Severe Plantar Fasciitis and Oral Cortisone: Email Advice

Dear Dr. Blake.
Thank you so much for posting and blogging about Plantar Fasciitis /Bursitis.
It has been very helpful for me.
In my hospital in Amsterdam i had all the treatings. I do not
have to name it again.. I told my orthopedic doktor about oral cortisone and he was
at least suprised. He never heard of oral cortisone with Plantar Fasciitis.

http://www.drblakeshealingsole.com/2010/12/oral-cortisone-king-of-anti.html

He gave me a cortisone injection.
No pain relief. Yes for 4 day.s..

At the moment i.m in Marbella/Spain.
Also here i have had, Fysiotherapy, laser. insoles...
no happy end . Pain and pain.. of course I used also ibuprofen, paracetamol,
naproxen and so on and so on.
I.m desperate.. 

Reading your artikel about Oral Cortisone..
And the Prednisone Burst.
I want please to ask you.
You are working with sport men and woman.
I.m a fragil woman from 70 years old and my weight is 60 kg.

I think that for every person the quantity of oral prednisone can be different.
So in my case what do you advice me ?? How much is responsable for me, as an old fragil woman to take ?

Dr Blake's comment: Please ask a pharmacist  if age and weight are a factor. I have not come across that. 

Considering the fact that I also have a severe pulmonary fibrose IPF, and i.m on PIRFENIDONE.
Thats  a very heavy and strong medicin.
The regular dose of Pirfenicone = 9 pils a day, but I can only handle 6 pils a day.

https://en.wikipedia.org/wiki/Pirfenidone

Dr Blake's comment: Your doctor treating the fibrosis, and the pharmacist mixing the drugs, would be the best at commenting if a 8 day course of oral cortisone would be contra-indicated. 
 
I would be so happy to hear from you and listen to your advice.
Yesterday I started with 2 pils of 5 mg (togehter) and it was too strong already.
My body was shaking..and sweating and so on..
Dr Blake's comment: That is probably your answer not to take. Sorry.  If you can get an MRI or Ultrasound, see if you do not have a plantar fascial tear. The treatment would be a removable boot for 12 weeks but you do not need the medicine then. Good luck . Dr Rich Blake

Yes i hope you have a little time to answer me.
Thank you so much Dr. Blake and I wish you all the best..
LOve.

For Stephen Curry Fans to Enjoy!! Math Analysis

http://fivethirtyeight.com/features/stephen-curry-is-the-revolution/

Accessory Navicular: Email Advice

I am enjoying your website. It has helped me to understand my navicular syndrome.

I am 64 and didn't have any problems till 2 years ago, thought I had a fracture but 

Dr informed me of my extra navicular bone in each foot.  Got thru that episode on my right foot after 3 weeks of rest etc.

Now, I wake up in the night with Left ankle pain, can hardly walk till I take ibuprofen, ice my ankle, wear my boot shoe and elevate. By afternoon it subsides and I can get around pretty well. This has happened for 3 nights now.

I do put pillows around my foot at night, it feels good. I do have a bone that sticks out on each foot.

Dr Blake's comment: Does the left ankle hurt at the bone? Does it hurt to put weight down or to move the ankle in circles or both? Answer by commenting on this post and I will reply to your comment. You should be icing 10 minutes 3-5 times a day and try the kinesiotape circumferiential wrap. The taping for the posterior tibial tendon dysfunction problem is probably the best for you. 

Your videos on taping and exercise have been informative.

I started doing the first exercise gently.

Any tips on how not to aggravate it during the night. Am I just stretching it in my sleep enough to upset the tendon ?

Dr Blake's comment: Try the posterior sleeping splint for plantar fasciitis. Works well at night for this. 

I wear my ankle compression sock or ankle brace on some nights.

This is getting in the way of my daily gardening etc.

Dr Blake's comment: Use a removable boot anklizer type just for gardening (you can put your orthotic and tape inside the boot).

Okay, not that type of boot!! Good luck, and get an MRI soon if it is not turning the corner. 

I do wear arch supports in my shoes. Ive tried a number of different types. Some aggravate it even more. 

Thank You for any help. I would rather avoid surgery. 

I use to work in SF years ago. I live North of Portland in WA now.

Frozen Ankle post Sprain: Email Advice

Dr. Blake,

Good afternoon.  I just came across your blog and I just want to say thank you for taking your time to respond to so many people!  I would love any information you could provide me after I tell you about my injury. 

