Foot Injury with Nerve Pain: Email Advice

Dr. Blake,
I found your blog this morning as a started in on two weeks of trying to completely not use my foot.  My email will be long as has been this nightmare Odessa.  I pray you can shed some light on this matter.

On July 29 I slipped on a wet spot in a store while wearing high stiff bottomed heels.   I slid gently into the slip and ended up on one knee with my left foot behind me as though kneeling to ask someone to marry me, plus perhaps a little more stretched out.  I got up and all seemed fine.  I went for my 3 mile walk the next 3 days with no pain.  On the 4th day I woke up with pain in the ball of my foot underneath the big toe and it became slightly swollen.  I could not pull my big toe back without sending a sharp pain down the foot.

Dr Blake's comment: This is the first sign of a small injury. The longer it is between injury and symptoms, the more minor the problem. I am looking for signs of hope for you. 

I went to the podiatrist and she did X-rays to see if the sesamoids were fractured and wrapped the foot.  That night the wrapping made the medial arch cry out in pain.  I took the wrapping off.

Dr Blake's comment: I make this mistake all the time since it is hard to know actually how tight to do in face of swelling that needs room to spread. The pain is not a sign of worse problems. 

The X-rays showed no fracture but a bipartite sesamoid and I only have one in each foot.
Dr Blake's comment: Bipartite Sesamoids are weaker than normal sesamoids, and thus, can get injured easier. It is usually a bad sign if x rays show bipartite sesamoids and point to an injured connection between the two pieces (weakest link in the chain). 

I continued to walk on it, limping and landing on the foot flat not really bending the joint under the ball.  A week later after Ice and Motrin I went back to the Dr and the swelling was down and the Doc said I was getting better and gave me hard orthotics with a high arch.  They made the foot hurt like heck again in the medial arch.  I still could not walk right.  My big toe did not work on push off and I could not make the foot walk. 
Dr Blake's comment: Orthotics should change function, off weight areas, feel borderline obnoxious, but never hurt. It is imperative to get them fixed by analyzing what is wrong and fix that (for example lower the arch in your case). 

 She did an MRI that only showed some mild edema by flexor abductor.  They could not visualize the sesamoids which kind of defeated the whole purpose.
Dr Blake's comment: This is impossible. Did you see the MRI? Can you look at the CD and send me images of the views that I normally show on my sesamoid posts. Something is rotten in Denmark!!

  She was flustered that I could not walk and threw me in a cam walker and thought maybe I tweaked a nerve and offered a cortisone shot.  I refused as she seemed to be guessing ( she would have put it in the tarsal tunnel).  Once again I only wore the boot one day and that night I had the worst deep aching pain in the center of my arch.
Dr Blake's comment: An injury causes pain. But, living with that injury, causes secondary pains from nerve protection, muscle/tendon favoring/splinting, inflammation not being controlled right. You need to do what you can to create a pain free environment while you are working on a specific diagnosis. Without a diagnosis, your treatment is too much guess work. You may need 2nd opinions, other tests, etc. 

Next I went to an orthopedic foot and ankle doc at the HSS.  He thought the nerve was getting trapped or irritated under the Knot of Henry. 
Dr Blake's comment: The Knot is back in the arch. The original injury is the ball of the foot. Do not lose focus on the ball of the foot, for the other pain is secondary. I like the idea of PT to reduce inflammation only. What about a repeat MRI to find those sesamoids, or a nerve conduction test if the nerve are being suspected. The same doc that does nerve tests are typically the best at calming nerves down with topicals and oral meds. 

 He wanted to do a diagnostic lidocaine shot but I refused.  He said PT with only modalities to bring down inflammation- come back in two weeks if not better and get a cortisone shot. The most tender point was right at the knot of Henry and that night after he palpitated  it I had the worst deep nerve pain.  When I got up I had pins and needles(. Which is the only time I have had this). They gave me a compound cream for nerve pain and with that and PT it started to feel better.  
Dr Blake's comment: Now, it is sounding better. The PT and topicals are probably working solely on the compensatory pain. But, the original problem goes undiagnosed. Have you found a shoe or boot/walker that allows you to walk comfortably. Sometimes, online purchase of a short leg walker from Ovation Medical and 1/4 inch adhesive felt from www.mooremedical.com you can fashion a custom made boot and padding to off weight the area. 

