a couple of half ironman. This year would have been my second Ironman. I have always been pretty active. 

This year I started feeling pain at the back of my heel. At first it was only painful in the morning and the pain would go away after a few steps. One morning it was more painful than ever and I even had difficulty walking. I also had a little very painful bump at the back of the heel. I took two weeks off from training and took iboprufen everyday. The pain did not get any better so I went to an orthopedic surgeon to see what I had as I wanted to get back to practice as soon as possible. I knew the ironman would have been out of the question, but I am hoping to race again the end of january 2016. 

According to the doctor I have an overuse injury. Inflammation where the achilles tendon connects to the heel. He took an xray to rule out bone spur and gave me a (long lasting) cortisone injection to the back of the heel. (I attached a picture of the back of my heel. The injection is placed next to the label on the picture. You can still see the brown spot where the needle went in.) 

It has been about 3 weeks since I had the injection. After about a week and a half after the injection the pain is almost completely gone. The doctor said that he didn't inject the achilles tendon and that I have nothing to worry about because it's my first injection in that area. He says it's okay for me to start running as long as I don't do sprints and hill running for now. 

My question is; is it okay for me to start running and what are the chances to rupture my achilles tendon? Both the orthopedic surgeon and my physical therapist say I have nothing to worry about, but I am still very afraid I might rupture the tendon. 

If the cortisone did go into the achilles tendon, does it always weaken the tendon? And when will the tendon be back to normal strength after the cortisone injection?

I hope you can help me out. 

Ps. I am a 34 year old male and haven't run since the injection which was 3 weeks ago. I would like to start running again, but only after I am sure the tendon is back to normal strength

Dear Triathlete:

     I am not a proponent as you know of any injections near tendons. I think some patients can tolerate, and others it causes weakness. Since you have already had it, I would recommend taking the next 3 months off from running, and focus on the other parts of the triathlon. Surely there is work to do on your swimming and cycling. With cycling I would not get off your seat until December 1st, and work on form mainly. Is this overkill? It maybe, but you always should err on caution. No negative heel calf raises also which place tremendous stress on the achilles when the heel is dropped lower than the ball of your foot and you raise up from there. Sorry. Rich The article below substantiates this caution. I have had too many athletes tear their achilles when the doctor said the shot was not going into the tendon, only a neighboring bursae. Chalk it up to a learning experience, many races ahead of you with a little caution now. 

http://orthoinfo.aaos.org/topic.cfm?topic=a00147

Achilles Tendinitis: Yes it can get better!!!

This email is from one of my favorite long distance patients. I treated her for achilles tendonitis last year with activity modification, icing, stretching and strengthening. The email shows that this basic approach was successful. She also found a wonderful video on self deep tissue mobilization of the calf, but not to be done if your knee cartilage is suspect at all. The technique requires your knee to be too bent forcifully for too long. But, given good knees, and given a calf or achilles problem, you may want to add this to your regimen. Another example of how I learn more from my patients than medical seminars some times. Rich

Hi Rich;

I meant to make a follow-up appointment with you for earlier this spring, and I got caught up with stuff and never did. Part of the problem (if you want to call it that) is that my Achilles was feeling much better... which meant I wound up putting off making an appointment to see you.

I think I don't need to make another appointment at this time, but I thought it would be good to send you an update.

I kept up with my calf stretches regularly (and heel lift exercises not-as-regularly but still every so often), to where my Achilles no longer bothered me. I stopped wearing the support boot at night. I also felt like I could finally start pushing off with my left foot and I didn't feel any sort of strain.

The big news is that I ran the Mountains 2 Beach Marathon (from Ojai to Ventura) this past May, and qualified for the Boston Marathon! Not only did I BQ; I did so with 5 minutes 12 seconds to spare, essentially guaranteeing a race spot by being able to register during Week 1 (with the rest of the "fast runners"). I have a friend of mine who only made her qualifying time with a spare 100 seconds, who was shut out for the 2016 race because the cutoff was 2 minutes 38 seconds (I assume you know how that two-step process works for Boston).

