Severe Heel Pain (in a friend!): More than just Plantar Fasciitis

Hey Rich
Just saw your You Tube video on Facebook.  I KNEW  I should have called you when

I had plantar fasciitis in July 2012.  

I have been limping around with severe heel pain in my left foot for over a year. Sometimes

both heels if I've been standing in one place for a period of time.  Grandma must be getting

old !!!

My friend and I had been walking for about 3 miles every day until one day I woke up

and couldn't walk.  My friend told me what was wrong as she teaches anatomy at the med

school here.  

I used a wooded thing over which I would rub my foot back and forth and then soak in a bucket

of ice water for about 20 minutes or... until I thought I would pass out ... which ever came first.

The plantar part seemed to get better but the pain in the heel is particularly bad when I've been sitting,

especially with my legs elevated in the recliner.  Ouch !!!

When I get up I limp around for 2-3 minutes until it works itself out.   

Is there anything you can suggest that might help?

I'm so glad that you have developed something that is helping others.

Many blessings,

julie (name changed)

Hey Julie, It is so wonderful to hear from you. I miss seeing you my dear dear friend (our friendship goes back almost 40 years!!!) Definitely let us take this 2 weeks at a time. First of all, if you can not get an MRI to make the diagnosis of a possible plantar fascial tear (good possibility due to the length of time and the severity of the pain), then we should just treat it like that for the next 3 months. I will send you the link to order an anklizer boot and EvenUP. Start wearing and continue icing. There will be enough time out of the boot that you will know that you are healing. Continue icing 3 times daily, but stop all plantar fascial stretching for now. We will put all other conversation on this same post. Love, Rich

http://www.amazon.com/Procare-Evenup-Shoe-Balancer-Medium/dp/B006IUU2TK/ref=sr_1_fkmr1_1?ie=UTF8&qid=1376971934&sr=8-1-fkmr1&keywords=evenup+shoe+lift

http://www.amazon.com/Anklizer-II-Low-Top-Walker-MEDIUM/dp/B001UFN59C/ref=sr_1_14?ie=UTF8&qid=1376971852&sr=8-14&keywords=anklizer+low+profile

Plantar Fasciitis: Email Advice

Hi Dr. Blake,

    My name is Stacey (name changed) and I just recently came across your website.

I have been suffering pain in my feet for about 9 months now. 

The diagnosis is plantar fasciitis and i have seen several different podiatrists who suggested different methods of treatment which have been unsuccessful.

I had custom made orthotics which I have worn now for about 5-6 weeks.

I work in a pharmacy so I am on my feet for 8 hours a day and am finding it painful with the orthotics. I was told this is to be expected and that the average person will see results in 15 weeks.

I am very worried I may be doing more harm than good and fear I may never rid myself of this awful condition. I find it very stressful and wonder if I should stick with the orthotics.

I am now considering reducing my hours at work or taking long term leave.

I would greatly appreciate your advice.

Regards Stacey

Dr Blake's comment: 

     Thank you so very much for emailing me. Plantar Fasciitis can be a very stubborn entity, but most patients can get it under control. On my blog I have so much advice regarding plantar fasciitis, that I hope you can find some further answers. 

     The most important thing is to make sure you do have plantar fasciitis. MRI scans are the most telling, and may help direct treatment differently. Typically, you initially get an MRI of the worse foot, and start with that. 

     The treatment for plantar fasciitis is lumped into 3 primary areas that can fluctuate in their importance from month to month. All three areas should be treated daily, and changes in each category made to help find what works. The 3 areas are flexibility (stretches), anti-inflammatory (icing, PT, meds, etc), and mechanics (off weighting, arch support, avoiding negative heel positions, etc.)

     I will assume you are icing for 10 minutes 4 times daily, wearing your orthotics which transfer weight to your arch, avoiding barefoot walking at home, taking many sit down breaks as your employment allows, stretching the plantar fascia hourly as long as the stretch does not hurt, taking 2-3 advil 3 times daily unless their are stomach issues, and have a few PT visits scheduled unless their is insurance issues. If you are not doing this, try to get it accomplished. 

     Read everything on my blog on plantar fasciitis so you can have as meaningful as possible conversations with your treating physicians. See if they will prescribe an MRI, PT, night splint, etc. If you do not have a well organized plan for home, taking time off will not help. You must start over, and reset your goals biweekly. Orthotic devices alone will never get the job done when you have pain for this long, and you may need a very special soft orthotic (like the Hannaford) just for standing. Orthotics feel the best jogging, second best walking, and worse standing. There goal is primarily to change how you walk. 

     I hope this helps you. Please keep me in the loop. Hopefully, your job will allow some moderation. Good luck Rich

http://www.drblakeshealingsole.com/search/label/Plantar%20Fasciitis

Orthotics causing Back Pain: A Common Problem with various Solutions

Dr. Blake,

I had posted about sesamoid problem after bunion surgery, and thank you so much for answering my questions.