But I still could not walk right.  I saw another Foot Doc from Hss for a second opinion and he said a nerve traction injury and it could take  2 years to calm down and to find good shoes.    He was against the cortisone shot as he said he saw idiosyncratic reactions that caused flare ups of nerve pain .  At this point I could walk around the house and short distances but was still not pushing off with the big toe or really stretching the arch at all when walking. 
Dr Blake's comment: It was a good decision to avoid the shot which can irritate an already irritable nerve!!! And, you were getting better. 

 The nerve pain seemed to be under control so I stopped using the cream.  2 days later the ball of the foot opened up and started to work.  My PT felt all my problems were with the FHL tendon as it was stretched and strained by the injury and this was where the tenderness and pain was.  The PT started me with very mild walk thru exercises to get my big toe to grab. 
Dr Blake's comment: I get very scared with this. The nerve is still irritable, and the system still too delicate. Weight bearing exercises are potentially too aggressive at this stage with so many wonderful less aggressive, non weight bearing exercises to chose from. 

 He did some massage to get the foot moving.  It helped somewhat but the more I could now make the foot move right( using the arch). The nerve pain came back. 
Dr Blake's comment: The art of medicine is in the timing of things. This was predictable. Your system still too irritable. Nerve pain, even when gone, needs a long time of respect before it allows a lot of stimulation. I love to keep patients on those creams for months after the nerve pain is gone. 


 It would burn at night and after a good day when I was able to walk barefoot around the house without a limp and felt the big toe start to grab that night it burned and hurt to just rest my heel on the bed.  At this point I still could not go down stairs although I could go up.  I could walk 2 aisles in the grocery store and then it would hurt in the arch.  Not able also is that once the nerve pain started I could not use ice it made it hurt more.
Dr Blake's comment: Angry nerves love pain free massage, heat over ice, gentle stretching. The nerve pain is secondary to your original injury, but now a major player. See if Low Dye taping is tolerated to support, but not press up. You course of events is very common, and some of it predictable, so cures can be found. Read all I have on the blog on nerve pain and tarsal tunnel, and CRPS. Many tips will be there.


 Also my first PT gave me exercises to do that had me lifting the forefoot off the ground while keeping the heal on the ground.  These made the foot hurt so much and my PT now said that was stressing the inflamed FHL.
Dr Blake's comment: It was just not the time to do weight bearing exercises. You were in the Immobilization Phase when some very simple exercises are needed, the diagnosis needs to be confirmed, anti-inflammatory measures rule and the creation of a pain free environment is paramount. 

  I decided to go back and see my foot and ankle dr prepared to get the cortisone shot to calm the inflammation.  He still said the next step would be to do the diagnostic lidocaine so he could be sure to know where to put cortisone. So I did it and it was a Hugh mistake.  The shot was placed in the tendon sheath by the knot of Henry.  The foot became numb from mid foot down and I had no pain for12 hours.  When it wore off my foot exploded in pain.  All the nerve pain was back and now it hurt to just gently run my finger along the FHL tendon and in that spot in the arch in the middle of the foot. 
Dr Blake's comment: I have only done this once to a patient, but it will live in my memory until I die. Injecting even local anesthetic into an unstable nerve is risky. I understand the principle of what he was trying to accomplish, but I am sorry that you had to experience it. Nerves like this can be unpredictable for several years. The symptoms can last for 4 days to 3 weeks. You must calm the nerve down with icing, or heat, or just rest. No compression at all. See a pain management specialist for oral medications (typically neurologists or physiatrists). Start using the nerve cream again if possible. Lidoderm patches are wonderful for this and you primary may be able to write for. 


