Big Toe Non Union of a Fracture: Email Advice

Hello Dr. Blake, 

I broke my big toe 6 months ago by 1st proximal phalanx. 

It wasn’t too painful. While it was ‘healing’ I developed pain under my big toe which I thought was pain from the break. It turns out I developed sesamoiditis. 

Also my toe is now a healed nonunion. I have been significantly impacted with pain most of the time. Walking even short distances was almost impossible for a while. 

Even now it almost always hurts some to walk at all. I had a boot for 2 weeks at 3.5 months. I am getting PT which seems to help with general pain in toes but not pain on bottom of foot. 

I was able to snowshoe on soft snow but hard ground is painful. I can swim with some pain and can’t push off wall with that foot. Biking hurts some. MRI showed no fracture or inflammation of sesamoids which presumably means tendinitis or capsulitis.

 I have arthritis which I had before break but it wasn’t painful. MRI 3 months ago shows inflammation under 1st metatarsal area. Tight shoes make pain worse even if soft. Touching spot on bottom of foot with shoes or ground hurts.  I am also now getting similar but less pain in other foot. I have a bone stimulator for toe now. 

Is it possible to get better? Is cortisone a bad idea? If it hurts so badly wouldn’t that mean the bones are sore? Is there any treatment for tendons if that is it? Do ultrasound or other treatments work? What should I ask my doctor at this point?

Thanks for ideas.

Dr. Blake's comment:

     So sorry to hear! A non union of the big toe typically requires surgery! Has this been offered? The bone stim is great but the toe has to be completely immobilized for 3-6 months while the bone is trying to heal! Typically any tendinitis or sesamoiditis is secondary to abnormal gait from the nonunion. So, do the best to heal the non-union or have the non-union surgically pinned. Hope this helps and I hope I understood the situation adequately. And, cortisone could help the joint capsulitis, but not good for bones trying to heal. Rich

Varus Wedging: A Simple but Powerful Means of Seeing if Correcting Pronation will Help An Area Painful

     Many of my patients not only come into the office with foot and ankle injuries (my speciality), but want to know if I can help their back, hips, knees, shins, etc. I start the process by watching them walk, and run if they are a runner. I try to correlate their symptoms with gait problems seen (like over pronation, over supination (aka under pronation), short leg syndrome, tight or weak muscles, and other instabilities. If the patient presents with over pronation, and has symptoms that even can be loosely tied to that motion, I prefer to use a varus wedge of 1/8 or 1/4 inch to see if removing some of the pronation will help them. You can apply the varus wedge (here I am using 1/4 inch rubber cork from JMS Plastics) to any insole, here the patient had a blue Superfeet insole. The wedge can be heel only, orthotic length only, or full length, all depending on the location of the motion (contact phase, midstance phase, or propulsive phase).

If the pronation is only at heel strike (contact phase), then a heel wedge may be all you need. If the pronation is during midstance, then an orthotic length wedge is normally used. And, if the pronation is during the propulsive phase (or in a runner's forefoot strike pattern), the wedge has to go out to the toes. 

The photo above shows the bottom of the right orthotic (on the left of the photo) with an orthotic length varus wedge of 1/4 inch, and the bottom of the left orthotic (on the right of the photo) with a full length 1/4 inch varus wedge. I love to tell my patients that sometimes this wedges are more important than an MRI of the involved area as success in reducing symptoms can help with long term treatment. 

Repost: General Advice for Patients with Foot Pain or Numbness Related to Nerves

Dear Dr. Richard,

I live in London, U.K. My job is in I.T. - so desk based all day.

I came across your blog today, looks very informative. I actually saw the video where you talked about pain around the heel possibly due to back issues.

https://youtu.be/E0E60NpOSHg

Please, could you provide some advice to me? 

I have had foot pain since last 4.5 years that started one morning after some leg exercises in the gym (possibly causing back issue?). I felt heaviness in the left footbed when I sat cross-legged in the office after gym. Now the issue is with both feet - which are very flat, but show arch if I am dangling my feet in the air, rather than standing on them. 