I am on second pair of custom orthotics and my back was so irritated that I could not function, missed one week of work, could not even stand long enough to make a meal.  I had times that my right side foot and leg just wanted to give up. Went to see a podiatrist hoping for help, he took the time to look at my x-ray before and after surgery, and told me the surgery was well done, except the first metatarsal bone was longer than it's supposed to be, which caused all my other problems.  He said surgery should be the last option, instead we should try pads.

Dr Blake's comment: Functional Foot Orthotics are just that----functional. They make a functional change in your body, and as podiatrists, we ask the rest of the body to please accept the change. When designing orthotic devices for sesamoid pain, two common problems can occur leading to back pain. The orthotic device places your weight too lateral, making you over supinate, leading to back pain. If this is the case, you should feel that the weight is going to your baby toe as you walk through your foot, or even worse, feel like you can sprain your ankle. Typically, the orthotic devices make you straighten your knee too much, and if you have tight hamstrings, the pull on the low back causes pain. These are easy things to change if recognized. Sometimes a simple adjustment can be made to allow you to be more centered or slightly more pronated. It is up to the prescribing provider to recognize what is going on when they watch you walk. Sometimes a whole new orthotic device is necessary. But, it is important to know what most likely caused the problem in the first place, so that you do not repeat the same mistake. 

This is what I felt ever after the surgery but you cannot do much to change the fact and it is affecting so much of my life now, I am horrified to think about another surgery, but other options seem to be running out.
Dr Blake's comment: If the metatarsal is too long, and it is causing all these problems, a temporary fix with orthotics should be able to be made. A long first metatarsal does potentially 3 bad things: supinates you too much (that can be corrected with orthotics), blocks your ability to roll properly through your foot jerking your low back (that can be corrected with orthotics), and straightens your knee too much by limiting normal arch pronation (that can be corrected with an orthotic device). I would always recommend trying to accomplish an orthotic fix for the problem first to make sure everyone truly understands the source of the problem. Then, if surgery makes sense, go for it. 

Your blog taught me more than all of the orthopedics surgeons told me, I really don't know what to do next, my big toe and the rest of four other toes simply don't land on the same level, and I felt the function of nerves and muscles are all affected.

I will seek other doctor's opinions locally, but I am so concerned about loosing foot and leg functions. Do you think correcting the bone(surgery) would help with sesamoid issue long term, or is it even possible to have surgery with sesamoid issue present?
Dr Blake's comment: You need information based on function not x rays right now. Go to a good sports medicine physical therapy that watches you walk. Do not influence them by previous conceived notions. Let me try and tie together your gait and back pain. I am assuming that the orthotic devices corrected for the sesamoid but lead to the back pain. Right? This is so common, I can not tell u!!! But, it may be an easy orthotic fix. Keep me in the loop. 

Thank you so much for your time, and how I wish I lived in California!

Further response from patient:

Thank you so much Dr. Blake!

I had one Acupuncture Dr. and one Orthopedics Dr. both suggested simply try Dr. Schol's full-length gel pad, which I did, I cut out some felt pads according to your website instruction, simply trying to level other four toes with the big toe, and a cutout to accommodate the sesamoid area. So far, have not had any bad pain yet.

I so appreciate your time.

Special Orthotic Design for Heel Pain

Correcting for Over Supination in Orthotic Design

Sesamoid Fracture: Email Advice

This email was received 8/15/13. 

Hello Dr. Blake, I just contacted you through your website but wasn't sure if it went through. I also forgot to add that I'm 35; thought that might be important to the osteoarthritis diagnosis. Here is my message again, please forgive if you already received it:

 

I've been using your blog as my go-to guide for the last 3 months. I sustained a stress fracture to the sesamoid bone closest to the outside of my left foot while coming down stairs wearing wedge heels.

Dr Blake's comment: This is called the tibial or medial sesamoid.

My first podiatrist diagnosed it as sesamoiditis and ignored my repeated phone calls saying I was in immense pain. Time to switch doctors. My current podiatrist took x-rays, by this time it was 24 days after injury, but found them inconclusive and ordered an MRI. In the meantime I was put on crutches. 10 days later, after insurance finally approved it and the results came in I got the news that it was indeed a stress fracture and was told I needed a plaster cast. I bargained my way into getting walking boot with the promise that I would treat it as a cast, sleeping in it and never walking on it.

Dr Blake's comment: I always try protected weight bearing since the cast holds in so much fluid that you need some weight bearing to drive the swelling out of the injured area. Protected weight bearing is with 1/4 inch layered adhesive felt to protect the area while allowing pain free weight bearing on the non injured parts of the foot. You can purchase a roll of 1/4 inch adhesive felt padding at www.mooremedical.com 

I've been a model patient and recently went back for my six week check up. (During this time I did take calcium, magnesium, vit d, and vit k, but only for one week as it caused stomach upset.) The doctor stressed the fact that this injury is very slow to heal and that if I move my big toe at all it impedes healing. He pressed on the ball of my foot and I yelped in pain. He said it wasn't healed. He said if it was healed I would have no pain at all. I thought this strange since I broke the big toe on that same foot 9 years ago and can remember being in pain for a few months after it healed. Surely this bone would hurt for a while even after healing! (Sure enough, reading your blog confirmed this!) So, he ordered another round of x-rays. I did question this since the fracture was found through MRI and not x-ray, but he said he wanted to order a bone stimulator and insurance would require a new set of xrays. I consented.

