Ankle Sprain Advice: General Treatment Rules

The top 10 treatments for ankle sprains are:

1.  Understand that the more severe the disability is right after the sprain typically correlates to the damage produced

2.  Create a pain free environment (0-2 pain level) as soon as possible with whatever is  needed (crutches, boot, brace, etc)

3.  If you see black and blue over the first 4 days, you have torn something

4.  Just because you have negative x rays does not mean something is not broken (you may need an MRI)

5.  Use all aspects of PRICE (protection, rest, ice, compression, elevation) for a minimum of 6 weeks.

6.  Begin strengthening the ankle as soon as you injure it with pain free strengthening exercises

https://youtu.be/8viOmi73Djo

7.  Ice only for the first 4 days, then start once daily contrast bathing, with more icing with aggravations

https://youtu.be/rRt5hC24Afg

8.  See a specialist when you think it will take longer than 2 weeks to completely heal, when you need crutches initially, when you can not bear weight, when you have sharp pain with each step, when you heard a loud pop with immediate swelling, and if the ankle looks deformed.

9.  Do not begin to exercise without a brace until minimum of 6 weeks and you have done some balancing exercises

10. After 2 weeks, if your disability is marked (limited walking or can not think about running) consider an MRI.

 

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

Treatment of Big Toe Joint Pain

Common Non-Surgical Treatments for a Painful First MPJ

                                        By Richard L Blake DPM MS

                                              

 

The first metatarsophalangeal joint is a fascinating area to treat because of all the variables involved. Since the end of normal stance in the gait cycle ends with pushing off the hallux with first metatarsal plantar flexion, we can have a difficult assignment. Patients with chronic big toe joint pain (including sesamoid problems, hallux rigidus, or chronic turf toe) may need multiple orthotic devices with modifications and accessories. Why do orthotic devices not work for these problems at times? Varus corrected orthotic devices work for some people to shift the body’s weight more lateral, but the higher the arch you make, the more plantar flexed the first metatarsal becomes, which can force the first MTPJ further into the ground and become further bent, worsening the pain. Therefore, where some custom orthotic devices (even an orthotic device made expertly for a pes cavus foot type) may work sometimes, other times you have to make a flatter arched orthotic device or no orthotic device at all. Below we will talk about various mechanical changes to help big toe joint pain in various stages and injury (from subacute to chronic to maintenance). I commonly think of pain in the big toe joint coming from excessive ground pressure, too much bend, malalignment with valgus forces, superficial pressure from shoe gear, compression forces across the joint, or a combination of some or all of these forces. To affect many of these causes, you have to direct treatment towards the propulsive phase of gait. Below are several strategies, (amongst many more!) that I hope will help you think outside your normal routine in creating a stable joint and improving pain.

Of course, it may be the left non bunion side that hurts

 

Immobilization Techniques

 

Spica taping helps restrict 1st MTPJ dorsiflexion. It is commonly learned with KT tape or Rock Tape since it goes around the bends of the toe easily. If the patient needs more restriction, and has the basic skill down, then 3M Nexcare Waterproof Tape is used. Typically one inch wide tape 7 to 8 inches long is centered dorsally over the top of the hallux. First the medial leg is brought down under the big toe joint and then runs under the first metatarsal. Then, the lateral leg is brought down under the big toe joint, and then runs parallel to the first strip along the same orientation of the first metatarsal. At least one half of the lateral leg should be touching the skin so that the tape can last 3-4 days. Rub the finished product to activate the glue of KT or Rock Tape for one minute. The big toe itself when you are finished should be just slightly below the 2nd toe. Spica taping is classic for hallux rigidus and turf toe, but can distribute the weight bearing forces away from the sesamoid for sesamoiditis or fractures as well. Spica taping can increase the compressive forces across the joint, which may hurt, so this may not work for all patients. https://youtu.be/l_4HESXCG40

       Spica Taping with paper tape to secure some loosened edges

 

Bunion taping is a technique done the same as the Spica taping except with different starting point and leg orientation. Done with the same tape as Spica taping, the center is placed on the lateral side of the hallux with one arm going superiorly and one leg inferiorly. When applied, the hallux is placed in neutral and first the plantar arm comes under the big toe joint and laid along the medial side of the first metatarsal. This is where you, and ultimately the patient, has to play with how tight to make it, balancing correction and too much pressure. The superior arm then comes across the joint and again is laid down on the medial side of the first metatarsal with about half touching new skin and half overlapping the other arm. This technique not only centers the joint, but also restricts some joint motion. Again, one minute of massage helps activate the glue. https://youtu.be/uD348O7pKwo

 

 

Accessories

 