Ok, so here we go. March 16, 2015, I went to one of those wonderful trampoline places for a birthday party and badly sprained my left ankle.  I had to be carried off and my ankle swelled up instantly.  It took me about a month to get an appointment to see a podiatrist.  In the meantime, I kept it iced, elevated, wrapped with an ankle brace and I was using crutches/cane/knee walker to get around.  My first appointment with the doc,  after x-rays, I did not break anything.  He said it seemed like a 3rd degree sprain with a high ankle sprain and it was frozen, which does not happen very often after a sprain.  He said this happens maybe 1 in every 1,000 sprains. Just my luck, huh?

Dr Blake's Comment: High ankle sprains involve the ligaments between the two ankle bones (tibia and fibula). When those ligaments get sprained, you lose forward bend of the ankle, thus "a frozen ankle". The more common lower ankle inversion sprains have full mobility to bend, it is the side to side ligaments that were injured and have to be protected. So, everything makes sense so far. Rich
 
I was put in a knee-high air boot, weight bearing and sent to physical therapy and  to check back in 6 weeks later.  After about 2 weeks, we realized my ankle was not moving or going to start moving, so we moved my check up to be seen earlier.  I had an MRI, and my doc said it was a basically a frozen joint and still the high ankle sprain and 3rd degree sprain. 

Dr Blake's comment: This is good medicine to get an MRI early in the game to rule out cartilage or bone injury. So far, you have been in the Immobilization Phase, and you are not going to gain alot of motion at this point until you are out of the boot. So, everything still seems normal. 

 We tried numbing it in the office about 3 times and tried to manipulate it, but that did not work.  So, he wanted to try a manipulation under anesthesia, where I could not fight him, but my insurance didn't cover that.  We are also in June 2015 by this time.

Dr Blake's comment: So, since a high ankle sprain can take 12 months or so to gradually loosen up as you balance pain free protection with gradually more and more stress, why was there so much concern about your ankle. Was it totally locked? How much did it hurt? What was the range of motion with the knee straight bending the ankle and with the knee bent? Do you have an excessive scar formation problem? Are we 100% sure that there were no bone/cartilage injuries?

  I was supposed to have surgery right after 4th of July weekend and found out that my surgery was not approved less than 24 hours before my procedure.  They would only cover the scoping.  My doc didn't want to just cut into me, so we tried to appeal the surgery and 30 days in, we found out the appeal was never started, so 60 days total, it was denied again.  This is now September, and by this time I would have rather him do both, the manipulation and scope, to be safe because the joint has been frozen going on 6 months now.  So, we scheduled my surgery and after it being cancelled one more time, the big day was October 22nd.  I had my one week follow-up and he released me to start back up physical therapy.  My 2 week follow-up, he removed the stitches.  We wanted to be aggressive with the therapy so the joint did not freeze up again, but not too much so the body went into shock and froze up by being to forceful too soon.

 

My physical therapy doc wanted to start dry needling me, but we had to wait until I could do a good stretch.  By the beginning of November I was being dry needled twice a week and she started grastoning me as well.  She thought because I had such short movement from the knee down for so long, that my muscles were so tight and that is why my ankle could still not move up very well.  I went from PT 3x per week, to 2x about a month ago.  In January I had a follow-up with my foot doc and he released me to full physical activity like I used to before my injury.  I was pretty active, working out pretty much everyday, so not working out for about the last 10 months or so has been killing me.

 

Ok, so I've been going to pt since my first post op and doing all my home stretching and my ankle is still not moving very well.  The front is better, but I am super tight in the inside,  like I can feel it pulling when I try to move my foot upwards.  After many breakdowns at pt, my pt doc told me a frozen ankle can take 1-3 years to fully heal, called it "a thawing out period".  After accepting that a few weeks ago, I am still not convinced.  I am tired of everyone telling me this does not happen very often and not really sure what to do.  We get it to stretch pretty good while Im at pt, but then it freezes back up.  I want to know what to do to fix this.

Dr Blake's comment: You definitely want a new MRI, because a one year comparison can tell you what is wrong and if there is anything to do to fix it. But, what did the surgery find? Too much scarring? Scuffed cartilage? More info on this tight ankle is needed. Make a comment to this post and I will reply directly to the comment. Yes, these can take this long, but I agree something does not make sense. Something is missing. 