I have registered and been confirmed to run Boston next April. I also won the "Boston 2 Big Sur" lottery so I will be running the Big Sur International Marathon down in Monterey a week after that.

Things got a little dicey after the marathon. Just a few weeks later, we took a vacation to Grand Teton and Yellowstone, where we ran two half marathons. Since we were doing a lot of hiking and also some camping, I actually didn't stretch as much as I should have... and so June/July was a little concerning because my Achilles tightness came back. I restarted working on them with diligence, and the issue has resolved itself now.

Now that I no longer feel gimped, I find that being able to push off with healthy feet/legs has made a tremendous help in my speed. This past weekend, I ran the inaugural Yosemite Half Marathon, and had I been suffering from Achilles tendinitis that course would have had me howling in pain; the course is 10 miles of downhill, with a leveling off/rolling streets for the last three miles.

However with my healthy Achilles, I was able to just remove my brakes altogether. I finished with a time of 1:40:51.9 and broke my previous PR by 10 minutes. My husband joked that I should put an asterisk on it because it was a gravity-assisted course, but I also came in first in my age group... THAT's legit, since everyone else in my age group also ran the exact same downhill course.

One quick question. A friend of mine forwarded me this video, and I'm wondering what you think. It makes sense; it's essentially like having someone press down on your knots while you try to work them out.

http://mobilitymastery.com/learn-the-one-stretch-that-relieves-plantar-fasciitis-shin-splints-achilles-pain-heel-pain-and-compartment-syndrome/

Cheers!

PS: Sorry about the Giants. The A's sucked this year, too.

Morton's Syndrome: Email Advice

This is an email received. High Arch Feet (aka Pes Cavus) by their structure place inordinate loads on the metatarsals. And, the nerves near the metatarsals can be daily crushed and irritated. Changing the mechanics first is crucial to help this syndrome.

Dr Blake, I urgently need your advice. I plan to walk the south island of New Zealand starting at the end of this year. I have pain in my foot like Mortons Neuroma and very high arches to the extent that I sometimes lose my balance. I have always used arch support insoles with a metatarsal pad. I think I need orthotics for this walk but I'm not sure there's time to get them made. I would also like your advice about protecting my feet during the walk. Could you help me? Thanks 

Richard Blake

You definitely have time to get new orthotics and break them in. Tell the provider that you are willing to pay for a Rush order. You can also experiment with longitudinal medial arch Hapads, but as a metatarsal arch. You go to Hapad.com. Use the right on the left side. I have photos on my blog at drblakeshealingsole.com. You must get the mechanics to off weight the sore area, combine icing, and perhaps a cortisone shot to decrease the inflammation, and you should be much better. Hope this helps. Rich

Of course, my latest photo of my grandson Henry Ellis Blake only 7 days old, and the cutest baby ever!!

Our Camino de Santiago in Northern Spain

Here is my first attempt at sharing our wonderful trip walking 12 days 189 miles along an ancient pilgrimage route in Northern Spain called "Camino de Santiago" or the Road of Saint James. It was an incredible trip with no injuries to report. Our shoe fitting at REI proved paramount to any success. My wife Patty and I trained for 15 months, with long walks almost every weekend. Since I am not a walker, so initially 3 miles seemed a lot. We gradually built up to 18 miles, although nothing can really prepare you for 16 miles a day, day after day. My wife and I used a travel company called MacAdventures to arrange our hotel stays (always nice) and baggage transfer (so only a day pack). It was incredible to accomplish through exercise something great, have hours to meditate (I spent a day alone thinking of my dad who passed last year), experience a deep rooted Spanish cultural tradition, meet people from all around the world (some who will remain friends), be in nature with incredible diversity of landscape, enjoy great food and wine everywhere even in small villages, and have time away from life, great but forever hectic (and this was a remarkable break from normalcy shared with your fellow pilgrims). What we learned is vast, but one special point rings loud. Everyone has their own Camino which is very special to them. It does not matter if you walk, bike, or even drive the Camino. It does not matter if you use taxis and buses at times. It does not matter if you have a back pack or a day pack. It does not matter if you do it all at once, or in sections (we did Stages I and II of the Camino Frances). It only matters that you experience what the Camino has in store for you and be open to what it teachs. My wife and I each had our own Caminos, yet we have an incredible shared experience. We are eager to finish the remaining 311 miles to Santiago de Compostela or just Santiago, but it may be in a few years due to family circumstances. 