Dr Blake's comment: For many injuries, like sesamoid, pain to palpation can be present almost forever, and it a poor indicator of healing. Functional pain, the pain you get from advancing from non weight bearing to weight bearing, and from weight bearing in a cast to weight bearing in a shoe with protected padding is more important. 

For one of the images I had to get down in a runner's stretch, completely pulling my toes back. (I did have to do this with the first round he ordered, but this was before we knew what the injury was.) Since he had just said moving my big toe would impede healing, I was wondering why in the world we were doing this, but I knew I needed the bone stimulator and had to do it. The tech and I had to bend my toes back and forth repeated trying to get mobility back in them so that I could get them back far enough for a good image. This maneuver left me in pain for several days afterwards.

Dr Blake's comment: Sports medicine as a discipline evolved around the concept of protected weight bearing, sensible motion to keep things moving as best as possible, and anti-casting as much as possible. I love to move things, weight things, touch things. The more normal the stimulus, the faster healing back to full function occurs. For every day you completely immobilize an area, it can take up to 4 days to get the area back to function. And, returning to a function state can be painful, but not a sign you are not healing. 

The results of the x-ray was that the sesamoid bone now has osteoarthritis in it. He said it was due to the fact that the bone is receiving no impact through walking in order to build it. He ordered the exogen bone stimulator and said to stay on crutches and come back in 2 weeks.

Dr Blake's comment: Osteoarthritis takes a long time to settle in, but the changes in the bone could be related to the fracture healing and the demineralization from non weight bearing. It is almost impossible to predict what this means in relationship to the final outcome. 

I go back in 5 days and insurance still has not approved the device. Fortunately a friend had one and I've been able to use it twice a day for the past 4 days. I also switched brands and have been back to taking calcium, mag, vit d, and vit k for the past 9 days.

Dr Blake's comment: Remember the goal standard is 1500 mg of Calcium daily (diet and supplement) and 1000 units of Vit D (unless you know your blood levels). 

I called the doctor yesterday and told him I did not want another round of x rays. He said he wasn't planning on ordering any, just performing another physical exam (presumably to see if it still hurts when he presses) and at that time he would consider ordering another MRI.

Dr Blake's comment: The first MRI is the baseline. The second MRI should be minimum 3 months (and up to 6 months if you are doing a bone stimulator). I hope you do not feel pressed into a quick solution!!

He did say removing that sesamoid left me in danger of developing bunions later on and that surgery would be a last resort. In the meantime, I've been on crutches for 8 and 1/2 weeks and have lost so much muscle in my calf and foot. My foot even has muscle spasms now, which from my very scientific research on the internet seems to be coming from loss of muscle integrity.

Dr Blake's comment: Unfortunately you are developing "cast disease" or "cast rot". If you want to calculate your road to healing, take the amount of time it takes to get you to full weight bearing without a cast, and crutches, and times by 4. At that time, you will have recovered from the damage caused by the cast. This is why I always say that a cast is a "necessary evil". When needed, it can allow something to heal, but it sure takes a long time to get your foot back, grossly and subtly also. 

In your opinion, what should be my next move? In reading your blog, it seems like it should be continued use of the bone stimulator, vitamins and supplements, and transitioning to walking in the boot for 3 months. But can I just "start walking" after not touching my foot to the ground for 3 months and losing so much muscle?

Dr Blake's comment: No, inside the boot you will need cast accommodation with 1/4 adhesive felt or an orthotic that off weights the sesamoid. You need to continue daily icing 10 minutes 3 times, learn to spica tape, and perfect the orthotic you will be wearing out of the cast. The rest of what is said is true.

I really appreciate any help and advice you can provide. Thank you for making your blog available, I would have been lost without it!

Dr Blake's comment: Great, I am glad it has been somewhat helpful, and good luck finishing this healing. 

Please Respect Our Elderly Patient's Right to Walk Safely On Our Streets: Patience Can Be Necessary

http://biggeekdad.com/2013/08/geriatric-traffic-jam/

Injured Sesamoid: Email Advice

This email was received 8/11/13 for time reference.

Hi Dr Rich

I have been following your blog for some time, as I have an injury to my tibial sesamoid bone on my right foot for 8 months. Like many people with this injury it I have spent a long time looking for positive information online, and yours is the most helpful source of advice on sesamoid injuries. I was hoping I would never have to email you but as time has gone on I would really appreciate your thoughts on what I do next. My story.

• December 2012- I suffered a fall from a 1.5 ft height and my foot was very sore/I was limping. I could bear weight and doctors saw nothing obviously wrong. 

• February 2013- my GP commissioned an XRay which showed nothing

• March - I referred myself to an orthopedic foot and ankle surgeon  who suspected sesamoid injury - I googled it and freaked out (!), visiting a podiatrist who confirmed the diagnosis and told me  takes 18mths-2years to be totally pain free.