Dr. Blake's comment: This is called a flexible flatfoot. The heaviness is a symptom of nerve dyskinesias, also called abnormal sensations like buzzing, burning, things crawling on your skin, or a rolled up towel under your arch or toes. 

Pain first thing in the morning has always been 3/10 level, never to the level of having to scream. The pain is worse if I walk a lot or stand at one place for more than a couple of minutes. 

Dr. Blake's comment: Yes, standing can be the worst time, since nerves like motion most of the time (like neural flossing exercises). 

The pain is around the heel area and travels up on the calves. Areas of soleus, behind the knee are always sore be it first thing in the morning or last thing in the day. The metatarsals and Achilles also have random tenderness.

Dr. Blake's comment: I always think nerve pain if there is tenderness but not swelling in the tissues. Do you have any swelling when it hurts?

Different types of insoles haven't helped. Recently I got expensive custom-made orthotics done, but I doubt them. Funny enough, I feel more comfortable wearing "Teva jetter lux slide sandals" than ASICS Kayano 25 that I am wearing with insoles. 

Dr. Blake's comment: Nerve Pain around the ankles, called tarsal tunnel syndrome or some version of it, can make patients wear the least supportive shoe or sandal so the sides of the shoe do not press against a sore spot. 

Recently I got MRI of feet done, which showed some bursa, inflammation liquid, little spur under left foot - which doctor said could be present in a healthy person's feet too.

The doctor also said that the plantar F hasn't got enough thickening to say that is an issue. He thinks I might have fat pad syndrome or something coming down from my back. I am currently waiting for my back MRI results.

Dr. Blake's comment: Yes, sounds typically double crush syndrome where the nerve is being irritated from above (even at the neck) and at the foot. The back MRI is a static exam, so will not pick up some back problems, but is a good place to start. You want to find a conservative peripheral nerve specialist, in the states they tend to be osteopaths, who will look at all the possible causes of sciatic nerve involvement. 

I have recently got some tape which my partner wound around my heels and that felt good after walking in that. I will try that for a few days.

Any guidance from you will be greatly received and I will make a donation too at some point as gratitude. 

Regards and many thanks in advance.

Dr. Blake's comment: I think you are going in the right direction. Make sure you are massaging the area three times a day with a gel or lotion for nerve pain, not anti-inflammatory (I have my patients buy Neuro-Eze online). Learn how to neural floss from a physio (my one video is below, but there are various techniques). 

https://youtu.be/g94F8g_jzGg

See if Lidoderm patches can be prescribed for a month trial. Begin 3 weeks experiments of the supplements that help nerve pain. 

1.      Lipoic Acid 300mg 2x/day

2.      Acetyl-L-Carnitine 2000 mg/day

3.      Inositol 500-1000mg/day

4.      Vit B6 50mg/day

5.      Vit B12 1000mcg/day

6.      Vit E (up to 1,600units/day)

7.      Thyroid Natural Supplements

Diet for Nerve Pain

http://www.rsdrx.com/four_f's_diet.htm

Here was the advice I gave to another patient:

 Nerve Pain is helped by some combination of the following (many of these topics are in the blog already):

• Neural Flossing three times daily (find out if sitting or laying techniques more productive)
• Nerve Pain supplements like B12, Vit C, (gradually you add one per month to check effectiveness so you would wait on this right now) etc 
• Some topical nerve cream applied 4 times daily (NeuroEze or Rx)
• Heat over ice
• No sciatic nerve/calf stretching (find out everything postural wise that is tasking your sciatic nerve from beds, sitting chairs, standing habits, workout techniques). 
• Oral meds (start with evening doses only of Lyrica, Neurontin, or Cymbalta). 
• Epidural injections into the L5 nerve root
• Soft based orthotic devices like Hannafords
• See if there is a Calmare Pain Therapy center near you 
• Sometimes TENS and Capsaicin is helpful (but you have to go through 14-20 days of more pain first)

Hope this points you in the right direction. Rich

Stretching Principle #3: No Bouncing!!