CRPS: Email Advice

Hi Dr. Blake,

I am hoping you can offer us some advice as we’re getting pretty desperate.  My son (13 years old) suffers from CRPS.  He has had pain for over 5 years, but the severe pain and hypersensitivity (and other symptoms of CRPS) for the past 2 1/2 years. We have tried prescription pain medications, lidocaine infusions, traditional Chinese remedies, physiotherapy, light therapy, psychology, and most recently neuroprolotherapy (he went into shock).  He is barely sleeping, attending school less than half time and losing touch with friends, etc.  (spiralling downhill and I worry about depression).  I know you ask people to be concise but I’ve attached a description if you have time to read.  Any advice you can offer would be VERY VERY mush appreciated.

Thank you so much,

Dr Blake's comment: 
     Thank you for sending the summary that I read. I am so sorry for this injury. Definitely see if you can get the 10 treatments of Calmare Pain Therapy in the nearest center. I am sure it is not 100% successful, but it is non invasive, and has great successes. Neuroprolotherapy seems very good, but this is with sugar water injections only. I am not familiar with the Ozone injections that gave your son his problems. Find someone for normal neuroprolotherapy if the Calmare gives suboptimal results. Every good pain management specialist that treats this has a topical cream they like. This is so important to find one that you can gently rub in to the tissue for desensitization three times a day. This has to be a daily fix no matter what else you are doing. I guess IV Ketamine Infusion is next, but I am not sure at what age they would start at. I sure hope this helps some. Rich

Sesamoid Injury: Email Advice

Hi, Dr. Blake, 

My 12 year old daughter plays year-round soccer at a very highly competitive level. In early June after coming back from a tournament weekend, she complained of her foot being sore and not able to bend/flex her big toe very well. After asking her more questions, we find out that her foot had been slightly sore when she pushed in on the ball of her foot with her fingers for a couple months. However, now it was sore to walk and her flexion was limited. 

We took her to a podiatrist. MRI revealed inflammation and a bipartite sesamoid. He said it didn't appear fractured because of the clean lines. She was in a walking boot for 4 weeks with no pain. Then, she started wearing her custom orthotics in all shoes. We kept her out of soccer and pretty much all other running activity for another 2-3 weeks. She had little to no pain. We then slowly started her back into soccer wearing her orthotics in her cleats. She would only playing at 50 percent effort/time for a couple weeks and slowly increasing that keeping her discomfort level below a 3. After each practice and game she did an ice foot bath. We also were spica taping her foot all day at school and at practice in the evening and games. All the while she was doing foot strengthening and stretching exercises. A couple of weeks ago she was able to go at 100% effort with very low discomfort. We continued to ice bath after each practice and game, but because of the little amount of discomfort, we discontinued taping. Last week she mentioned it was getting a little sore with pressure again and this weekend at the end of her game she was in a higher level of pain than she had been in several weeks. 

Ugh! Will this ever go away and will she be able to be back playing regularly at her level of soccer? She's only 12 and the podiatrist doesn't do cortisone on children her age, which is fine. And, I don't want to resort to surgery. 

We are struggling with really knowing what her pain level is because she has a hard time determining when she has the "ok" kind of pain and when it's "time to pull back kind of pain". Her podiatrist told us/her that a low level discomfort is normal. 

Please help this mom who jumps to the conclusion that her child will never play soccer normally again! 