• Had an MRI showed no edema. Dr Blake' comment: Edema means swelling, which is a sign of injury and the body's healing response. I believe it is impossible to have a fracture without bone edema, so perhaps you do not have a fracture. 
•  Surgeon diagnosed bone bruise but commissioned a CT scan - the report said there was a small area of cortical break involving the plantar surface of the medial sesamoid. Dr Blake's comment: Not sure what it looks like, but the plantar surface can be normally irregular and look like a cortical break (just a possibility, and hope!!)
•   I asked about a boot/crutches and was told if he had seen me originally at the acute phase he would have put me in a boot, but now there would be little point. He told me it would heal in time and suggested 6-8 weeks of offloading using dancers pads. I decided to be more cautious and asked his opinion on a podiatrist (I didn't want to go back to the first one) and he referred me to a colleague. This podiatrist was positive - told me he could almost guarantee in 3 months I would get better and told me to do calf stretches three times a day (apparently I have super tight calves) and I was given temporary orthotics and told to walk with a heel strike
• In the meantime I followed your advice - taping my foot, icing/contrast bathing, ensuring proper vitamin supplements as much as I could. I cut out running, heels (the most upsetting part for me as I am only 5ft) and rested as much as possible. I sought out stories of people who had this injury too - a professional footballer who had this injury from impact too and after three cortisone injections considers himself healed. I also spoke to a former model who broke her sesamoid bone in half through wearing heels but finally saw a recovery after 2-3 months using a bone stimulator (wanted to include these stories in case it helps keep others positive). My surgeon was very conservative about cortisone but did say a small amount via ultrasound guidance might be sensible down the line
• April - I received custom orthotics. These raised my arches (I was told my feet pronate and are flat, aggravating the sesamoids), but actually stopped right behind the ball of my foot - something which I always questioned. I was told the weight was being offloaded down the metatarsal head. 
• May - No real improvement - pain would start up as soon as I walked any distance - My surgeon offered cortisone. I asked him about  bone stimulators - he confessed not to be an expert/use them, but said they would do no harm. So I managed to source an exogen express from the ebay and used it for 3 weeks. I then contacted a sports orthopedic surgeon who promoted the use of exogen for as a second opinion. My new doctor commissioner a new MRI - he said he was immediately skeptical of the diagnosis (said if you stared at a scan too long you can convince yourself of non-cortical fractures). Dr Blake's comment: I agree so far!
•  I went to see a physio therapist who said  I had modified my gait to protect the sesamoid, She told me to try and walk from heel to toe, exactly as I did with my other foot and strengthen the foot with glute and balancing exercises and walk barefoot as much as possible. I did this, but the proper walking aggravated the injury.Dr Blake' s comment: What ever I tell a patient, if their body tells them differently, it is always best to listen to your body and the signals it gives out. 
• June - my new doctor studied my new and old scans for a long time. He also asked a radiologist colleague to do the same separately. They both concluded there was never a fracture, but that sesamoiditis/inflammation had built up over time. He suggested cortisone to break the cycle of inflammation and told me to stop using the bone stimulator as it would counter-balance the cortisone. He also referred me to a different podiatrist who said my orthotics did nothing to offload the sesamoid area 
• July - I had the cortisone injections (20mg in two joint areas) and started to wear new orthotics -  modified to include a forefoot dancer's pad
• The cortisone has made some difference, but I still have pain when I walk if I don't wear trainers (especially when I try to walk 'properly' - its like a constant toothache in my joint, along with occasional sharp pains down the joint at the side of my foot . My foot  lack a lot of strength and I often feel pain in my little toes, side of foot and ankle too - I feel like I need to click the joints often etc. I emailed my new doctor and he has suggested another injection. I've also been going to the gym in the last month to try and build up strength through cross-training.

Sorry this is a long email - but I wanted to give you the full history in the hope you might be able to give me your expert thoughts on some questions.( I would love to send you my scans but whilst I have them on CD I don't have the software to open them on my computer):

Dr Blake's comment: Just ask the place to give you a copy with a reader for a PC. You can mail to me at 900 Hyde Street, San Francisco, Ca, 94109. 

1. Was my first podiatrist right? Does it just take a really long time to recover? And have you actually seen people  recover fully if they have a tiny hairline fracture/bone bruise?

Dr Blake's comment: I would have not expectations at you not healing. You do not have an injury that tends not to heal well. However, being a specialist in biomechanics, I do know you could have a difficult foot to get the right orthotic for that truly off weights the area well. If that is the case, then you keep re irritating things over and over again. See who in your area is great at orthotics. 

2. As Dr's disagreed with the diagnosis but not the treatment - I still have a niggling doubt there is an resolved tiny fracture and was I wrong to stop bone stimulator? Could I restart this or is this out of the question now I have cortisone in my system? If so, would there ever be a time when I could?