 

Last week, I went and got a second opinion from another podiatrist.  He took more x-rays and looked at my MRI from before the surgery and I had pics from my scoping.  He told me it looks like he only scoped the front of my joint and not the back.  He showed me my MRI and the notes, and  there was no evidence that it was a high ankle sprain.  He said I did a number on it, but in the lower bones, I banged both together in 2 spots and he showed the bruising.  From the x-rays, he said it looked cloudy in the back part and when he showed me that my heel doesn't move side to side, because he believes the scar tissue it still there.  That was a pretty hard pill to swallow.  He recommended getting a steroid shot and ordered a JAS splint for my ROM issues.  The doc said he had a similar patient and he did the scope of the ankle and then put a cushion in the back to help with movement and she is at 80% mobility.  Here I am 4 months post surgery and unless I am very warm and all my weight is stretching the joint, I am not where near that.  I didn't get the shot that day, but I have it scheduled for Monday, Feb. 22, and I am very nervous.

Dr Blake's comment: Okay, now we are getting somewhere. So, I am sorry I am answering this after that appt. Definitely opt for a new MRI. If the initial MRI was misread as no bone injury, no wonder you are not better. If you injury bones, they need to heal before you can begin to get mobility back. I did have a PT who could not work for 3 years waiting for her bone edema (swelling) to completely resolve. Exogen bone stimulators can definitely help, along with flushing with contrast bathing nightly. There is still hope. Can you send a snapshot of the MRI image or two that shows the one edema?

http://jointactivesystems.com/

 

I have a follow-up with my main doc on March 1st and I am going to ask if he scoped my whole ankle or just the front.  I am also going to ask about my MRI. 

Dr Blake's comment: Most docs just scope the front in these cases, the back being too hard to see. To access the back potentially can cause more tissue damage or scarring, so he probably erred on caution which makes sense. 

 

I guess my question to you is whether you think the shot is a good idea? 

Dr Blake's comment: If you had a shot on your visit fine, but keep them to a minimum until you know the bone/cartilage has completely healed. So get another MRI, get an Exogen bone stim if the bones still light up, get me some pictures. Hope this helps you somehow. Rich

 That is how I came upon your blog, looking up info about the steroid shots.  When they told me they would have to inject the shot into the ports where I was scoped, I freaked out because I am still in pain when my therapist tries to work on the scars.  I am only 31 and I just want to be able to be active again.  I thought after my surgery, I would be fine and now to find out that it is still frozen in the back, I am not sure what to do.  I asked the doc I had the second opinion with, was all this dry needling to get my foot to move basically a waste if the scar tissue is still there?  He said it isn't hurting anything, but I said it isn't really helping anything either and he said no.  I just spent the last 4 months going through some rough stuff and to find out my ankle it still messed up, I don't even know where to begin.  I have been reading reviews about these shots and I am reading more negative ones than positive.  I just want to make sure I am doing the right thing.  I really hope this and the JAS splint helps, because I really do not want to go through another surgery if possible. 

 

Any help would be greatly appreciated.  Thank you for taking the time to read this.

 

Very Respectfully,

Words to Live By

This was an email sent from a friend. I agree with everything said. It is always good to reflect alittle on how we are living on this earth. Love, Rich

As we grow older, and hence wiser,

we slowly realize that wearing a $300. or

$30.00 watch   - - - - - - -

they both tell the same time...

 

Whether we carry a $300 or
$30.00 wallet/handbag - - - - - - -

the amount of money inside is the same;

Whether we drink a bottle of $300 or $10 wine - - - - - - - - - -  - -

the hangover  is the same;

Whether the house we live in is 300

or 3000 sq. ft. - - - - - - - -

loneliness is the same.

 

You will realize,

your true inner happiness

does not come from

the material things of this world.

 

Whether you fly first or economy class,

if the plane goes down - - - - - - --

you go down with it...

 

Therefore.  I hope you realize,

when you have mates,

buddies and old friends,

brothers and sisters,

who you chat with, laugh with,

talk with, have sing alongs with,

talk about north-south-east-west or heaven & earth, ....

That is true happiness!!

 

 

FIVE UNDENIABLE FACTS OF LIFE:

1. Don't educate your children to be rich.
Educate them to be Happy.
So when they grow up they will know
the value of things not the price.

2. Best awarded words in London ...
"Eat your food as your medicines.
Otherwise you have to eat medicines as your food."

3. The One who loves you will never leave you
because even if there are 100 reasons to give up

he or she will find one reason to hold on.

 

4. There is a big difference between

a human being

and being human.

Only a few really understand it.