Dr Blake's comment:

     First of all, you are to be commended for the great and thoughtful course of action. Unfortunately, there can be many bumps along the way and you need to use the same common sense with each one of them. Children do have a hard time in general distinquishing good and bad pain, so typically parents must team with the coaches to pull the child when limping. I have found that bipartite sesamoids can fracture, but this does not sound like a fracture due to her good early return to soccer. This years advice though would be 100% spica taping while playing, removing any cleat under the sesamoid, making sure the orthotics have good arch support and great dancer's pads, and icing twice daily during the season. If you ever get an xray, please take some photos. Hope this helps some. Rich

Sesamoiditis: Email Advice

Hi Dr. Blake,

I am so grateful to have found your blog about sesamoiditis. I have had it for three months and I've tried everything (complete rest, ice, anti-inflammatory, physio, acupuncture, custom orthotics, a boot, taping), and I've been five weeks non weight bearing completely. But I still have swelling and pain.

Dr Blake's comment: Any time someone mentions non weightbearing I know that the pain and swelling are going to last longer. When you go non weightbearing, the tissues swells much more, since weight bearing with every step pushes the fluid back towards the heart. Swelling is the body's way of healing, bringing in the right stuff, but it always brings in more swelling then it needs, and the non weight bearing does not allow you to get rid of it. 

I've decided to get a cortisone injection. The doctor said if I haven't had healing from all the rest yet, I need to take  the next step. 

Dr Blake's comment: Cortisone, without knowing what the tissue looks like on MRI is risky. One hopefully is fine to shrink swelling, and diagnostically should tell you if all the pain is actually coming from within the joint. 

My question is how long I should keep my foot off the ground after the shot (to prevent tendon rupture)?

Dr Blake's comment: As long as the joint is within the joint, there is no weight bearing restrictions. You can not run for 2 weeks!!!

Should I go weeks non weight bearing? 

Dr Blake's comment: As soon as you can stop non weight bearing the better, but that has to be your doctor's decision (and you of course). 

And how long before I do some gentle foot exercises? 

Dr Blake's comment: Typically, even if you are non weight bearing you can do met doming, Single leg balancing with shoes and orthotics, posterior tibial and peroneus longus therabands, and achilles stretches. Remember, if there is weight bearing and if the exercise puts too much weight on the injury, you can stand on 3 or 4 books next to each other, with a hole for the injured area. Hope that makes sense. For the achilles stretch, just putting the front of the foot off a 2 inch thick book works. 

When can I deep water pool run?
Dr Blake's comment: Now!

 I'm willing to rest completely for as long as it takes, as this has been the worst experience of my life. I'll do anything to heal. I'm just afraid that this shot is only going to be short lived. 
And in your opinion, is it true that some people never ever heal from sesmoiditis? 
Dr Blake's comment: No, I have never seen a patient not heal from sesamoiditis. I have seen injuries that were called sesamoiditis, but were something else that required surgery. That is why I would even self pay if you have to for an MRI for peace of mind to know exactly what your diagnosis is. 

Thank you in advance. I'm hoping I'll be one of the lucky ones to whon you are able to reply.
Dr Blake's comment: This was sent during my vacation to Spain, so I am 3 weeks late. I hope it still helps. Rich

2nd Metatarsal Pain: Email Advice

Hi Dr. Blake!

I'm so glad I stumbled upon your blog today and that you're taking
questions! I have what's been "officially diagnosed" as bursitis on
the top of my left foot at the second metatarsal head and am hoping
you can shed some light on treatment for this aside from
ultrasound-guided cortisone injection.

The backstory:

In July 2014 I suddenly developed pain btw the 2nd & 3rd metatarsals
on my left foot near the toes. I don't recall injuring my foot but I
had been wearing some "barefoot" sandals a lot and having some issues
with my foot sliding around in them, which caused a lot "gripping" of
the toes. (I had already spent many years "barefooting" without issue
in Vibram Five Fingers at this point, but had moved from TX to PA
about 8 months prior and spent a lot of time in slippers/shoes because
of the cold, so simply wearing a minimalist shoe was not the issue.)