•#3    Do not bounce while stretching, hold steady.

The third stretching principle I would want all of my patient doing was to hold the stretch steady and not bounce or move in any way. We have talked about holding the stretch for 30-60 seconds (Principle #1). It is also to important when doing 2 or 3 sets to alternate between the sides right and left (Principle #2). Therefore, stretching should be relaxing, non hurried, and gentle to the body. These principles can be applied to any stretch you perform, and I have individual examples of problems when these rules are broken. I usually have my patients demonstrate how they stretch and I look to see if they are breaking any of my rules. 

Plantar Fasciitis: Top 10 Treatments

Plantar Fasciitis

 

The top 10 common treatments for plantar fasciitis:

 

1. Plantar Fascial wall stretch for 30 seconds 5-10x/day

2. Rolling ice massage 2-3x/day for 5 minutes

3. No negative heel stretches

4. Avoid barefoot walking (something like dansko sandal at home)

5. OTC or custom orthotic devices to transfer weight into the  arch (you must feel that the   heel is protected and weight is in the arch)

6. Physical therapy or acupuncture (2x/week for 4 weeks and then re-evaluate)

7. Posterior sleeping splints when morning soreness over 5 minutes (these can be used at any time as rest splints when you are going to sit 30 minutes or more)

8. Low dye/arch taping daily initially and then with strenuous activity (Try Quick Tape from www.supportthefoot.com for tape that works and lasts up to a week)

9. Activity modification to avoid “bad pain”

10. Calf stretches (straight and bent knee) 2x/day

This can be such a stubborn problem that it is easy to get very frustrated. Very few people need surgery (even if you have a heel spur noted on x ray) for this since there are so many options for treatment. I once did a thorough review of the literature and found easily 72 different treatment options that made sense. These treatment options are so numerous that we are normally limited only by our time and imaginations to develop a successful treatment plan. Each week (or every 2 week interval) there should be improvement once active treatment begins. If improvement plateaus, make a change. Analyzing what is working and what is not working should be part of the process.

When treating plantar fasciitis we typically deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanical support (transference of pressure from the painful areas to non-painful areas or limiting the pull of the fascia by less pronation, less big toe joint dorsiflexion, or less impact stress to the arch). Most cases of plantar fasciitis need simple solutions like daily icing (anti-inflammatory), plantar fascial and achilles stretching 3 times daily (flexibility), and arch support (either custom orthotics or store-bought arch supports). Some more stubborn cases of plantar fasciitis need the above along with physical therapy to improve flexibility and anti-inflammatory measures, custom-made orthotics if not already manufactured, night splints to gentle stretch out the plantar fascia, and many other options. Cortisone shots are actually never given for plantar fasciitis, since you do not want to inject and weaken the plantar fascia. Cortisone is given to the area under the heel (typically a bursitis which develops secondary to the chronic inflammation) and away from the fascial bone attachment. 

In resistant cases, 3 months in a removable cast can help calm down the inflammation and strengthen the plantar fascia which may have some micro tearing not well visualized on MRI or felt by the patient. The moral of the story with plantar fasciitis is never give up. Keep trying to find the right combination of anti-inflammatory, flexibility, and mechanical support. Also remember that 25 to 30% of all cases I see for plantar fasciitis for a second opinion, have something else. Neuritis, bursitis, stress fractures, plantar fascial tears all head the list in the differential diagnosis that may need completely other forms of treatment. 

The above was an excerpt from my book “Secrets to Keep Moving”. 