Dr Blake's comment: Please try to heal without cortisone if possible. I would prefer you to ice and contrast daily and take NSAIDs then to use cortisone. It can mask pain too much. Short acting cortisone is fine, and the initial shot to get ahead of the problem/inflammation was fine, but I would not go there again. I love the bone stimulator, but sounds like no fracture, so there is no place for the stimulator. The bone stimulator actually stimulates the bone, important for fractures, but stimulation can also increase bone inflammation and pain/sensitivity. It could actually keep the bone sensitive to pressure that you do not want.

3. My second doctor said I could have up to 3 injections - I know you are no fan of cortisone, but icing/taping/orthotics have given me no obvious improvement - its been only thing to push me into some form of recovery (if temporary/misleading) - would a second shot be a bad idea?

Dr Blake's comment: Just remember how long it can mask pain, and give you a false sense of security. What are your other options? Physical Therapy with cortisone in iontophoresis? Acupuncture? Better orthotics? More daily icing/contrast bathing? I would feel more comfortable with cortisone if your orthotics were perfect, and you had no other options. As you walk, do you feel that the orthotics take weight off the injured area 0%, 50%, 90%, or 100%. You want the weight in the middle of your foot and off the sesamoid area. Put lip stick on the ball of the foot under the sesamoid, carefully put your foot in the shoe, walk down the hall or outside, take the shoe off, does it look like the weight is off the sesamoid. I know alot about orthotics, and it can still take me many attempts to design the best orthotic for this function. 

4. Is walking barefoot/foot balancing helpful or should I offload wherever possible- it doesn't hurt at the time, but can afterwards.

Dr Blake's comment: I find no purpose in walking barefoot. My blog is loading with foot exercises to get the area strong. One of my patients sent a great video recently on FHL eccentric strengthening which looked great. The exercises should not hurt during or after. You have to experiment. Try rearranging books to stand on for single leg balancing where you float the big toe area. Ice after any exercises to calm down the irritation for 10 minutes. 

 Any thoughts you have would be really appreciated and I will of course make a donation to your blog.

Dr Blake's comment: Thank you so very much and I sure hope this helped some. Rich

Please do not comment on the stomach rolls!!! I am doing sit ups every day!

Thanks so much (if you could keep me anonymous that would be appreciated)

Sesamoid Fracture: Email Advice

This email was received August 11th, 2013 for time reference. 

Hello Dr. Blake,

My name is Michael (name changed)  and I am in my early 20's. I have been a runner for the past 5 years and I love it. Back in December 2012, I tripped over my big toe (not while running) and knew right away that something was wrong. I went to the doctor to get it x-rayed but, since the metatarsal bone was not broken, my doctor told me nothing was wrong and to ice/rest for a couple of weeks. I did this until the pain was much better and the swelling went away and then slowly returned to running, biking, yoga, and all of the other things I love to do while still incorporating stretches and strengthening exercises I had found online for my foot. 

Dr Blake's comment: I would have to say that from the sounds of things that your original injury definitely healed. 

The pain was almost completely gone (would just have some issues from time to time) until I decided to skate one day in June. I pushed out and immediately felt a sharp pain in the ball of my foot where I had injured it before. After putting it off for a couple of weeks, I finally decided to go to the podiatrist. He x-rayed my foot and immediately found that one of my sesamoid bones was fractured. I have now been in a boot for 4 weeks and have two more to go and when I went back for my half way check up the fracture was still there and I am now on cortisone pills for the swelling and inflammation.

Dr Blake's comment: A fractured sesamoid should be immobilized for 3 months, while an off weighting orthotic is being designed to help with the gradual weaning process of boot to athletic shoe. That process along can take 2-6 weeks. Whatever happens, as you begin to wean out of the boot, you can not have more pain. Hopefully the boot has brought the pain level between 0-2 while you are walking in it. 

Now that you know my story I have a couple of questions. I read on your blog, when used properly, cortisone pills can sometimes help inflammation and pain. This was great to hear and we shall see how they work for me on an individual basis. My main question is this: do sesamoid fractures usually heal and will I ever be pain free again? I am having a very hard time physically and emotionally due to the fact that I am so young and am normally very active. I miss working out and I have not read the best recovery stories about this injury. I want to avoid surgery if possible and my podiatrist is on the same page. I like that is seems you have the same ideas about surgery. I am really just looking for some words of encouragement from an outside source or any positive feedback that you have gotten or seen from a sesamoid fracture recovery. 

I thank you so much for taking the time to read my email and for creating a blog that allows for me to further research what I am going through.

Sincerely, Michael

Hope you will be back running soon!! 

Dr Blake's comment: Sesamoid Fractures are very tricky, but sound principles and patience can get most patients through without surgery. All guidelines to treatment are close approximations/generalizations. You can still heal even if you are an exception. What are the most important points for you right now? 