My chiropractor did regular ART on my foot over several months but
there was no improvement, so he tried Graston. A few weeks after he
started trying Graston on my foot, in Oct 2014, the pain moved from
the inter-metatarsal area to the joint at the head of the 2nd
metatarsal. The pain became more severe, and by Thanksgiving 2014 I
was unable to walk.

X-rays were negative but MRI in early December 2014 showed a stress
reaction at the head of the second metatarsal as well as inflamed
bursa. I was put into a fracture boot and spent 4 months in it
full-time. I spent another 2.5 months transitioning out of the
fracture boot into running shoes. By June 2015 I was full-time in
running shoes, but still in pain.

Dr Blake's comment: So, my first question revolves around levels of pain from the initial injury to the fracture boot to the running shoes. As you transition, it is okay to keep the pain between 0-2 levels, but not allow greater than 2. 

MRI in June 2015 showed that the bone was 98% healed but there is
still bursitis at the head of the second metatarsal. Orthopedist
recommended ultrasound-guided cortisone injection to address it, which
I haven't done yet.

Dr Blake's comment: I agree with your resistance to cortisone as the bone was still healing. PTs can use transdermal (non injectable) cortisone to shrink the bursitis. The procedure is called Iontophoresis and you typically go 5 times in a 10 to max 14 day period. 

At the beginning of Sept 2015 I began to see a podiatrist for therapy
twice per week. He places the 2nd & 3rd toes in traction for 10 min,
followed by 10-15 min of electrical stimulation, and then tapes the
foot to support & relieve pain. The tape is kept on for a couple days
each time. I've been for this treatment 6 times over 4 weeks and have
experienced some improvement, but he tapes my foot differently every
time and the more recent times it hasn't been as helpful or has even
increased my pain.

Dr Blake's comment: It is more the traction and electrical stim that is helping the symptoms. 

His theory is that my issues stem from my feet being structurally
unsound and that if he figures out how to tape my foot to relieve pain
then I can get orthotics that will essentially do what the tape does
and then I'll be fine.

Dr Blake's comment: I have never been able to minick the support tape does to an insert. They are too different in approaches. However, if you were getting relief from just tape, you can be assured that this has a partial mechanical treatment. 

Side note about my feet: they are very, very flat. I had severe
bunions (& bunionettes) from childhood, which were surgically removed
16 years ago at age 21. Both my 1st & 5th metatarsals were broken in
both feet. The bunionectomies were Austin and the podiatrist says they
effectively shortened my 1st metatarsal, making the 2nd one too long
and setting me up for this bursitis issue. It's also worth noting that
on my other foot (the right foot) the bunion has been slowly starting
to come back over the last 3 years, and my big toe is drifting towards
the other toes. It bothers me because I have tightness in the arch and
between my 1st & 2nd toes, but it's not painful.

Dr Blake's comment: Flat feet in general place too much pressure on the 2nd metatarsal. If you add shortening bunion procedures, you have the perfect storm of getting a problem with the second toe or metatarsal. The secret to your rehabilitation is to design off weight bearing pads to float the 2nd met head, at least to give it less pressure. Have you tried simply marking the sore area with lipstick, transfering that spot to your shoe insert, cutting out that spot and perhaps even another layer. Then, adding a Hapad support just behind it (close to the arch). 

https://youtu.be/-v9IrSucQpE

So what do you think? Orthotics? Cortisone shot? Anything else I can
do/consider? I'm very frustrated because I haven't been able to walk
properly in over a year and am experiencing all kinds of other
hip/back issues now as a result. I'm only 37 and really want to be
active again!

Dr Blake's comment: I would work mainly on the mechanics as mentioned above. I would also get some Budin splints for some shoes. I would ice pack twice daily for 20 minutes. I would get the PT. Then, send some comments to this post. Hope this helps. Rich

http://www.drblakeshealingsole.com/2010/04/pain-in-front-of-foot-possible-help.html

Thank you for any insights or recommendations you can share!

Chronic Ingrown Toenail: Email Correspondance Post Chemical Nail Root Procedure

One of my patients recently came in for a chronically ingrown toenail. He wanted a permanent fix, so I suggested he schedule for a chemical matrixectomy (where 2 applications of 89% phenol is used to kill the root (aka matrix) cells. 5 days before this email the procedure was performed, and I had emailed the patient to see how he was progressing. 