5. You are loved when you are born.
You will be loved when you die.
In between, You have to manage!

If you just want to Walk Fast,

Walk Alone!

But if you want to Walk Far,

Walk Together!

 

SIX BEST DOCTORS IN THE WORLD:
    1. Sunlight
    2. Rest
    3. Exercise
    4. Diet
    5. Self Confidence and
    6. Friends


Maintain them in all stages of Life and enjoy healthy life.

 

Sent with Smiles,
Affection and Love !!

Post Sesamoidectomy

Hello again dr Blake!

At 10 months after tibial sesamoidectomy I'm happy to report some progress. There has ben no severe flare-ups since November. I have been able to do all my daily activities pain free (working, even standing for up to eight hours in the OR, shopping, walking to the store etc) and have noticed that I've gained back my usual, quite fast walking pace. I've also started the walk-run program, and progressed up to 3 minutes of running but at that point there was some pain again so now I've got to start over at 2 minutes. Somehow, running seems a lot worse for me than walking, even though I have a thicker dancer's pad while doing that. The winter weather has been very crappy (pardon me) this year, and I've not tried cycling yet. It's a hobby I used to love and I'm anxious about not being able to do that again.
I'm happy about living pain free now, but still I long for the long hikes and cycle rides I used to do... Should I just forget about those now and find other hobbies? Can I still expect progress this long after the surgery?

Dr Blake's comment: Definitely, as you gradually stress the joint, the scar tissue will become more normal, and the body's own neurological protection will lessen (less sensitiivity). Hope you are continuing to ice twice daily to keep the inflammation down, even on relative non-exercise days. Making sure the biomechanical support and off weighting is correct is crucial in the Walk Run Program (link below). Thanks for inspiring others with a similar situation. It is typically a 2 year post op course. 
I'm contemplating about getting PT to analyze if my gait is stressing the sesamoids too much, and also to guide with some exercises for the foot. It's hard to find the time for rehabilitating the foot with my busy schedule and now that I'm pain free on 90% of the days, I just kind of forget about it...

Wishing you a lot of sunshine in the coming spring!

http://www.drblakeshealingsole.com/2010/03/walkrun-program-for-injury.html

Referral Source: AAPSM for quality sports medicine

Hello Dr. Blake,

I am a nurse, 66, very active (till recently) with hallux limitus. I had the issue a few years ago but it went away with shoes, rest and so forth.  I would like to see someone like you in the Austin Texas area (or fly to see you if necessary - this could be difficult but I would do it!) but cannot seem to figure out how to assess by websites.  I have seen one person so far but did not like his nonconservative approach as I think orthotics and PT could really help.  Short of learning how to tape and get shoes and orthotics from web reviews I feel kind of on my own.  Austin must have some good people but I cannot find.  I wonder if you have heard of anyone here from one of your professional meetings or so forth?  I know if you mentioned a name that would not mean you know they are good, but just that I would go see and assess for myself.

I really want to do the right things for myself.  I stopped jogging and don’t want my overall health to deteriorate because of pain but also don’t want to ignore the pain.  I just bought 2 pairs of Finn Comfort shoes with a sort of rocker bottom and I am feeling lots better after that.

Thank you for your time and being so great!


Thank you so very much for your email. I am past president of the AAPSM (link below), and the members in general are more into sports medicine and keeping their patients going than most podiatrists. This is where I would start. There are 4 podiatrists listed from Austin and I personally know Drs Valencia and Brace. Good luck!!
http://www.aapsm.org/members.html

Children's Health Article

With the rise in childhood obesity and diabetes, this article emphasizes the role of moderate to vigorous activity to improve health. 

"Physical activity seemed to be the main explanation for the differences in childrens’ adiposity. Every 10 minutes per day of moderate to vigorous physical activity was associated with 3.5 percent lower body fat at the end of the study, even after adjusting for fitness levels and the amount of screen time. This amount of exercise was also linked to a 4.8 percent increase in insulin sensitivity."

http://www.reuters.com/article/us-health-children-adiposity-diabetes-idUSKCN0VI24L

Exogen Bone Healing System recommended by Dr Blake

http://www.exogen.com/non-union/

     Over the last 10 years, Exogen has been the only bone stimulation system I have used. I am very pleased by the results. I have no financial connection with this company. My patients use 20 minutes once a day for 6 to 9 months. It has almost eliminated surgery for some injuries like sesamoid fractures. 