Toe Separators/spreaders come in various shapes and sizes and materials. A medium gel toe separator that has the shape of an hour glass is conservative bunion care 101. Foam toe separators have more width and therefore work better for a lot of my patients. They can, however, be too long and cause ingrown toenails, but you can simply shorten them with a scissor. With overlapping toes, you either need the hour glass shape of the gel ones, or the toe separator that slips over the 2nd toe (or 1^st and 2^nd toes) and has a toe separator attached medially to the second toe, taking care it doesn’t migrate and sit under the 2nd toe, potentially worsening a hammertoe. My mantra in bunion care is to maintain stage 2. The toe separator immediately puts the bunion, which may have started the day in stage 3 or 4, back into stage 2. As you walk, the forces through the big toe joint are more normal and should slow down the retrograde forces. This centering of the joint will allow for normal muscle development and strengthening, as well as help alleviate pain from lateral joint impingement. Toe separators can and should be used after bunion surgery, if no second hammertoe surgery was done, to help maintain the correction while the muscles and scar tissue are transforming.

 

Carbon Plates with Morton’s Extension work well with an orthotic device on top. Here only the first metatarsal head and hallux have the carbon plate distally. You want a Varus biased orthotic device that gets you into the middle of the foot well. However, with some severely pronated feet, this can be a great challenge. If you can get the weight more central, this device works well allowing normal motion without big toe bend and it is appropriate to only use on the symptomatic side. A common problem with this design is when the hallux is too far lateral and falls off of the plate. Sometimes you have to use bunion taping (as previously described) and/or toe separators (also previously described) to get the hallux over the Morton’s extension. And again, if the patient pronates too severely into the Morton’s extension, the pressure can be too much, and may be more a candidate for the next design. https://jmsplastics.com/product/nrg-plates/

 

 

Correct Toes invented by Oregon podiatrist Dr. Ray McClanahan, slips over each toe, gently separating them, and were designed to use for walking and running. Since Correct Toes will place each toe in a much separated position from each other, there are only a select group of shoes that they will fit into. I tell my patients to look at the list on the following website, also start with walking around the house in loose slippers to get the feel of them. Altra, Keen, and Lems shoes are my go-to shoes right now known for their wide forefoot. Some patients have too narrow a foot for the current design, so I often remove the area lateral to the 3^rd or 4^th toes and they are still getting the benefit of the separation of the 1st, 2nd, and 3rd toes. Even if the patient wears them for a short time at home, they will get a benefit from them and many have described a greater sense of power at push off. https://www.correcttoes.com/

 

Orthotic Modifications

 

Dancer’s padding/reverse Morton’s extension is a ⅛ inch or ¼ inch pad that typically goes under the second through fifth metatarsal (1). If the fifth metatarsal has symptoms, then place it only under the second through fourth metatarsals. It can be applied to anything (orthotic device, shoe insert, sandal, ballet slipper, bare foot, etc.). If you increase the padding to ¼ inch, make sure the patient does not feel that they are “falling into a hole” which would make things worse. You can also offset the second pad a little laterally and proximally (or distally) which helps transition the edges (if you are layering 1/8 inch pads like adhesive felt). This pad typically reduces the plantar pressures across the joint by 50% or more, however, many times the pronation effect of the dancer’s pad must be balanced by an arch support to pull the patient laterally at the midfoot. I prefer OTC non plastic orthotic devices for this since the goal of plastic based orthotic devices is meant to increase 1st MTPJ motion. It may just not be the right time in the rehabilitation for a custom plastic device (Return to Activity Phase) when you are trying to off load a sore sesamoid or painful hallux rigidus (Immobilization Phase). I recommend Dr. Jill’s Gel Dancer’s Pads to every one of my patients with big toe joint pain. https://drjillsfootpads.com/retail/ They come in ⅛ inch and ¼ inch, and sometimes you need to make the hole bigger, depending on the patient’s problem. They stick on one side, which allows you to place it directly on skin or on an orthotic device or shoe insert, and are primarily for sesamoid injuries. You typically only need to place it on the affected side, unless you are using ¼ inch, which you should use a ⅛ inch on the contralateral side for balance.

 https://youtu.be/GG-mSjtSwj8

 

Cluffy wedges were designed by Dr. James Clough (play off his last name) in Oregon (2). It is a small pad that fits into the sulcus under the proximal phalanx to offload the sesamoids as your weight rolls forward. The ⅛ inch adhesive felt is usually 1 inch by 1 inch or slightly smaller. It cannot go under the distal phalanx or it will increase 1st MTPJ dorsiflexion. I never used it until 10 years ago when a patient of Dr. Clough moved to San Francisco and needed a new podiatrist. She was wearing her cluffy wedge as part of a fractured sesamoid treatment. When I asked her if it was helpful, she stated she would not leave home without it. So, it became part of my treatment from that point on, and like most of these mechanical treatments, 50% of patients feel that it is very helpful. So, when patients present with 1st MTPJ pain on their first visit to my office, they all leave with three mechanical changes to begin to manipulate the symptoms: spica taping, dancer’s padding, and cluffy wedges.