Patient's Response:

Thanks for the follow-up email, Dr. Blake.  I was just going to email you today!

My toe is doing great.  Outside of a little on the first day/night, I have had zero pain.  I also have had zero oozing, and virtually no bleeding.  In fact, the only blood I see is on the tip of the Q-Tip when I insert it at the base of the nail halfway thru the soakings.  And actually that little has even stopped, as I ran out of the Q-Tips you supplied, and now I am using regular store bought Q-Tips.  It seems to me that I could even stop the soakings, as I don’t see them adding anything?

Dr Blake's comment: I tell the patients to soak twice daily for one hour for 2 days, then twice daily for 30 minutes until they feel like the soreness is diminishing and healing going well, then once a day for 30 minutes for a minimum of 4 weeks (and it can be up to 6 weeks). The acid, which has been used to destroy the nail forming cells, produces dead tissue which the body needs to flush out. Keeping the wound open for the first couple weeks with Qtips or face cloth, prevents the hole from sealing over, and allows the bad stuff to come out. 

In fact, my ONLY concern is if the wound has “closed up” or “scabbed up” (mentioned sometimes happens), and so the needed discharge is not happening.  Does that seem possible/probable given the info above plus the two pictures?

Dr Blake's comment: You photo below looks like the wound is really open well. Good job with the Qtip!!

Let me know if I should continue with the soakings, the Q-Tip “gentle jabbing” (with slight pain), and/or the antibiotic with band-aid – and if so, for how much longer?

Thank you again!

Typically after all this soaking and covering, the wound needs to be less macerated with 50% air exposure. As soon as you are home for good, soak for the 30 minutes, then dry off and leave open to the air all night until the next morning. Oxygen (air) is a great healer.

Dr Blake's comment: 

     You are definitely looking good. Continue once a day 30 minute soaking to continue to pull  out. You do not need the q tip, but each day after you bath, take a face cloth or piece of gauze and gently scrub the wound placing pressure on the nail border and then wiping outwards away from the nail for 30 seconds. Makes sense?? Send me more pictures in 2 weeks. During the day, topical antibiotic and bandaid. During the evening 12 hours, expose to air. Great healing!!! Rich

Ankle Snapping: Email Correspondence

Dear Dr. Blake,

How fabulous you are taking questions again! Just my wonderful luck and timing! Thank you!

Dr Blake's comment: I am hopeful to be more consistent now. I have had a wild year with my dad passing and my mom living with my wife and I part time. It has been great to have this time with my mom. I thank everyone for their patience, and I apologize to those I could never answer back. 

Peroneal subluxation. I’ve been scouring your blog looking for info on this. At this point I am self diagnosing (I know, I know) but with my myriad ankle issues I’ve read a lot of information over the years about different ankle esque conditions. I am now 43 years old, still very active. My left foot had the lovely sesamoid fracture which occurred at age 39 I believe. It appears to be fine now but a good year of healing and more time of tenderness ensued. Then I’ve dealt with a 20 + year ankle fracture that occurred during a hard sprain (I thought) while snowboarding. My outer ankle (again left foot) continues on with the multiple fragments hanging out in my subtalor joint. I’ve chosen to forgo surgery since I really have a few occasions a year of periodic swelling and pain.

So today I am writing on behalf of my right foot. Until now I’ve really had no issues with it but am realizing now it’s been taking up serious slack for my left foot. Here’s what’s happening.

I significantly ramped up my yoga routine over the last 8 months and I’ve done a lot of hiking over the summer. A lot of several hour jaunts up steep, very fast elevation gains. Since the trails are fairly smooth and clear with just some uneven areas I just wear Keen brand waterproof lace up low top shoes. Not a ton of support but it’s a nice low shoe that doesn’t bother my left ankle issues and seems to serve well in many trail conditions. Overall comfortable and semi supportive I guess. Have practiced yoga for 20 + years and the yoga I do is fairly strong, vinyasa flow. Lots of odd angles and pressure on the outer ankles doing pyramids, side angles, balancing poses on one foot, warrior I’s etc. etc. Yoga as much as I love it can be oh so hard on ankles and notice more and more pressures/sensitivities while doing it (left ankle is speaking of some Achilles issues at the moment..will save that for another day).