Post Op Sesamoid Removal: Email Advice

Hi Dr. Blake,

I'm not sure if this is the best thread to ask my question on, but I couldn't find exactly what I was looking for.
I just had my stitches taken out yesterday from having my sesamoid (tibial?) removed. I had the same procedure on my other foot 4 years ago by an awesome doctor in Monterey. Unfortunately, this time it was done by a Navy doctor and I had no choice. They don't seem to care all that much about recovery and follow up and the only instruction I was given yesterday was to grab my big toe at the base and push it as far forward and backward as I could for an hour a day. She said if after a month it's stiff, then I could do PT. Does that seem normal to you? Last time I did PT right away for a couple of weeks. 

It just seems really stiff and there is a lot of numbness. Nothing like last time. I just want to make sure that there isn't anything else that I can be doing since I've been left to my own devices for healing it.

Thank you so much for any info you can send my way for stretches or ice/heat therapy suggestions for 2 weeks post op!

Dr Blake's response:

Hey Amber, sorry for my delay in responding. I hope you are healing well. You should definitely get a referral for PT which is typically started between 2 and 6 weeks post op. Three times daily you should either just lay your foot on an ice pack for 15 minutes or do contrast bathing (as long as you are doing something three times daily to influence the joint swelling). I do not think you should just move the joint up and down (see my post on Hallux Self Mobilization). Do you have protective orthotic devices and/or can you make dancer's pads, but it is important to off weight the surgical area for the next year at least to some degree? You can definitely start doing metatarsal doming three times a day, and even flat footed balancing with the ball of the foot off the ground. Hope this helps you some. Rich

Photo of the Dancer's Pad Placement 

http://www.drblakeshealingsole.com/2010/09/swelling-reduction-video-on-contrast.html

http://www.drblakeshealingsole.com/2010/09/hallux-rigidushallux-limitus-self.html

Recurring Tendinitis (primarily peroneal): Email Advice

Hi Dr. Blake,
I have had recurring tendonitis diagnosed in various tendons in my lower leg and foot over the past 2 years. Started with overuse sesamoiditis, posterioal tendonitis and peroneal tendonitis. MRIs of foot, knee and even back after an EMG because of calf muscle atrophy. I am a climber so this constant injury is very frustrating to not be able to walk lain free, let alone climb. A podiatrist and now an orthopedic surgeon recommend a tendon sheath injection for the Peroneal tendon issues. I have pain at attachment under arch and at side of calf below knee. Weakness and increase pain wih movement. Also tendon pops at ankle. I have done pt and various therapies only to platue. Do you thimk the shot is best way to go? What questions do I need to be asking to make sure it is safe?
Thanks, Sarah 

Dr Blake's response:

Sarah, sorry for my delay in responding. I am assuming that the MRIs only came back with tendinitis and no tears. The PRP injections are gaining popularity, make some sense, but I just have no experience with it to recommend clearly. Definitely no cortisone into the muscle, tendon or sheath for fear of rupture due to transient weakness (which could last up to 9 months). Review the blog article on BRISS for tendinitis. See if there is anything missing in your treatment. Have you been adequately immobilizing in a below the knee removable boot for up to 3 months? Do you then to supinate excessively even with orthotic devices? When you return to activity, do you just go back to an overuse situation? Sounds like unless you can not get the tendon strong, it will be permanently the weak link for activities. How can it be made stronger? Or why haven't the PTs been able to make it strong? Sorry more questions than answers. Rich 

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

Positive Link between Probiotics and Diabetes Improvement

http://www.newsmax.com/FastFeatures/diabetes-probiotics/2016/01/10/id/708878/

CRPS: National Study On Right Now: Participants Needed

http://www.studycrpsnow.com/

Calmare Pain Therapy for Foot Nerve Pain: Email from Patient

This email was Happy New Years to me. I have been working with this patient for many years. I recommended Calmare Pain Therapy several years ago. She had to drive to the doctor's office, stay 2 weeks at a hotel, and get the 10 required treatments to help her very severe left foot nerve pain. She may require some booster treatments in the future. Right now she is very gradually testing out her new left foot!! 

Happy New Year!!! 

I’m emailing you with fabulous news about the effects of the Calmare pain scrambling treatments that I received in December. 

After 10 sessions, the intensely debilitating nerve pain has drastically dissipated! Words can’t even touch the depth of gratitude I feel and the degree of excitement I have with this increased mobility in my life. Since Dec. 22nd, I’ve danced for 10 minutes at least 3x, have walked with a friend for 50 min, have gone window shopping with another friend, and even baked muffins! 