                                                                                      

No Heel Lifts is the general principle in treating any metatarsal problem (3). It can be a challenge when the heel lift is for a short leg which just happens to be on the side of the big toe joint problem. This can be remedied by making the lift into sulcus length with a cutout for the big toe joint (lift with dancer’s pad combined). A patient with an orthotic with a rearfoot post for increased stability can also act as a heel lift. This can be remedied by removing the rearfoot post and placing midfoot medial and lateral supports to hold correction. I using the rubber cork from JMS Plastics ¼ inch in the medial arch and ⅛ inch under the cuboid/5th metatarsal base. If the heel lifts are for Achilles tendonitis, then you have to decide what the worst pain is for now and make the appropriate adjustments. Lastly, patients should of course avoid shoes that have any heel for often longer than it takes for the 1st MTPJ pain to resolve (typically an extra month).

     The side note to this is that flat shoes with no lift in the heel can make it harder and more stressful to push off. Typically, the no heel lift rule works for standing long hours since the weight gets back into your heels more. But, if flat shoes are painful to push off when walking and/or running, try to combine a small heel (even ¼ inch can help) with some good forefoot cushion and flexibility.

 

 

Shoe Variations

 

Rocker Shoes have been popularized by the Hoka One One shoe company and are a must try for my 1st MTPJ pain patients (4). These shoes are much better than the extrinsic rockers we used to ask shoe cobblers to add to shoes, as these tended to be a tripping hazard for my patients. The position of the rocker has to be just right to roll the patient gently across the injury, so your patients should speak to the salespeople about the 3 common positions for the rockers and what shoes have which one. Some of the shoes will naturally put a slight Varus bias in the roll which may help until they break down laterally, which is when patients will need to replace their shoes. New Balance 928 and the dress shoe line Allegria also have rocker bottom options. One negative of rocker shoes, however, is that sometimes the heel is too unstable and can create a negative heel effect, which can be further damaging for the 1st MTPJ. Rocker shoes do separate the ground from the foot more than traditional shoes, and elderly patients in particular do have to be extra careful about tripping.

 

Bike Shoes with embedded cleats have been a wonderful find for my practice. Chrome, a San Francisco company specializing in bike messenger apparel, has a line of non-athletic looking bike shoes that can pass as semi-dress shoes. Other companies like Shimano or Pearl Izumi have mountain bike shoes, called “hike and bike shoes”. The cleat is embedded so you are not walking on awkward cleats, and they serve as a very stiff soled shoe. These can be a much better solution than a CAM walker with an EvenUp on the opposite side, and are less irritating to people’s backs. The motion in these is abnormal, using more hip and knee motion since you cannot push off, but since they are used as a pair the symmetry tends to work well. Even if the patient is initially in a boot, these shoes or Hoka rocker shoes may be a great transition before normal shoes. You can also wear your orthotic devices, dancer’s padding, cluffy wedges, spica taping, etc. with this shoe (as well as with the boot). Just be careful when wearing outside during the rainy season, as these are more slippery than regular shoes!

 

Skip lacing can dramatically take pressure off the 1st MTPJ. The distal medial hole of the shoe lacing may or may not be over the big toe joint, but it can still produce pressure downward from the top. You can skip the medial and lateral last two holes distally, or you can just skip the medial hole to better maintain shoe stability. First, take out all of the laces except the most distal. Make sure that the laces are even. Take out only the lace that runs through the hole near the big toe and transfer it through the hole one above that is still on the medial side and then through the hole directly lateral. If you think about it, if you had placed it originally in the distal medial hole, it then would have ended up here in the second lateral hole. The original distal lateral lace will also go through the second medial hole, so two laces through the same hole. From this point on, the lacing is normal up towards the ankle. This will alleviate pressure from the top down onto the big toe joint. The link attached has a lot of other fun lacing variations to try.  https://runrepeat.com/top-10-running-shoe-lacing-techniques

Here the right big toe joint area is skipped

 

Exercising/Strengthening

 

Self Mobilization for Hallux Limitus (5) is a gentle tool that patients can learn when the range of motion of the big toe joint is limited. The technique of self mobilization was taught to me by Drs. Rue Tikker and Timothy Shea and has been a valuable part of my practice for 40 years. The principle of self mobilization is short, quick motions in directions that are not normal for the joint to move. So, to improve dorsiflexion or plantarflexion of the big toe joint, and to break up some scar adhesions, you perform four motions:

1. Dorsal and Plantar Gliding
2. Side to Side Rotation
3. Clockwise and Counter Clockwise Rotation
4. Long Axis Extension

These are grade 5 mobilization exercises, so are meant to be done with quick movements. I measure before and after mobilization and typically get a 5, sometimes 10 degrees gain. The principle of mobilization in this case is to stabilize the proximal segment (metatarsal) and move the distal segment (proximal phalanx). So, you stabilize the first metatarsal head so that does not move, and you grab the proximal phalanx of the hallux. Remember you are moving the proximal phalanx on the first metatarsal head in 4 ways it does not normally move. You glide it up and down, you abduct and adduct, you rotate like a clock in both directions, and you pull it out straight.  The patient must do it 3 to 4 times a day to slowly gain motion, and maintenance for some will be once a day indefinitely. https://youtu.be/FBTeWbdGrzs

 

Metatarsal Doming or Arcing is the best way to strengthen the short flexors (hallucis brevis) along with Single Leg Balancing. Metatarsal doming is an isometric exercise for a six second count, four second relaxation and then repeated ten times total, for at least three times a day. While standing or sitting, the first part of the exercise involves straightening all of the toes. Keeping your toes reasonably straight, lift the metatarsal heads upwards while keeping the tips of your toes against the ground as you count to 6. Try to feel the tension in the metatarsal arch as you squeeze the tissue as you do with every isometric. That squeeze feel is developing muscle bulk and tone, and patients begin to feel the difference in their feet within weeks. Once they are doing the exercise correctly and consistently, they can do it in the supermarket checkout line, etc, without having to look down. https://youtu.be/GY-mJjXmeIc

 

 

No Achilles Tightness is a very important aspect of 1st MTPJ treatment (6). A tight Achilles’ tendon drives a tremendous force downward into the metatarsals, which the ground reactive forces have to match. It is why when we talk about vital measurements, Achilles flexibility is crucial to learn. When the ankle can't bend past ninety degrees (more subtle forces as the bend gets closer to 10 degrees) at the middle of mid stance and as the body weight continues to move forward, the heel will lift up early, the midfoot collapses, or the foot abducts, all of which drive abnormal pressure into the forefoot. When you stretch the Achilles’ tendons, both with straight knee and bent knee positions, the actual stretching itself can put a lot of pressure on the big toe joint. Instead, you can hang the big toe joint off the end of a thick book, so as you stretch no weight goes into the big toe joint. You can also build a well with 4 books arranged to make a float for one spot. Purchasing a cheap but thick sandal, and then having a shoe cobbler cut out the big toe area, can help patients avoid irritating their joints while stretching, etc. https://youtu.be/0eAqJ4-oKTM

 

References

(1)Cohen, BE. Hallux Sesamoid Disorders. Foot and Ankle Clinics, 2009-03-01, Volume 14, Issue 1, Pages 91-104.

(2)Clough, JG. Functional Hallux Limitus and Lesser-Metatarsal Overload. J Am Podiatr  Med Assoc (2005);95(6): 593-601.

(3)Zhang X and Li B. Influence of in-shoe heel lifts on plantar pressure and center of pressure in the medial-lateral direction during walking. Gait Posture. 2014 Apr;39(4):1012-6.

(4)Lin, SY, Su PF, Chung CH, Hsia CC, Chang CH. Stiffness Effects of Rocker-Soled Shoes: Biomechanical Implications. PloS One. 2017 Jan 3;12(1).

(5)Brantingham JW and Wood TG. Hallux Rigidus. J Chiropr Med. Winter 2002;1(1):31-7

(6)Cazeau C and Stiglitz Y. Effects of Gastrocnemius Tightness on Forefoot in Gait. Foot and Ankle Clinics, 2014-12-01, Volume 19, Issue 4, Pages 649-657.

Morton's Neuroma: Excerpt from Book 2 of Practical Biomechanics for the Podiatrist

The following is an excerpt from my book on Practical Biomechanics for the Podiatrist. 

https://store.bookbaby.com/book/practical-biomechanics-for-the-podiatrist1

 

Schematic of Morton’s Neuroma

 