 I talked to the Dr and the Dr who gave me the shot ( ultrasound guided at Hss). They had never seen a reaction like this and were confounded.
Dr Blake's comment: I am probably not as good a doctor as them, between me and my colleagues, we have seen this a lot. 

  I was left on my own.  The ortho said go to a neurologist.  It's been two weeks since the shot.  The foot is better but has been sent back beyond the beginning.  My PT did some massage and I had a good day and thought perhaps it was passing.  Then he massaged the FHL tendon deeply ( I don't think either one of us realized how re inflamed it was) and since then (last Wednesday) the foot is burning and I can' walk between rooms without burning pain in the arch of my foot.   And now the ball of the foot is re inflamed and swollen!  Back to the beginning!  On Friday
Dr Blake's comment: Please get this calmed down, and do not do anything until you email me. See if your area has a physical therapist that specializes in neuro-based PT, totally different then typical musculo-skeletal based PT. You should read the post on Checklist for treating CRPS, and begin understanding how to treat nerve pain. What ever your original injury, you now have a nerve injury that needs to be honored. 


 I went to the neurologist who was no help.  I did refuse Emg test since the foot is  so inflamed and had such a reaction to the lidocaine shot I did not trust that it would not further inflame the foot. 
Dr Blake's comment: Thank you for so much common sense!!!!! It is all in the timing. It is not the right time with the nerve so grumpy!!

 He sent me across the street to some bigwig podiatrist who heard my story hardly examined the foot and said RSD.  He sent me for an ultrasound and X-rays which I will get back at weeks end.  Both my ortho dr's PA and my PT do not agree with RSD .
Dr Blake's comment: All bad nerve pain is not RSD, although some of the same concepts of treating RSD or CRPS will/do apply to you. One of my posts goes over the Harden classification for CRPS (modern day RSD). Our job my friend is to not develop it with repeated flares over and over again. 

  I have no color or temperature changes and my pain is still pretty much contained to original area of injury.  My PT has treated a lot of RSD and said its simply not presenting that way.  He can massage it and it only hurts after.   He is at a loss.  After that shot just simple stretching of the FHL inflames it.  He will continue with ultrasound and TENS and he and the PA said just stay off of it for a few weeks ( something I' ve never done). So here I sit on the couch 21/2 months later unable to walk with a bunch of baffled pros.
Dr Blake's comment: Believe me, I give tons of second opinions, and you are catching this cycle so early. You have to stop thinking of time right now, and focus on healing, which may take a long time. But, it will be as logical and all your flareups have been once we realized you had a bad nerve reaction. It brought you from an orthopedic/podiatrist/physical therapist injury into the world of nerve pain. 

Dr. Blake I am not doing well with this.  I could face a definitive illness with a path and plan for recovery but this no knowing what it is or how to treat it and all the missteps by pros (HSS for goodness sake) has given me terrible anxiety.  I can't sleep or eat and feel out here on my own.
Dr Blake's comment: This is the realm of nerve pain. It causes suffering, where orthopedic injuries to the musculo-skeletal system cause inconveniences. I think you understand what I am saying. You need to create a pain free environment while you find docs/PTs that understand what I have just said, and can treat it. I will help as much as I can, but locally you will find your best options. 

  Even my GP of many years who I love says he just does not know what to do.   What are your thoughts?  What should be my next move?  My PT suggested going to a physiatrist he trusts that could coordinate things.  Should I go to yet another ortho?  What do you think happened with that shot?  Have you seen this before?
Dr Blake's comment: Yes, the physiatrist is a great choice. Right now stay away from the orthos or pods, unless you hear of one that has a knack for nerve pain. Also, find a neuro PT, even if the PT you are seeing does not like me for suggesting. Unless, I hear a better rationale for treating your nerve pain, I do not want any one but you massaging your foot. 