I’m taking things s l o w l y and steadily to ensure that I remain on this healing path. Wow, there’s nothing like an absence of nerve pain to bring out the giddy “kid in a candy store” and the “where do I want to travel to first” parts of me. I’m embracing this moment fully with glee and at the same time, am humbly moving forward to stay within the zone of diminished nerve pain. I am sooooo thrilled!!!! I still have joint, tendon, and ligament pain in the ball of my big toe joint and throughout the tendons and ligaments that connect to it. However, now that the nerve pain has diminished, I trust I’ll be able to tend to these mechanical issues with greater and more rapid success. Aho!

Thank you from the bottom of my heart for your prayers. I deeply appreciate you holding my healing journey within your heart and for your prayers during these treatments. I connected to the web of support many times while receiving these treatments  and want you to know how palpable and significant your prayers were … and are. Thank you. Truly, thank you.

(And, if there is anyone who didn't receive my prior email, please forgive me as I’m sorting through my 800+ contacts and I very possibly missed you.)

For those of you from the Bay Area dance community, I hope to see you soon - even if for 10 minutes at first - on the dance floor. I look forward to being with you within the non-verbal depth of our meditation practice and welcome connecting with you there. And for all of you from the Bay Area, I’m now available for walks in nature - as long as you’re open to sitting together at the midway point to rest and commune with the elements.

I wish you a year of rich and heartful connection with all that brings joy to your world. And, I wish for this planet and for all sentient beings who live upon it, that this is a year when the human race acts on greater behalf of this generous, amazing, abundant, stunning, and interdependent orb of life.

Love to you,

Swelling: Contrast Bathing to reduce swelling after injury

Contrast bathing is one of the best ways of reducing swelling. This is even true for deep swelling in the bone/soft tissue which is not visible to the eye. The normal routine involves:

• Obtain two containers large enough to accommodate the body part involved.
• Place the two containers side by side, one is filled with ice and cold tap water (approx. 55 degrees F), and the other filled with warm/hot water typical for a hot tub (approx. 100 degrees F). Use your fingers first to test that the warm water is not too hot.
•  Place the body part in the warm water first for 4 minutes, and then immediately into the cold water for 1 minute. This is a perfect technique for feet, ankles, and hands.
• Repeat this cycle for a total of 4 times totaling 20 minutes.
• You should also feel that you are looser and less swollen.
•  Attempt to do this once a day on work days, and twice daily on your days off.
•  Move the body part through a pain free range of motion while immersed in the warm water.
• Continue contrast bathing for 1 week longer than you think you would need based on your symptoms.

As long as you are using ice in the cold bath, it is not necessary to try to keep the warm container near 100 degrees F during the full 20 minute cycle. As long as there is a good difference in temperature, you will obtain the desired result. The warm water causes vasodilation increasing blood flow, while the cold water causes vasoconstriction decreasing blood flow. By going back and forth between the two water baths, you can create a mechanical pump for the swollen area. While immersed in the warm water for foot or ankle injuries, pretend your big toe is a paint brush. Gently move through the letters of the alphabet, using both big and small letters, then on to hieroglyphics, or Chinese lettering. While immersed in the cold water, keep the body part still.

This is an 80% heat to cold ratio with the goal of reducing swelling. Following the typical 3 days (72 hours) of ice after an acute injury, I find it helpful to slowly build up to this amount of heat/cold ratio. For 3 days, I will use a 1 minute heat alternating with 1 minute cold cycle (1hot/1cold ratio), repeating 10 times, for the same 20 minutes. If the body part is less swollen and the patient feels less stiff, I will advance the patient to 3 days of 2 hot 1 cold ratio repeating 6 times for 18 minutes. Again, if the swelling is reducing and the range of motion feels better, I will advance the patient to 3 minutes heat and 1 minute cold repeating 5 times for 20 minutes. After 3 days of further improvement, then on to 4 hot and 1 cold as described above. Normally, if the swelling has been around for 2 weeks or more following an injury, it is okay to start at the 4 to 1 ratio. If you aggravate your injury during the contrast bathing phase, just return to ice for 3 days or more until the symptoms have stabilized. Following the aggravation, normally the 4 to 1 ratio is fine to restart. Never use heat, only ice, immediately after an injury or with re-aggravation of an injury.  To summarize the above:

Days 1 to 3 Ice Alone
Days 4 to 6 Alternating 1min warm/1min cold cycles repeat 10 times
Day 7 to 9 Alternating 2min warm/1min cold cycles repeat 6 times
Day 10 to 12 Alternating 3min warm/1min cold cycles repeat 5 times
Day 13 and on Alternating 4min warm/1min cold cycles repeat 4 times



Contrast bathing should never make a patient feel more swollen and stiff. If so, you are using too much heat and must begin to experiment with less heat as mentioned above. However, it is worth the effort. Contrast bathing can produce incredible gains in range of motion, pain reduction, and lead to quicker returns to activity. A wonderful addition to contrast bathing is elevation. With the increased blood flow due to contrast bathing, immediately dry off, wrap the area with some form of compression, lie on the floor, and elevate the injury as high as possible for 20 minutes. You can gently move the ankle up and down to help the drainage process. For most foot and ankle injuries, lie on the floor and get the foot up on the wall or couch way above your heart level. I call this Super Elevation!!!

Since the typical ankle sprain leads to swelling for 3 to 4 months, and a bad ankle sprain can be swollen for over 1 year, you may be contrast bathing for awhile. Be a good multi-tasker, but never do contrast baths near a power surge. As the soreness goes away, you may experiment with just 20 to 30 minutes of warm water soaking alone. See if you get the same results. Good luck.

Rehabilitation of any injury is a logical game if you know the rules. Inflammation can get much worse with heat, so ice initially, and then as you aggravate or irritate the injury as you move through the rehabilitation process, ice some more. Ice is for initial injury for 4 days, and for months and months with repeated irritations. So, there will be many days where you ice and contrast bath both at different times of the day. You have to distinguish between the chronic pain with swelling (time for contrast bathing) and the acute pain of aggravation (back to ice). At times the aggravation can be for 2 days to 2 weeks, so the icing alone will feel like you are back at square one. The rehabilitation process for patient, therapist, and healthcare provider is one of learning to minimize these aggravations/irritations while allowing as much function as possible.

And more Adele....

Happy New Year!!!

Dear Dr. Blake,

Knowing that we are now published poets,

has served me quite well,

wouldn't you just know it,

I've another poem yet to tell!

"Ode to the Podiatrist & A Happy New Year!"

January 1st is coming,

kicking off another year,

may your feet keep you walking, running,

and joy produce your only tear,

Healthy feet are a treasure,

both right and left,

they have you dance with good measure,

while carrying your heft,

Ode to the great Podiatrist,

who keeps them healthy and strong,

this warm gratitude you can't miss,

for it would just be all wrong,

Stand tall as tree,

but never forget,

your healthy feet support thee,

Here's to the Best Year Yet!

Happy New Year Dr. Blake!  I hope you and your family have a wonderful 2016.

Love, 

Please enjoy Adele's new song: Water Under the Bridge

Accessory Navicular: Email Advice

Hi Dr Blake!

I'm a young adult with flat feet, extreme high arch and accessory navicular.
It all started 6 years ago when I had pain right at the extra bone. I did ballet at the time and soon after, the pain was unbearable to the point of sharp pain at the bone every step I took. At that time, my treatment was icing, taping, ankle guards, orthotics and pain killers everyday. I even had 3 sessions of physiotherapy every week for 2 years. I experienced numerous ankle sprains through walking in a day where my feet either sprains inwards or outwards (even while wearing ankle guards and orthotics) and was literally unable to run. I even tried chinese healing to reduce the swelling. It got to the point where I'm  so used to the pain because I experience it with  every step i took. I saw an orthopedic surgeon who failed to pick up the accessory navicular problem and thus did nothing with it.

Dr Blake's comment: High Arch feet when unstable can be extremely difficult to treat and need an expert in making podiatric custom orthotic devices. 

I stopped ballet 2 years ago and the pain at the bone got better. I stopped wearing ankle guards a year ago. I've been on orthotics and very expensive arch support shoes for 5 years (24/7) but I notice that my ankle still severely slops/falls inward when walking. There is also some pain involved. So I'm  wondering if it's  time to consider surgery if this is a problem that may continue for the next 40 to 50 years.

Dr Blake's comment: Glad you are feeling better. Yes, surgery to remove the accessory navicular should be an option to give you a stronger arch. But, it is complicated, and requires that you find several surgeons and get their opinions on whether it will help you. I am hopeful you are doing a daily home strengthening program for your arch, especially the posterior tibial tendon. Also, if you have a complication with the surgery, is that a risk you are willing to take? 