     The basic mechanics of Morton’s Neuroma formation is pretty common knowledge. The junction of the medial plantar and lateral plantar nerves come together between the third and fourth metatarsals possibly making this nerve thicker or more sensitive. The motion of the 3rd metatarsal which articulates with the 4th metatarsal, and the motion of the 4th metatarsal which articulates with the cuboid, can be different enough that the intermetatarsal nerve branch can get irritated with the independent motion of the 3rd and 4th metatarsals. The overall motion of pronation always increases the metatarsal motion adding to the possibility of Morton’s Neuroma pain. If the nerve is already hypersensitive from low back issues or piriformis syndrome, or excessive pronation at the ankle with bowstringing of the posterior tibial nerve at the medial malleolus, or traction from over strengthening of the popliteal nerve with hyperextension of the knee, etc, then the pain can come on easily and with more disability. Morton’s neuroma pain, along with low back issues, etc, is called double crush syndrome. I have patients where triple and quadruple crush were in play with their presenting nerve pain. It is so common to have L4/L5 nerve root issues that cause pain around the 3rd intermetatarsal space with or without a neuroma. You always have to treat the foot, but you always have to be aware that nerves are superhighways to the brain. They get irritated anywhere along the chain from the foot to the skull, and nerve pain can be the worst pain people have to deal with. The opioid epidemic is one aspect that gives us perspective into this complex problem, because with bad nerve pain, patients many times feel they have no other choice. When the nerve pain starts at the foot, or the foot is just part of the picture, it is so important to be successful in treating each area. I tell my patients that the two things I hate the most as a podiatrist are nerve pain and infections because both are treatable, but possibly life changing if I fail.  
     The treatment of Morton’s Neuroma pain must always be 5 pronged (even though we are just focusing on the mechanics in this book): mechanical, inflammatory, neurological, diagnostic, and as a team (physiatrists, neurologists, pain specialists, etc.). The last point on nerve issues that I want to make is that nerve problems present in one of 3 ways: numbness, numbness and pain, or just pain. These 3 presentations are the same process that responds to treatments the same, even though patients respond and react to these 3 situations differently. The treating doctor should respond and treat them the same.

 

Schematic of how foot pain can be caused or heightened in intensity by back problems

 https://youtu.be/E0E60NpOSHg   Nerve Pain Video 

     To tie this into Chapter 3 and 4 on gait and biomechanical examinations, when a patient presents with Morton’s neuroma symptoms, the most important examinations to do in 10 minutes (or 20 minutes) are:

• Gait Findings of Pronation

• Gait Findings of Limb Length Discrepancy that puts stress on low back

• Gait Findings of Knee Hyperextension

• Forefoot to Rearfoot Alignment

• Metatarsal Alignment

• Ankle Joint Dorsiflexion for equinus forces to be reversed

          Other Special Tests
         

• Straight Leg Test for sciatica

• Tinel’s Test for Tarsal Tunnel Syndrome

• Wide Feet (or at least wider than shoes)

 

Common Mechanical Changes for Morton’s Neuroma/Neuritis (with the common ones utilized in RED)

1.  Metatarsal Padding

1. Orthotic Devices emphasizing Metatarsal Support

1. Forefoot Off Weighting

1. Soft Tissue Mobilization

1. Toe Separators

1. Buddy Taping

1. Neural Flossing

1. Metatarsal Doming

1. Standing Strengthening Exercises

1. Rocker Shoes, Carbon Plates, Bike Shoes with Embedded Cleats

1. Budin Splints

1. Sciatic Nerve Advice

1. Skip Lacing

1. Wide Shoes

 

     Metatarsal Padding for support of the metatarsals will stabilize the area and separate the metatarsals so the nerves do get irritated. Its mechanical function is to off weight the sore area, separate the metatarsals for less nerve entrapment (spreading the metatarsals), and transfer weight more proximal back towards the heel when standing. This is explained in the metatarsalgia section above. The main difference over metatarsalgia is that nerves probably can take a little less pressure initially then if there were no nerves involved, and then get used to more, and the placement may be slightly more medial for metatarsalgia. The nerves can be so red hot that they can not take any pressure, and this indicates they need a lot of nerve treatments at this point: orals and topicals, neural flossing, local and spinal injections, etc.
 
Practical Biomechanics Question #245: Nerves can be both helped and irritated by metatarsal pads. Since classic Morton’s neuromas usually love metatarsal pads, what would it indicate in terms of treatment direction if the metatarsal pads proved very irritative and intolerable?
 