  I know the one ortho frowned upon the cortisone injection and said its always risky for a shot near a nerve.  At the time I thought he meant a cortisone shot but maybe he meant Any shot could irritated the nerve?  Do you know any great podiatrists in the NYC area.  Any help would be so appreciated. I am lost.
Dr Blake's comment: I only know 3 great sports podiatrists in New York State: Dr Karen Langone, Dr David Davidson, and Dr Robert Conenello, but maybe they could point you in the right direction. Believe me, there is nothing in what you said that does not make sense, that podiatrists have not seen, that treatments do not exist. Hang in there, and I hope this helps you some. Rich

Thank you, S

Patient's Response:

Dr. Blake,

Thank you so much.  I've been completely resting the foot and the pain goes down to almost 0 if I don't move it or walk on it.  Is that a good sign against RSD?  The PT did deep massage on the FHL tendon right under the big toe and gentle stretching ( pushing the foot back from the ball of the foot) now the ball of the foot is painful and swollen again-could that have been the reason?

Also, the nerve cream stings when I first put it on which it did not do originally- is that ok?  And lastly- Dr Conenello- is he great?  He is right by me -  would he be a great choice to guide me thru the rest of this rather than the physiatrist? 

Thanks,

Dr Blake's response:

S, Glad Rob is close, he is kind and smart. You need someone to manage your foot while a physiatrist works on the pain. No shots for now, in your foot at least. Rob may know where to send you, or if he is qualified to help. A good new start!!! You need a team however. With nerve pain, there are times to Honor the Pain (now), and times to Push Through the Pain (someday). You definitely need some weight bearing, some massage, some ankle rotations, some achilles stretching, etc, but start slow. Take it 2 weeks at a time with the next 2 weeks to get new direction, not irritate your foot at all, experiment with ice and heat, continue with nerve cream but gently, get into someone who can put you on Neurontin or Lyrica, and keep me in the loop. Rich

Bursitis: Email Advice

Hi Dr. Blake,

I have what seems to be a stubborn adventitious bursa under and around my fifth metatarsal that developed because my foot was very supinated. 

Dr Blake's comment: A bursae is a fluid filled sac that develops between the bone and soft tissue, deeper than a blister, in response to abnormal pressure. One can see from the video below that over supination will cause excessive pressure on the outside of the foot.



 I've been able to stretch and ease the peroneal tendons that seemed to be causing the supination.
Dr Blake's comment: As the foot supinates, or rolls to the outside, the peroneal tendons must be strong to stabilize. Focus you attention on strengthening the peroneal tendons. The video below emphasizes the peroneus longus exercise with the ankle in neutral. If you do the same exercise with the foot pointed downward, you will also get the peroneus brevis tendon. 



  The burae comes back with any type of pressure, even stretching.  
Dr Blake's comment: Once the bursae forms, even normal pressure can keep it irritated. I love deep ice massage three times daily to try to break it down, physical therapy with ultrasound and deep friction massage if self treatment is not successful, and injections or surgery if those are unsuccessful. You must off weight the area on a daily basis. You need a dancer's pad not for the first metatarsal, but for the fifth metatarsal. See my video from yesterday on using 1/8th inch adhesive felt from www.mooremedical.com to create an off weighting system in all your shoes (great if you can attach this to your orthotic device). 





I'm wondering if cold laser therapy or some other treatment might help.  The bursa doesn't respond to cortisone, and it won't let me bicycle, even with orthotics.  Because it's on the bottom of my foot and is connected to other tissue, surgery probably wouldn't be a good idea.  Thanks in advance for your advice,

Regards,

Dr Blake's comment: I like the old beating up of these bursae, and I have no experience with cold laser. I like, and have good results with cortisone shots when the icing and PT not help. The surgery is rare, so I would not go there right now. Get an MRI if it is stubborn to make sure you are really dealing with a bursae and not another cause of a soft tissue mass. Good luck!!

Nerve Pain Around Big Toe Joint: Email Advice

Doc,

I have nerve pain that presents around the 1st MTJ pad, but is centered between the 1st and 2nd MTJ pad has stopped me running and severely effects my ability to walk normally. 
Dr Blake's comment: This is either a local problem with the deep peroneal nerve, or an L4/L5 Disc Issue. 