Lastly, Sorry for the long question and i appreciate  your time taken to read and answer my question.
Thanks and Regards,
-J.

A Podiatry Christmas Poem

 'Twas the eve before Christmas

and Dawn took a look,

she took a look at her cold bare foot,

You see, the stockings had been hung by the chimney with care

and this made Dawn's foot to be chilly and bare!

Alas, the report she sent Santa, Doc Blake and all,

was that her foot was healed, heel, toe and all!

Dear Dr. Blake:

Merry Christmas to you.  You had asked me to send you an update in December.  This might not be in the format you expected....but none the less the foot is fine.  Thank you so much for your excellent care.

Dr Blake's Christmas Response:

Thank you so very much Dawn

As I am watching the rain green up my Lawn

Thank you so very much Dawn

This poem will surely make you Yawn

Your great news brought tears to my eyes

I could tell that they weren't mere lies

And for this I will take note and Rise

Yet, I know with your feet, this is probably not goodbyes.

Love, Rich

Possible Hypermobility Problem: Email Advice

This was an email I just received as I am catching up on emails as a Christmas present to myself (sick I know, but somehow therapeutic to my soul). Merry Christmas and Happy Holidays to all my readers. Rich

Dr. Blake: 

I was on the podiatrym.com and saw your comment on the hypermobility of the first ray joint. 

I have bilateral foot pain for many years.  My left foot has the hypermobility more so than the right.  I have a bunion on the left.  I have had many orthotics made within six years none of them really helping.  The first podiatrist I went to in 2007, made this huge orthotics and made me wear motion control sneakers with them.  I was told that my feet were not to move in the sneakers, I feel this was a big mistake.  Perhaps this made the problem worse.  I never had this problem until I started wearing orthotics.  I also have a problem with my left hip (weak hip, core and pelvic).  My gait has is really off. 

It was not until last year when I visited an orthopedic doctor who said I have a lot of hypermobility in the forefoot and that my ligaments and tendons are too weak to support my weight.  After visiting at least six podiatrists, not one of them ever mentioned this problem with my feet.  The orthopedic doctor wants to fuse the bones in my feet.  After getting a second opinion from another orthopedic (Mass General) who said absolutely no to the fusing and not knowing how to help.  I really don’t know what to do.  My feet literally throb from pain and I feel as I am grasping the ground and my big toe joints hurt so much as they are being pounded into the ground.  I have been everywhere looking for help and cannot get the help I need.  I visited a foot doctor in Worcester and he could not figure out what to do, except offer me another pair of orthotics, but he never mentioned the hypermobility of the first ray joint. 

I have been on Dr. McClanahan’s site and purchased a pair of correct toes and have followed him on getting out of orthotics and going to minimal shoes and exercising my feet.  My feet are in so much pain from exercising and they are not getting any better.  I am so discouraged and just cannot believe no one can help. 

I was wondering if you would know of any foot doctor in the Boston area who would have been the expertise to helping me get out of pain without surgery or orthotics. 

May I ask you would strengthening the feet help with the hypermobility or am I wasting my time.  My lower legs, calves hurt so much, I have been told that the certain muscles are not functioning, as well as my glutes.  From being an athletic person to not being able to walk without pain is very discouraging.

I would appreciate if you could possible help finding a doctor who could help. 

Thank you. 

Dr Blake's response: 

     Thank you so very much for your email and I am very sorry for your struggles. There are many types of hypermobility, from mild to severe, from static to functional. Sounds like you have a severe case, although at times mild cases just spin out of control. Typically when rehabing a patient with hypermobility you find you need longer immobilization, longer periods of re-strengthening, and it takes longer to return to activity. It is a careful balance. Not too many podiatrists or orthopods believe that hypermobile patients should go without orthotics and learn ways of joint taping or splinting that helps. I have never had a hypermobile patient had a joint fused, and I am not sure what that would do to the stresses on all the other joints in the lower extremity. I would find a local PT who deals with Ehlers Danlos patients to help you first, and they may have a suitable podiatrist for you. To me, orthotics devices are crucial, although not with motion control shoes. You should see if by orthotic devices, activity modifications, anti-inflammatory measures, and perhaps assistive aids, you can re-establish a pain free environment of 0-2 pain levels. Then, spend the next year getting your feet stronger, not be walking in minimalist shoegear, but by a calculated home/gym strengthening program done daily under the instructions of the PT. I sure hope this helps you. Rich