Avoid Negative Heel Stretching

Achilles StretchIng: One Stretch to Avoid (when you have achilles tendinitits or plantar fasciitis)

 

 

 

     A vital part of the treatment of achilles tendinitis and plantar fasciitis is stretching these structures. The photo above shows a very powerful achilles and plantar fascial stretch. The position is normally used in an eccentric achilles strengthening program. It normally feels great as you lower one or both heels off the edge of a stair or curb. But this stretch, called Negative Heel Stretching, or Negative Heel Position, can be damaging to your tendon and/or plantar fascia. I do not recommend it at all, but I mainly emphasize it with my achilles and plantar fasciitis patients to avoid with a passion. With the heel in a vulnerable, non-protected, position, the heel is lowered into a position it is just not used to being. If you think about heel position in life activities (functional activities), our heels are either at the same height as the front of the foot, or elevated above the front of the foot as in a normal heeled shoe. Negative Heel Stretching places our heels in a position that life has not accustomed them to being. Almost our full body weight goes into the achilles attachment in the back of the heel and into the attachment of the plantar fascia into the bottom of the heel. Golden Rule of Foot: Avoid Negative Heel Stretching. Do not take a chance that this stretch is overloading the weakened areas leading to greater damage of the tissues. There are too many other ways to stretch these areas. Whereas you should not do with achilles or plantar fascial pain, you have to be very cautious even when you have no prior pain history in these areas. Eccentric achilles training can go from you heel off the ground as much as possible to a stable level ground position (it is still eccentric). 

The following is an excerpt from my book “Secrets to Keep Moving”. 

Metatarsal Doming or Arcing: One of the Best Foot Intrinsic Muscle Exercises

Just had a patient come in with a possible plantar plate problems. I started him taping or wearing a budin splint, and also keeping the small muscles under the metatarsal strong with metatarsal doming or arcing exercises. It is important to look at your toes when doing them so they have minimal to no curl. I do not recommend toe curls like picking up marbles or towels when there can be a possible plantar plate tear. 

https://youtu.be/GY-mJjXmeIc

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Gait Evaluation Checklist: For Those Trying to Learn Gait Evaluation

 Gait Evaluation Checklist (circle findings)

1. Head Tilt                       (Straight, Lean Right, Lean Left)

2. Shoulder Drop

3. Asymmetrical Arm Swing

4. Dominance to One Side

5. Trunk Mobility               (Limited, Normal, Excessive)

6. Hip Hike                                  (Right or Left)

7. Belt Line                            (Higher Right or Left)

8. Hip Rotation                   (limited, normal, excessive)

9. Excessive Shock               (Right or Left or Both)

10. Limited Knee Rotation            (Right—straight vs external,    Left—straight vs external)

11. Excessive Internal Knee Rotation           (Right or Left or Both)

12. Heel Motion at Heel Contact       (Right—eversion, none, inversion, Left—eversion, none, inversion)

13. Symmetry of Arch Collapse         (Right more vs Left more)

14. Digital Clawing          (Right or Left or Both)

15. Angle of Gait              (Right—internal, straight, external, Left—internal, straight, external)

16. Other Structural Variations: Pes Cavus, Pes Planus, Tibial Varum, Genu Valgum, etc

17. Correlation to Symptoms: _____________________________________________________________________________________________________________________________________________________________________________________________

18. Other Observations: ______________________________________________________________________________________________________________________________________________

Heel Stress Fracture: But Is It Due To Weight Bearing?

This is the side view of the heel bone on an MRI.

The view is a T2 image highlighting swelling.

The heel bone (calcaneus) should be very dark if normal.

The fracture line with surrounding inflammation is seen at the top of the heel bone.

Here is the same image but T1 which highlights the bone.

The fracture line in the heel bone is very clearly seen.

Again, this fracture did not originate from the impact of the heel on the ground.

Perhaps harder to understand, but this is a cross section through the back of the heel bone.

It is T2 so highlights fluid or inflammation

Again, the inflammation is in the upper half of the heel bone. 

This fracture was not caused by striking the heel to the ground, but perhaps a weak spot in a bone that is weak with osteoporosis.

Stretching Principle #2: Alternate Between Sides

•#2    Alternate between sides while stretching (for example, right achilles with knee straight, then left achilles, then right, then left).