So about mid summer I began to notice this ‘snapping’ happening on the exterior of my right outer ankle, going up my leg a few inches. When I place my fingers over the area and rotate my foot clockwise I feel a band or bands shifting side to side (more over the back portion of the ankle bone). The snapping is especially noticeable climbing steps or hills or pushing off to the left in a side step motion with pressure to outside of right foot. Along with the snapping I found myself waking in the morning and rotating that ankle as I felt like it needed a stretch and multiple cracks sound off from the ankle area as I rotate it clockwise. Lots of cracking. It feels really good but now I’m trying not to do that.

Here’s the thing. There is NO pain in my right foot. Maybe after a long hike I feel a touch of soreness near outer part of ankle but there is no swelling, no pain during any movement. Definitely no pain or tenderness over the snapping areas. But the snapping seems is getting worse and it’s becoming very unpleasant. I haven’t been to a doctor yet because as I’ve mentioned I live in a remote area where each doctor visit begins with the most basic diagnosis, then a long wait ensues for a specialist in an area not usually related to the specific area you are requiring assistance for.

I would love any advice on bracing, exercises, taping, and/or suggestions I could offer to my physical therapist who may know little about the condition. If you feel like this could be masquerading as something else or would like me to get an x ray or consult with a physician before a reply I can do that. Hopefully I’ve done a good job self diagnosing :)

Thanks in a advance for any words you may have for me and thanks for the many you’ve already provided me!

Cheers!
 

Dr Blake's response:

     This syndrome of snapping ankles is does come from the peroneal tendons moving over themselves. There can be only muscular tightness involved, or a combination of tightness and inflammation. The treatment is exploratory. Most start and work on the inflammation with icing twice daily, and begin some form of peroneal muscle massage (say with a rolling pin or massage stick). You need to stay away from tendon massage since that is hard to avoid irritating. ART or soft tissue mobilization of the peroneal muscles (not tendons) can be very helpful. A few cases I have seen are joint related with some joint mobilization needed (to get it unstuck!! in the wrong position). I can image it can develop from weakness, but I have never seen that, so peroneal tendon strengthening seems to not be helpful. I see this over and over on the side that was not injured, as a secondary limping residue. It seems that if we want to take pressure off our left side, we love to go all the way over to the lateral (outside) of the right. A change in foot pronation (more!!) could cause this. Have you noticed any change in your right side mechanics? Hope this helps you. Rich

Here my wife Patty and I are walking into Azofra in Northern Spain Sept 2015

Patient Response:

Good afternoon Dr. Blake,

Awesome about your journey! The pics are wonderful! I had seen a bit about it on your blog but wasn’t too clear on how far you went.  That is quite a ways!!!! Wow! :) I’ve heard that trek is amazing and so inspiring and also that Spain is very very lovely. On a side note my condolences to you for the loss of your dad. Hope you all are making it through.

Thanks for you quick reply to my questions. Your post is great! It gives me hope that it’s not too serious and perhaps a simple fix! I have been told by several massage therapists that my lower legs are horrifically tight! There are also some adhesions here and there. I have just begun exploring foam rolling and use of a tennis ball for self massage and I will investigate this issue with that. I think you are right on. Right side mechanics? Wasn’t sure about that question. I don’t think I’ve had any issues if you were asking direct. In looking at my shoe soles each seem evenly worn on newer and old pairs. Only the tiniest bit of extra inner foot wear.

Wanted to pass on to you that I was able to get into my physical therapist who agreed yes the peroneals are for sure snapping on the right leg as I described. Then she told me braces or sleeves wouldn’t be very helpful and then gave me some oldish advice about strengthening. Oldish in that what I read was thats what they USED to advice patients. The new info is parallel with what you are saying that strengthening does little to assist the issue. I will get down to the business of experimenting and see what I can do for it and will update you.