A) Listen to your body and do not accept more pain as you go from stage to stage.
B) Bones need Calcium and Vitamin D3 to heal, make sure your diet is good.
C) Swelling is your enemy, even deep swelling in the bone which you can not see, it cuts off healing circulation, so icing and contrast bathing daily is extremely important.
D) Typically at 3 months post injury you are getting out of the cast, and 6 months after the injury you are beginning a walk run program, so go slow with each stage.
E) Your podiatrist can begin making an off weight bearing orthotic device now, or modify your present ones, so when you begin to wean out of the cast, you are protected.
F) Avoid all anti-inflammatory meds after you finish the cortisone pills, since many slow bone healing.
G) Even with the boot, you should be riding a stationary bike, swimming, and other core activities that do not put stress on the sesamoid, or force bending the big toe joint. 
H) Ask the podiatrist if you are a candidate for a bone stimulator.
I) Ask if a baseline MRI can be taken, in case you need one in 6 months to check on healing.
J) Learn spica taping and how to make dancer's pads (also called Reverse Morton's).
K) Find out when you should start re-strengthening your foot (met doming, single leg balancing with a hole for the sesamoid, inversion/eversion therabands, etc). 

I hope this all helps Rich

Enneagram: The Sacred 9 Types. Which one are you?

Personality typing has been used for centuries and for many purposes. The best one I have ever found and used is called the Enneagram, or 9 Types. It was relatively unknown as a oral tradition until first written down in the 1950s.

What has this to do with a Podiatry blog? Your personality influences greatly how you exercise, how you respond to a doctor telling you what it wrong and what to do, how you deal with your injury, how you deal with others around your injury, etc.

It is actually hard to tell what number you are. Your close friends and family can tell easier. The number describes what your basic drive deep inside is (I realized how superficial I really was/am when first reading about it). It is part of a journey into healing yourself (we are all wounded to some degree), and it is helpful dealing with others.

I like the concept that if you had 9 people in a room with a single goal, if all 9 were a different personality type, all 9 would come up with a different opinion. So, if I tell 9 people with 9 different personality types the exact same thing, I will get at least 9 different responses. This has always been called the Art of Medicine, and the Enneagram can at least give you piece of mind that difference is fine. It is okay when some of my patients do not agree with what I say. People process what they hear, see, read, etc so differently.

So, what are the basics.

A) The Person is actually part spirit, body, and soul.
B) The 9 Types deal with the basic drive of the Soul (our deepest drive in life!!)
C) The Soul is divided into Mind, Will, and Emotion (Heart)
D) The 9 Types have 3 Mind Drives, 3 Will Drives, and 3 Heart Drives
E) These drives are us at our core, we can not change it if we tried
F) Each basic drive of personality has pros and cons
G) We grow as an individual by looking at these pros and cons and developing the ones, and suppressing the bad ones.

What are the 9 Types?
1 is The Perfectionist or Reformer (Will)
2 is the Giver or Helper (Heart)
3 is the Achiever or Success Driven (Heart)
4 is the Romantic or Individualist (Heart)
5 is the Teacher or Observer (Mind)
6 is the Loyalist or Trooper (Mind)
7 is the Epicure or Zest for Life (Mind)
8 is the Boss, Challenger or Leader (Will)
9 is the Mediator or Peacemaker (Will)

2 psychologists, who use the Enneagram solely in their practices, last year independently said I was 100% a 9. I always thought I wanted to be a 2 (great for medicine), or that I was a 5, but as I have read more and more, they are right and I am a 9. As you learn your number, you can see how the positive side and negative side affects your life. Without any further reading, look at the 9 numbers above. Can you think how each of these drives could make you great or break you down.

Can you see yourself, your friends or family, or colleagues as predominately one number?
This really has helped me in dealing with groups of people to see that there will be differences in opinion that are equally valid as mine.

We are One Number at our core, but each number has 2 strong wings that we can develop to get stronger or weaker (our choice). We can not pick our wings, as we can not chose our Basic Number. They are what they are. We can just grow with them. We could grow emotionally and perfect the good qualities of our 3 numbers.  See we can possibly be 1/3rd perfect people. LOL

Wings for Each Number are:
1 (Perfectionist) has 7 (Zest for Life) and 4 (Romantic)
2 (Giver) has 8 (Boss) and 4 (Romantic)
3 (Achiever) has 9 (Mediator) and 6 (Loyalist)
4 (Romantic) has 1 (Perfectionist) and 2 (Giver)
5 (Teacher) has 7 (Zest for Life) and 8 (Boss)
6 (Loyalist) has 9 (Mediator) and 3 (Achiever)
7 (Zest for life) has 1 (Perfectionist) and 5 (Teacher)
8 (Boss) has 5 (Teacher) and 2 (Giver)
9 (Mediator) has 6 (Loyalist) and 3 (Achiever)


The video below is a good start if you want to learn more. They tell you where to take a test, but I would check out some easy books (not too psychologically based) describing this topic. The video below had some other helpful descriptions.