Classic Longitudinal Metatarsal Pads for Morton’s Neuroma Pain (Hapad, Inc)

 

     Orthotic Devices emphasizing Metatarsal Support was also discussed in the metatarsalgia section. Its mechanical function is to off weight the sore area, support proximally, spread out the metatarsals to decrease entrapment, shift the weight more proximal while standing, and immobilize the foot somewhat for less motion. Certain feet, if supported well, will give the patient wonderful metatarsal support (like most pes cavus foot types). I find the classic Root Balance technique to be great in general for its emphasis on metatarsal support. Any orthotic laboratory should be able to give you advice on corrections to the impressions that will maximize the metatarsal support, the same as giving advice on corrections for lateral arch stability or medial arch stability. With Morton’s Neuromas, we want to maximize the intrinsic metatarsal support the impression can give us, and when needed, begin to add additional extrinsic metatarsal padding. This improved metatarsal support, especially when it is intrinsically applied, can make an incredible difference in support of the tissues involved. Support means stability or immobilization of the sore tissue.
     This all sounds nice, and is true, but the crowding of the shoe caused by an orthotic device and its added pads, etc, may not be tolerated in most shoes. For each patient, one variable may prove the most important for both helping and producing distress. I have had to abandon more shoes due to Morton’s neuroma conditions than any other problem.

 

Crazy Shoe Searches with Neuroma Pain

     Forefoot Off Weighting is initially applied with ⅛ inch adhesive felt, and then other types of glued material like Spenco, poron, or grinding rubber, to make it more permanent once the correct position for maximum pain relief. Its mechanical function is to off weight the sore area. For most cases of Morton’s neuromas, this will be under the 1st and 2nd metatarsal heads, and the 5th and somewhat 4th metatarsal heads. The process is started at the first visit with the adhesive felt. The patient is given more material with instructions to experiment. Occasionally the position that brings the most relief is not anticipated. If you can find the most sensitive spot plantarly, you can mark it with lipstick and have the patient transfer that spot onto the top of any surface to find the exact spot to float (off weight). When patients present to my office with previous orthotic devices, I always do this to make sure the accommodations are really in the correct spot, which they normally are not. Millimeters count here.

 

This patient with Morton’s Neuroma pain felt relief with this combination of metatarsal pads, off weight pads, and full length pads

 

Practical Biomechanics Question #246: Due to the fact that Morton’s Neuromas do not like tight shoes, every pad must be carefully tested for both positive and negative results. What are some options to help patients when the shoe and insert combination are helpful, but after hours of wear the neuroma starts to hurt due to the crowding?
 
     Soft Tissue Mobilization is an incredible help in releasing trapped nerves. Its mechanical function is to improve soft tissue mobility for less nerve entrapment. I apologize for forgetting the name of the podiatrist that initially turned me on to this twenty five years ago for I owe him a thank you. I not only have patients do self mobilization three times a day with topical nerve creams, like Neuro-Eze or Neuro-One (both L-Arginine based), with the goal to move the metatarsals around, but a prescription for physical therapy for soft tissue mobilization is typically given for 8 visits. At the same time, I have the therapist advise the patient on a sciatic nerve program and teach neural flossing or gliding. Also, instructions for the TENS unit daily program are occasionally given to the therapist.
 
Practical Biomechanics Question #247: How does foot rigidity cause or aggravate Morton’s Neuroma pain?

Soft Mobilization can be with a professional or self directed

 

Toe Separators are a simple, but sometimes very powerful, tool to change the biomechanics of nerve irritation. Its mechanical function is to change the dynamics of the nerve pressures. There are very thin wafer-like toe separators, but I prefer the normal small gel hourglass shaped ones. Since Morton’s Neuromas are typically between the 3rd and 4th metatarsals, these toe separators are placed between the 3rd and 4th toes. It seems like 50% of patients think it is helpful. This was taught to me by Dr. Remy Ardizzone.

 

     Buddy Taping of either the 2nd and 3rd toes, or the 3rd and 4th toes, when there was Morton Neuroma pain, seems to work the 50% of the time that toe separators do not. Its mechanical function is light immobilization of the tissues involved. I typically use 1 inch wide Coban or Coflex which sticks to itself and not the skin.

Here the 3rd and 4th toes are Buddy Taped 

     Neural Flossing or Gliding is a way to stretch and relax the sciatic nerve as it comes off the back, through the piriformis, down the hamstrings, splitting behind the knee to go into the back of the calf and side of the lower leg, and finally onto the top and bottom of the foot. Its mechanical function is to gently floss the nerve making sure that there is no swelling or scar adhesions. There are many variations. Some of the variations will excite the nerve more, and some will work better on the peroneal nerve or the posterior tibial nerve. The standard floss is where the patient lies on their back with the resting leg bent at the knee and the foot flat on the ground or yoga mat. The side to be moved starts where everything is flexed as much as possible (toe dorsiflexed, ankle dorsiflexed, knee flexed and hip flexed without pulling pelvis off the table). Then 10 rhythmical rotations slowly and gently are started from flexed to extended (hip extended, knee extended, ankle plantar flexed, and toes pointed), never stopping at either end of the exercise. Nerves hate prolonged stretches and love motion. Neural Flossing is typically done 3 times a day, on a hard surface since you need to have the pelvis and spine as stable as possible. I will talk in a minute about standard sciatic nerve advice.