Before I go I wanted to mention my left foot. The achilles pain I mentioned. Last week when emailing you the snapping in my right foot was far more annoying than the pain in my left but now it’s becoming critical and increasingly debilitating! It’s not constant but caused mostly by the weird pigeon toed bent back foot angle used in yoga warrior pose and the same type of foot position in surfing (left is my back foot). Today with every pop up and ride aaaagh the pain!!! Medium stabbing and burning. It’s been bothering me a bit more each time I go out but today was bad. The pain is very central to right behind the outer ankle bone running up an inch or two. But it’s actually really hard to locate exactly where the pain is originating from. Only about a 3 inch diameter area. My PT said it was not achilles. Had me going up on my toes and other moves and nothing hurt it moving or palpating except three inches above the ankle bone I get an electric shock sensation when I press on it. I know there’s a million things it could be. Old fracture, arthritis, bursitis, more peroneal business but does anything stand out to you? 

No hurry on this! In fact I’m sure I have hit my quota of questions. Like two years ago lol.

Have a beautiful day!

Dr Blake's response:

     The left is probably in neuro spasm. PTs typically can use electical stim to break the spasm. Docs will use trigger point injections with local anesthetic. You can try to use deep ice massage with some painful acupressure. Rich

Tips for Parents Re: Children's Feet

http://www.news-medical.net/news/20150923/Practical-tips-to-help-parents-spot-childrens-foot-problems.aspx#learnMore

Shear Ban for Friction Relief

http://shop.tamarackhti.com/ShearBan_PTFE_Self_Adhesive_Sheet_p/749.htm

I have been happy with the use of this product in areas of shoes or orthotics that I want to eliminate friction stress. 

Ankle Swelling Advice

I hurt my right knee a while back. Since my right knee was injured, my automatically put all my weight onto my left leg. I've been doing it for so long that now I have fluid in my ankle. It's the size of a silver dollar. I asked a Dr if I can have it drained but he rejected because it's small. It hurts when it's cold and it seems like it's growing. I don't want arthritis to go to my ankle. Should I get another doctor's opinion or am I stuck with it?


Dr Blake's response: 

Fluid like this can be from stress produced by limping. Drain it, but still limp, and all the fluid comes back. It can be a separate problem, like a ganglion cyst, which can be easily drained. See my blog for treatment of ganglion cysts at www.drblakeshealingsole.com. So, I would definitely get another opinion, and if it is causing disability of any sort, see if you can get an MRI. I have attached a video on contrast bathing that can help with the swelling. Do it for 10 straight evenings and see if the swelling subsides.

Julie Lopez Shoes: High Heels with Some Thoughtfulness

Perhaps the shoe industry of high heel wearers is starting to go in the right direction. Anyone with personal experience please comment. Please also see my video below of the pros and cons of high heel shoes. 

https://youtu.be/vPgnrvCzzC8

https://youtu.be/VWaMbMvFM1Q

Foot Pain after Fall: Email Advice

Hi. About 5 months ago, I fell down some stairs in my house. At the time my foot and ankle became swollen but it wasn't that big of a deal. Over the past couple of weeks, my foot has given me a fit. I can barely walk on it without a limp. It hurts to put much pressure on it and it is very swollen. It hurts on the top of my foot and my ankle. I've gone to the doctor and he gave me an X-ray and said that he saw no fracture or arthritis and he gave me a steroid forinflammation. Its no better.

Dr Blake's response:  

That would be a difficult connection to make since over 4 months went by and your ankle was fine. However, if you have been relatively inactive for the last 4 months, and now are increasing the activity coinciding with this flare, then they could be connected. Definitely ask for an MRI to look for a hidden bone or ligament injury. Probably should begin treating with a removable boot (like an Anklizer) until the results are in. Good Luck. Rich

I thought I would throw in this unbelievable video.