Another solid principle of stretching is to alternate between sides when you have to do more than one set on each side. A good example is the achilles shown above. The alternating stretches are:

1. Right side 30 second stretch with the knee straight
2. Left side 30 second stretch with the knee straight
3. Right side 30 second stretch with the knee bent
4. Left side 30 second stretch with the knee bent
5. And then we start over for the second set with Right side 30 second stretch with the knee straight
6. Left side 30 second stretch with the knee straight
7. Right side 30 second stretch with the knee bent
8. Left side 30 second stretch with the knee bent

Everyone finds that the second set the stretch is much deeper and more effective.

Openness to Ideas and How Medicine is Influenced

“I believe in everything until it’s disproved. So I believe in fairies, the myths, dragons…. Who’s to say that dreams and nightmares aren’t as real as the here and now?

—John Lennon

Excerpt From: Kim Lim. “1,001 Pearls of Spiritual Wisdom.” Apple Books. https://books.apple.com/us/book/1-001-pearls-of-spiritual-wisdom/id1448334830

The quote from John Lennon is one I love to hold on to (and not just because I want more from Santa). It expresses an openness to ideas, and a sense of wonder in the world to possibilities. Why does everything have to be proved beyond a doubt to be considered correct? Medicine can get too entrenched with that Black and White Mentality. When the John Lennon approach is utilized in medicine, good things happen all the time. You know that Dr. Anthony Fauci cured a non cancerous disease called vasculitis, which was almost 100% fatal, with a cancer drug in the seventies. People thought he was crazy, but now only 2% of those patients die from vasculitis. This was before the AIDS crisis where he was thrown into the spotlight. Of course, we have to not harm patients. We have to analyze the risks and benefits. We should discuss with our patients if we are trying something somewhat dangerous that we have never done before. But, at times, with should take that leap forward, as Dr. Fauci (my hero) did and continues to do. 

Rules Guiding Treatment: Excerpt from upcoming book entitled "Practical Biomechanics for the Podiatrist"

The following excerpt is from my upcoming book entitled "Practical Biomechanics for the Podiatrist" which should be released at the end of 2021 or summer 2022. I hope that there is wisdom in these words. 

And, as a patient, when it is obvious the rules being followed are not helping, speak up about a possible change of course or in some modality. 

More About Rules

Many rules in medicine are just guidelines. You need to learn that there are general rules of a profession or discipline and there are golden rules (some that you will need to create) that will guide your practice. A general rule is a guideline whereas a golden rule should not be broken, at least by you.  For example, the general rule is that lateral foot pain is from over supination and medial foot pain is from over pronation syndromes. The exceptions to this general rule are numerous like lateral ankle or subtalar joint impingement from over pronation or posterior tibial tendon strain from over supination. Therefore, general rules are guidelines with exceptions. An example of a golden rule is that if we help the patient create a 0-2 pain level for all phases of rehabilitation and all activities the patient will be given the opportunity to get better.  Learn the general rules of your profession, but create your own golden rules. Write them down, say them out loud, and to others, and do not vary. The next few paragraphs include a couple of my many golden rules that help me practice, and as a podiatrist you may agree or have your own golden rules. 

      Golden Rule: All bone pain can be caused by poor bone health. Seems very simple written that way. A patient presented with severe bone pain causing shin pain for 2 years. I was the 8th doctor he consulted. He was 27 years old. At the first visit, with none of his previous records yet to go on, I applied my golden rule due to his palpable shin bone pain and ordered a bone density test. It came back that he had severe osteoporosis with the bones of an 83 year old. He is gradually improving with the help of an endocrinologist. This had been missed at a major university hospital.

      Golden Rule: Medial meniscal pain is either helped with valgus wedges or varus wedges. It took me a while to learn this one practicing in an orthopedic clinic. The general rule is for valgus wedges to be used with medial meniscal pain to attempt to open up the medial knee joint line. If that did not work, meniscal surgery was done. But, I remembered that Dr. Root had taught that pronation caused tibial inversion which can crowd the medial compartment. When patients did not respond to valgus wedging, I just flipped them over to give them a varus wedge. It proved to be around 45% of the patients responded to varus wedging and 45% of the patients responded to valgus wedging, with 10% still needing imminent surgery. In the long run, some of those patients did require surgery but some 40 years later are still coming in for their wedges to be made.