Type 1 Perfectionist has beauty through organization, with slight stiffness
Type 2 Giver is friendly and pleasing
Type 3 Achiever reaches for the sunshine, strives for recognition through successs
Type 4 Romantic is unique, experiences richness in relationships, artist expression can be easy
Type 5 Teacher is passionate in pursuit of knowledge, finds identity in understanding
Type 6 Loyalist believes in overcoming fear by strength, and feels safer in groups
Type 7 Epicure appears passionate and lively, loves to fly high and look towards pleasures to come
Type 8 Boss is an attention grabber, prepared to face all competitors
Type 9 Mediator is happy and restful

 I sure hope this simple introduction was interesting enough to have you look into the topic more. As a good Type 9 I feel happy to bring this info to you, and to satisfy my personality wings, I feel great that I achieved this goal (Type 3) and supported by blog readers (Type 6). Have a great day!! Rich

eBikes: Are they for You?

As I turn 60 next year, and want to increase both my overall exercise, and my outdoor exercise, I am looking into one of these to help me in both area. I will have to combine Christmas, birthday, anniversary and father's day gifts together, but it looks worth it. Several people I know have one and just love it. Patty, are you reading this blog post, or should I give her more hints!!!!

Enjoy these beautiful Photos!!!

http://www.yiminghuphoto.com/portfolio/landscape.php

Post Calcaneal Fracture: Email Advice

Hi Dr. Blake,

     You helped me once before with advice regarding Neuro Eze cream for my feet.  If you don't mind, I had a question about peroneal tendons/muscles.  I broke both my heels 7 years ago and had plates/pins installed.  Over the years my feet have gradually become more and more supinated, to an extreme point where management with orthotics is impossible on my left foot.  I'm 5'6" and weigh 145 lbs.  It's occurred to me that I'm sore right where the peroneal tendons run, and I can't put my big toe on the ground.  I didn't start out this supinated.  Is it possible that I have a peroneal injury from the plate or accident that is making me more supinated?

Dr Blake's comment: Thanks for the email. Since the supination is on both sides, you have to think first of mechanical causes. The most common is gradually peroneal weakening since the surgery somehow disrupted their normal function. You could have peroneal nerve problems, originating from your back, since you are supinating too much. Supination is one of the biggest causes of low back dysfunction. The plates also can be loosening up around the lateral side of your foot irritating the tendons, shutting them off from normal function. 

    On my left foot, there's a 3/4" inch gap between the big toe and the ground.  I've seen a lot of podiatrists and orthopods, and no one has mentioned the peroneals.  They've suggested options like calcaneal osteotomy and/or plantar flexory first ray osteotomy.  Do you have any other ideas for treatment?  (I used to bicycle a lot but can't use a cycling shoe now.)  Thanks so much for any advice.

Regards,

Dr Blake's comment: Please have someone tell us if you can get your heel straight to the ground. This video below may help you understand this.



I would not consider a surgery unless the peroneal tendon function is evaluated by a physiatrist/neurologist  and a physical therapist. The MDs will perform a Nerve Conduction Test with EMG (muscle test) and the PT will be more practical about muscle strength and function. A bone scan or MRI should be done if there is questions about loosening of the plate on the lateral side of your foot. Any surgery like this should be pre investigated with a fine tooth comb to understand why this is happening, not just how to fix it. The fix may be simple, and have nothing to do with surgery. I hope this is in your case. And, I hope this helps you. Rich

PS Please review all my posts on excessive supination, one of my most favorite topics, to get a strong handle on some of the conservative options, but also so you can ask those treating you the best questions. 

Infant's Shoes: Email Advice

Hi Dr. Blake,

I am currently looking to purchase a pair of shoes for my 14 month old daughter. I have not put her feet in shoes until this point, and I wanted to ask what good options would be? Thanks for any help! I love your blog!

Dr Blake's comment:

     Experts in Children's Feet (which I am not) say that if the child has had normal development (crawling by 8 months, walking by 12 months, no history of severe flat feet in family) then a flexible shoe should be used. The 2 best companies are Robeez and Stride Rite for this type of shoe. 

     If the child does have delayed crawling/walking patterns (my second one did not walk until 15 months), then a rigid shoe should be used. Stride Rite also makes this type of shoe. 

     I hope this helps your decision. Rich

Low Dose Naltrexone: Bright Help for Patients with Nerve Pain

This was an email I recently received. I have worked with her on the orthotic side of helping her nerve pain. The Hannaford based orthotics were definitely helpful, but she remained with incredible pain. I recently went to a nerve lecture regarding CRPS. At this lecture, the pain specialist mentioned Low Dose Naltrexone and sublingual Ketamine as great drugs for nerve pain. This patient definitely agrees with LDN. 


Hello Dr. Blake,

How are you?  Long time no see.

I would like to come and see you in August so that I can have my orthotics redone again.  I've been taking a drug called Low Dose Naltrexone and experiencing great benefit.  IT has almost no side effects – it's a glial cell modulator – and the neurologist I'm seeing has been very helpful. 

Dr Blake's comment: This young lady has been suffering years with nerve pain. I was so happy to open the email from her. I asked her to fully explain the dosage as best she could. Here was her response.