 

 

Neural Flossing of the Right Leg with the Stable Leg Side Immoble. Here the right leg is already starting to straighten where the left leg is anchored to the supporting surface.

 

Neural Flossing of the Right Side starts with the right hip, knee, ankle and toes pulled up, and then gradually these 4 joints are pointed

 

Practical Biomechanics Question #248: Neural Flossing is 10 slow flexions and extensions. What puts more stress on the sciatic nerve: Knee Straight vs Knee Bent?
 
     Metatarsal Doming was previously discussed in the big toe joint section. Its mechanical function here is to make the foot more stable taking stress off the nerves.

Metatarsal Doming is an Isometric with 6 second contraction 4 second relax

 

     Standing Strengthening Exercises, along with metatarsal doming, will help keep the injured tissue strong. Its mechanical function is to increase stability by strength. We have to avoid toe bend exercises due to the location of the pain (like heel raises, planks, downward dogs, etc.), but the many versions of Single Leg Balancing, and standing poses in Yoga, Chi Gong, and Tai Chi are a wonderful way to maintain strength which avoid toe bending. Other modifications can be done to cardio workouts like staying flat footed while doing the elliptical, or having the pedal in the arch or heel on a stationary bike.

Single Leg Balancing to help develop Intrinsic Foot Strength

 

     Rocker Shoes have been previously discussed in the big toe joint section. You probably should also consider Bike Shoes with Embedded Cleats and Carbon Plates when immobilization seems necessary to bring the pain down between 0-2.

 

Hoka One One Rocker Shoes

     Budin Splints were previously discussed in the hammertoe section. Its mechanical function is to immobilize the motion of the local nerves. For Morton’s Neuromas, they change the biomechanics of the stresses in the area. Typically I use a Single Loop Budin Splint (also called hammer toe regulator) and get equal results by buddy taping 2 and 3 or 3 and 4 with Coban tape. In several cases of Morton’s Neuroma with a really sore 3rd toe, the patients may find the biggest relief over the 2nd toe only, over the 4th toe only, or getting a double loop for the 2nd and 4th toes combined. This is a way to indirectly immobilize the local nerve. Budin Splints are primarily immobilizing the metatarsal phalangeal joints, and you can add metatarsal padding to the bottom of the splint to off weight the sore areas also.

 

Here a Budin Splint is placed over the 3rd toe for Morton’s Neuroma pain with a small Hapad metatarsal pad. This is ideal for using the previously discussed lipstick marked on the sore spot to find the exact location of the pad

 

     Sciatic Nerve Advice is needed for any nerve condition you treat including Morton’s Neuromas. Its mechanical function is to find ways to decrease the stress on the nerve like various positions. Nerve irritation affecting the foot can come from anywhere. The nerve can be irritated from the exhausting long hours the patient sits. The nerve can be irritated from a bad mattress. The nerves can be irritated by the lifting or torqueing at their jobs. A simple prescription to a physical therapist for a sciatic nerve program should be all you need. However, tests including straight leg, Tinels, intermetatarsal nerve sensitivity on exam, can be retested for improvement evaluation, and point to how high the nerve tension is on the body. I try to discuss what is nerve sensitivity with the patient, so they know what to report. Nerves can hurt for sure, but also give symptoms of burning, itching, buzzing, tingling, prickling, sharp stabs, and numbness. I want to know where and when they have any other nerve symptoms called dyskinesias, even if it is the upper extremity, since I am looking for patterns or overall neural tension in the body. We all know that we must bend our knees when we are picking up something. The worst stretch on the sciatic nerve is when the ankle is bent (dorsiflexed), the knee is straight, and the hips are bent forward. Even having 2 of these together can be a problem, especially straight knees and dorsiflexed ankles. What position are we in when lowering our heels off a stair? Or doing the downward dog? These are positional questions you expect a good physical therapist to know and change as they evaluate a patient’s routine.
     This is a good time to remind the reader that Physical Therapists do have a subspecialty in nerves. There is an Academy of Neurologic Physical Therapists. Have your patients with nerve pain see if various offices have therapists specializing in the nervous system.
 
Practical Biomechanics Question #249: Nerve pain, like that of Morton’s Neuroma, has many mechanical treatments. Name 4 mechanical treatments for intermetatarsal nerve pain.
 
     Skip Lacing is a common way to take pressure off an area, even when the pain seems all plantar. Its mechanical function is to decrease compression across the sore area. Nerves hate compression. Typically I will remove the lacing from the distal eyelet,  but occasionally two. 