      Golden Rule: Low Back Pain that feels worse with walking or standing or moving may be helped with foot biomechanical corrections. A 24 year old patient with golf related low back pain was referred to me after 2 years of physical therapy, micro-disc surgery, and then 2 years of chiropractic treatments. He experienced no pain sitting or lying, only walking and after one hole of golf (many attempts in those 4 years). When I performed my initial cursory gait evaluation, I noticed a lean to one side (many causes of that), and he commented I was the first person to watch him walk in 4 years. Osteopathic evaluation noted a possible ½ inch short leg and some foot pronation. Due to the length of his disability, immediate AP Pelvic Standing X Rays in Normal Stance Barefoot were taken documenting 7/8th inch short leg. Within months after correcting all his shoes, he was back playing full rounds of golf with no problem. We never got around to correcting the pronation part of the picture. Years later I met his dad who informed me that he was doing great, and only asked if I felt the back surgery had been necessary. Oh well for my $200 treatment!

      Golden Rule: Always Treat all 3 causes of pain in patients presenting in pain (this is a tie in to my last blog post). Those are mechanical causes and their treatments, inflammatory causes and their treatments, and neuropathic causes and their treatments. A problem can be caused by one source, but need to be treated by all three. A problem can start mechanical, and then have the inflammation and nerve hypersensitivity develop days and weeks or months afterwards. I find that body reactions to a problem are like a bell shaped curve with an average reaction and people on either side of average. It does not matter what response you are talking about (swelling, pain level, scarring, nerve hypersensitivity, muscle atrophy, etc.) there are those that hardly have any reaction, or a more normal reaction, or an exaggerated reaction. The wonders of the human body are on full display at times. Almost daily I see patients for 2nd opinions with heel pain treated with orthotic devices that are not improving. The orthotic devices are typically well constructed, but create too much heel pressure. The general rule with heel pain and orthotic devices is that the devices should soften the heel and transfer the weight to the arch. It is typically easy for me to adjust their current insert. Yet this is only the mechanical treatment of the heel pain, with the inflammatory and nerve aspects of treatment normally needing more options. It can be tricky since what helps inflammation does not normally help nerves, and vice versa. Nerves hate ice, love heat. Inflammation loves ice and heat can make them worse. Sometimes finding out how a patient responds to ice or heat can help guide the treatment of what is most important at that time.

Treating all 3 Sources of Pain is Crucial

Developing a Treatment Plan with the 3 Sources of Pain in Mind

                                            By Richard L Blake, DPM

                                                 Past President of the AAPSM

    

 

 

    Dealing with pain in a Sports Medicine Practice can be a very difficult, challenging, and frustrating process. The patients want to get better as soon as possible. Some have high pain thresholds and some low. Let us take a look at approaching the 3 types of pain, dealing with Good versus Bad pain, and getting the athlete moving forward towards a complete recovery.

 

     What are the 3 general types of pain that come into play in podiatry practice? These are mechanically induced pain, inflammatory pain, and neuropathic pain. Of course, there is much overlap in all 3 areas. When a patient presents to your office, you will need to decide what is the primary pain to deal with at that time, with it possibly changing over the next few days. So often, the problem may have started with mechanically induced pain syndrome (for example, over pronation causing plantar fasciitis syndrome), but by the time you see the patient, the inflammatory aspect has spun out of control, and the neuropathic pain from limping and tweaking the low back is causing level 10 pain. Simply making orthotic devices and/or taping the foot to address the mechanics may be in the long run helpful, but it should not be the initial focus.  So, be mindful at each visit with the patient what type of pain you are primarily dealing with right then. 