It used to be that people began with 1.3 ml and slowly went up to 3 and then 5 ml.  However, Kaiser now compounds it and makes it in 5 ml caps.  My doctor recently gave me 5 ml caps.  That was effective, but then I went up to 10 and found it even more effective.  I asked if I could go up to 15 and she was fine with that because it is such a safe drug.  I now take 15 with no side effects and now have incredible results.  I walked a mile on cement sidewalks tonight.  Watched a movie and walked a mile back with only a very mild pain sensation that occurred only near the end of the walk.

I took 5 for a couple of weeks, 10 for 4 more weeks and then began 15 about two weeks ago.  I'll stay at this level, probably.

She is Dr. Rubenstein – neurologist in pain management dept at Santa Rosa Kaiser.

Good luck!

HI,

One more thing:  Doctors are told that LDN should be taken at night.  This can cause the one negative side effect which is overly vivid and intense dreams.  My doctor said I can take the drug anytime – it's not necessary to take it at night.  I take it after breakfast and it works beautifully.

Dr Blake's comment: Please also see the wonderful video from Dr Chopra whom I first learned about LDN. 

Better Exercise not More Exercise should be our Mantra

As the summer winds down, and we settle in for a great Fall workout program, the following article highlights some of the key aspects of a smart and effective schedule. The highlights focus on what to avoid to stay injury free:

1. Too Much Too Soon
2. Poor Planning and Goal Setting
3. Wrong Workout Gear
4. Poor Exercise Form
5. You Don't Mix It Up
6. You Think Negatively
7. Poor Nutrition
8. Don't Rest Enough

After looking over this list, I am suspect in 5 of these categories, and at 59 years old, I am prone more to injury unless I straighten up my act!!!

http://www.sharecare.com/health/type-2-diabetes/health-guide/diabetes-smart-tips-guide/diabetes-exercise-mistakes?isEndPage=false&topicUri=type-2-diabetes&healthGuideUri=diabetes-smart-tips-guide


On a personal note, tomorrow August 7th, I am starting a personal 150 day program to get in shape and shed 30 pounds. I will try to use the advice learned from this nice article to stay focused with better cross training, a more positive attitude, better diet and amount of sleep (less blogging!!??), and a gradual buildup in my exercises.

Sublingual Ketamine for Severe Neuropathic Pain

I keep hearing about sublingual Ketamine for severe nerve pain flareups. All MDs that I discuss this with are reluctant to prescribe. Here at least is blog post from one pain specialist supporting it. 

http://painsandiego.com/2012/08/22/ketamine-iv-vs-nasal-spray-or-sublingual/

Motion is Crucial to Life: Enjoy and Keep Moving!!

This is my next goal to learn this!!! We all need challenges even though I have two left feet!!

Doctors Constantly Use their Phones to Communicate with their Patients: This Doctor Lost Her Phone Temporarily

Ball of the Foot Pain: Eccentric Flexor Hallucis Strengthening may help

I have been corresponding with this patient for a long time after he injured his right sesamoid bone (forgot which one). The rehabilitation was long, but successful. This is one exercise I have never thought of or recommended that he felt was invaluable. Concentric strengthening of the long flexor to the big toe is to pull the toe downward (a standard exercise). This is eccentric strengthening of the same tendon where the toe is being pulled up while the patient tries to point the toe downward. Therefore, the long flexor (FHL) to the big toe is elongating while contracting which is the definition of an eccentric contraction. We use this technique all the time for hip, knee, and achilles/ankle problems, why not the big toe? You start with 2 sets of 10 reps, and gradually over time build up to 2 sets of 50 reps. Good luck and thank you to my blog patient!!!

Stretch those Hamstrings: The Curse of being Chair Bound

Most of us sit too much for many reasons. This wonderful video emphasizes this and gets us out of our pattern of being "chair bound". Do these motions to get your body more flexible very gradually and gently. There is no rush to be more flexible. Avoid pain and listen to your body. You may not be able to go too far, but a slight gain in flexibility over the next few months, with the development of a few new habits, may be all you need. I have always said "Movement is one of the Secrets of Life" and this video shows how prolonged chair sitting may be a curse. I personally love anything type of exercise I can do laying on the ground, sad but true. LOL 

Humor: Never Lose It!!

The work I do I think is important. Sometimes I think it is so important that I lose sleep worrying over my patients, and what I need to do, and whether I will get it right. Sometimes, this attitude is very counter productive, and I get grumpy, irritable, and begin to work my self to a quick grave. Podiatry is my passion, but passions can overwhelm you. Passions can break you down. When a good friend sent me this video about the Humor of Ronald Reagan, while he was the President of the United States, one of the most serious demanding jobs in the world, I had one of those ah-ha experiences. Never lose humor. Never lose your self humility. Get rid of that feeling of how important you are, just do your best every day. Relax more, enjoy your friends and family more. Set your priorities better (of course, I am only talking about myself!!) 

Blister Care: Brief Video Presentation

http://www.drblakeshealingsole.com/2010/12/blisters-body-glide-to-rescue.html

http://www.drblakeshealingsole.com/2010/04/general-principles-on-blister-care.html

Webcast: 2 Most Important Aspects of Orthotic Design for Heel Pain Treatment