 

2 eyelets are removed to reduce pressure temporarily across the metatarsophalangeal joints

 

Wide Shoes really produce the same effect as the skip lacing. Its mechanical function is to prevent medial to lateral compression forces on the intermetatarsal nerves. New Balance was the first company for me that really helped with their variety of shoe widths. Now other companies at least have several widths per size. Then there are shoes that just run wide like Keen, Lems, Altra, etc.

 

Practical Biomechanics Question #250: Any foot nerve pain should be assumed that the symptoms are at least partially coming from higher up the chain. If a patient presents with Morton’s Neuroma pain, but presents with numbness on the top front half of their foot, where does some (or all) of the problem arise from?

     I will close with a copy of my Nerve Pain Algorithm for treatment options for peripheral neuropathy, Morton's Neuromas, Tarsal Tunnel, Baxter's Nerve Entrapment, etc

 

Trekking along the Via Francigena

My wife Patty and I were captured by another hiker walking along the historic Pilgrimage road called the Via Francigena. We walked a section this summer from Switzerland (seen here) towards Tuscany for a total of 313 miles walking in 21 days. This is our favorite photo of the whole trip as we wander in the Swiss Alps. Besides great hiking boots fitted expertly by the staff at REI, which we spent 7 months breaking in, I only need Compeed blister protection and my wife Quick Tape from support the foot.com for her plantar fasciitis. My photos are slowly getting placed on my facebook page on Richard Blake. 

Video on Subtalar Neutral where the foot and leg are lined up

Video on Introduction to Subtalar Neutral

https://www.veed.io/view/987c652a-3adc-4756-a8f5-f9751f306622

Preparing for Upcoming Medical Visit: Key Factors in HIstorical Review

I   How Intense (use Pain Scale) is the pain? What Irritates (makes it

worse)?

     Patients present all the time to my office with injuries or pain syndromes. The patient may tell me that they have pain somewhere, but the intensity of the pain at various times of the day are crucial. Sometimes, the physical examination completely matches the level of pain and other times not. When not, the examination is much worse than the pain that the patient complains of, or the examination is fairly negative while the patient complains of much more pain than expected. This all means something, but it can take time figuring that out. 

     When a patient has had pain for awhile, they have normally tried various treatments (including rest). It is important for me to know what helps them, and equally important what irritates them. Sometimes the description of what irritates them separates the probable diagnoses (from nerve to bone to tendon). Some generalizations would be: Bone injuries are sensitive to impact, nerves are sensitive to positions, and tendons are irritated by motion only. 

My Biomechanical Article Just Published highlighting 3 Examination Techniques

https://urldefense.com/v3/__https://authors.elsevier.com/a/1fqKq3Ao0oredx__;!!CqLityr3mSQ!G_Mk9g-wBjl4ZN42IYMe08BNSO_EKDKS5qsN8ogZFMmtb40tfIHqLL_74qPTeMDg_q5_q1wm0S8jq7-ZX5nyzZSdt7JC2iB9kQw$

   This article highlights 3 of the most important biomechanical measurements Podiatrists should learn. The three are: Achilles Flexibility, First Ray Ray of Motion, and Relaxed Calcaneal Stance Position.

Historical Review: Helps You Organize for an Upcoming Visit, and Helps the Health Provider Immensely!

A   What is your Assessment of the problem (what do you think it is)?
What part of your Anatomy is involved?

     When you are seeing a healthcare provider about your symptoms, try to be organized in your thoughts. Standardized questions that you will be asked may not hit on the individual issue you are facing. Perhaps, boring to some who want to have full faith that the medical people will ask the key questions, this self examination that I have started several posts ago may hone in on your injury right from the start. 

     Of these self examination questions, your Assessment of the Problem may be the most important. I have so many patients tell me that they knew the diagnosis was not what the doctor or therapist came up with and stuck with for the year of unsuccessful treatment, but for some reason never spoke about what they thought was going on. Get it out on the first visit.

     This also applies to patient's fears that they need alleviated. The two common fears are cancer when a mass or growth is on the foot, or that the diagnosis will mean they will never walk again. If you have a concern like this, the question can be phrased simply "could be cancer, or will this mean I will have permanent problems?" 

    And lastly, the Anatomy involved should really be honed in before your appointment. Foot and ankle pain that I deal with can be very vague and that works against our finding some answers. At least if the problem involves a big area try to focus on what hurts the most. And, don't be like some of my patients who put their foot up and say it hurts, but can not really advance the discovery from there. In their defense, sometimes feet or ankles only hurt when you are doing something (running, hiking, dance, etc), and stop hurting completely when you stop. But, the more help I can get from the patient's self examination of the problem, usually the better.