 

     The true uniqueness of podiatry in this world is our understanding of mechanically induced pain syndromes and their treatments. It is not the goal of this short article to stress these, but I would like to summarize the most common ones seen. Our expertise has taught us many treatments for each area below, so we can explore many avenues if the pain remains stubborn (for example, variations in stretching routines or OTC versus custom orthotic devices or even surgeries for metatarsal misalignments). The 6 areas of mechanically induced pain syndromes commonly evaluated are:

1. Over Pronation (linked to 30 plus symptoms)

2. Over Supination (linked to 20 plus symptoms)

3. Short Leg Syndrome (linked to 10 plus symptoms)

4. Poor Shock Absorption (linked to 10 plus symptoms)

5. Tight and Weak Musculature (like weak VMO or weak posterior tibial or tight achilles and hamstrings)

6. Miscellaneous (like fat pad atrophy, hip degeneration, metatarsal malalignment, etc)

     Key to our treatment of patients is our ability to create a pain free environment for that patient (typically 0-2 pain levels sustained). We must develop skills on protected weight bearing techniques. When the patients 

 

                                         Here off weighting the heel with 1/4 inch adhesive felt

 

typically first present to your office with pain, you must get them to understand the concept of Good versus Bad Pain. Good Pain is pain at the start of an activity that disappears during that activity. Good Pain has little to no aftermath pain from an activity. Good Pain does not cause you to limp, and the pain can be kept in that 0-2 level. Good Pain can have an occasional sharp twinge that disappears in seconds with repeated activity. 

 

     As the patient and I try to team up to produce this pain free environment, all 3 types of pain are initially reviewed for their relativeness in the presentation. How much of the present pain can be helped by mechanically changes only (if a mechanical correlation has been made)? How much of the present pain can be helped by anti-inflammatory measures (patients are typically started on icing 2 times daily and contrast bathing each evening)? And how much of the present pain is neuropathic (it is always good to review the concept of "double crush syndrome")? 

https://youtu.be/E0E60NpOSHg

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     I think it is best to work through these problems at each visit. At the first visit decide how the treatment should be started based on how you weigh the various types of pain as it presents. Let us take a patient presenting with severe achilles pain (level 7-9) in 3 scenarios to work through this. 

 

 

 

1. Achilles pain, acute in nature, associated with long history of back pain and no clinical signs of swelling are noted.

2. Achilles pain associated with long history of long distance running, that has come on gradually and is getting worse and worse, with thickening of the tendon on examination.

3. Achilles pain, acute in nature, after stepping off a curve, with swelling, ecchymosis, and errythema.

     With all 3 of these presentations, you have to decide:

1. Does any test need to be ordered?

2. Is there any mechanical factors that caused or can help reduce the stress on the area? Even though heel lifts/clogs/boots typically help mechanically reduce stress on the achilles, and all need them, what presentation seems to be the most mechanical? (Answer 2)

3. Is there any inflammation that can be treated? Even though all 3 presentations can be helped by anti-inflammatory measures, which presentation needs it the most? (Answer 3).

4. Is there any nerve pain which may not respond to anti-inflammatory or mechanical treatments? What is the cause of this nerve pain? Which presentation seems neuropathic? (Answer 1) 

I love an oral prednisone burst in situations where the pain is high and I am not sure if it is inflammatory or neuropathic. The neuropathic patients typically may only get a very little relief from this 8 day course, and the treatment can be directed towards Lyrica, etc. 

     In summary, the practitioner will be daily surrounded by pain syndromes from mechanical, inflammatory, and neuropathic causes. It is the health care provider, with the patient practicing good vs bad pain recognition, that must create a healing pain free environment while slowly learning if there are mechanical causes to be treated, and anti-inflammatory and anti-neuropathic measures to be undertaken. A bi-weekly or monthly approach is commonly done as the symptoms change with the treatments recommended. Add to good treatments, remove treatments that seem useless, but overall, learn what is at the root of the pain syndrome so it possibly can be avoided in the future.