 My GP took an xray to rule out fracture.  He thinks it is a neuroma and has referred me to a podiatrist, but I won't be able to get in for another month.  As you know that's a long time for a runner, and I hate to be doing anything that would make it worse for a month.  So my question is, is contrast bathing good for nerve pain? 
Dr Blake's comment: Patients with nerve pain love contrast bathing in general since it soothes the nerve by removing inflammation from around the nerve. 



 That seems like something fairly benign that I could start doing right away.  In my desperation, I also grapped some Dr. Scholls metatarsal pads and am experimenting to see if I can find the right spot for placement to see if it addresses the pain.
Dr Blake's comment: Go to www.mooremedical.com and order a roll of 1/8th adhesive felt. You will have more flexibility in where you put padding. Be creative!!!

https://www.mooremedical.com/Index.cfm?Ntk=all&No=0&Search=Search&Ns=Searchorder%7C0%7C&Ntx=mode+matchpartialmax&Ntt=adhesive+felt&x=33&y=9

Which leads me to my deeper question. I have heard a podiatrist say that a neuroma is a symptom of some underlying issue that caused the nerve to fire off in the first place, and that the underlying cause should be found and addressed in addition to treating the actual neuroma.  Is that the way you approach it?
Dr Blake's comment: Nerves fire bad for many reasons. It can be the nerve itself locally, it can be just a symptom that the nerve is stressed somewhere above (double crush syndrome), and it can be from an outside irritant from poor mechanics, bone spur, swelling in the area from a broken bone, etc. You have to treat the nerve, but not have tunnel vision and also look for other reasons the nerve is unhappy. 

Thanks for this blog! It has been very informative.
Regards,
Michael (name changed)

Supination: Orthotic Designs for Preventing Excessive Supination

This video discusses the common orthotic mold corrections utilized by labs for correcting supination problems. 

Big Toe (Hallux) Soreness: A Method of Padding and Taping

Below is a video describing padding and taping for a painful big toe under the joint closest to the toe. This joint can get over stressed for several reasons--especially related to limitation of big toe joint motion and the presence of an accessory ossicle or sesamoid. Recently, a patient emailed me regarding pain in this area. I wanted to do this video for her especially, but I have many patients with this problem. 

Nerve Irritation Post Ankle Sprain: Email Advice

Hi Dr. Blake,

I haven't seen you in many years (I think my last visit was around 2004/5 re: my plantar problems while qualifying for the Boston Marathon), and now find your immense blog! Since then, I got married, had 2 kids, and am quasi-coming up for air. Would you please advise me...I hurt my ankle again =(

Late last night, I rolled my left ankle outward while trying to get on a dome-shaped balancing ball at the gym. I heard a popping sound on my way falling down to the floor. I was able to get some ice on my ankle at home. But since then, I've been limping around the house (hardwood floors) and trying to avoid chasing my kids (ages 3 1/2 and 2). My biggest concern is a tingling feeling around the ankle bone that radiates down to my heel and up to my arch area.

I've wrecked this ankle before in a stupid snowboarding accident and have sprained it several other times in my life. But I don't remember the tingling. I'm worried about that because isn't that an indication of nerve damage?

Thanks so much for your advice! I'll call your office to make an appointment if the tingling is still going on. I went to the gym today and worked out my upper body. People thought I was nuts hobbling from machine to machine...

Best regards,

Dr Blake's Response:

Hey Allie (name changed), sorry for the delay. Yes, you must of jerked the nerve real good. It can take a while to calm down. If you have an ankle brace that ties up, that may rest it well. You can also adjust the lacing so that it does not push hard into any sore areas. Continue icing for 96 hours, then begin contrast bathing once daily. See my blog post on how to start contrast bathing. Be good to it and hopefully it will settle down quickly. Rich

http://www.drblakeshealingsole.com/search/label/Contrast%20Bathing

Nerves love non painful massage. And they usually love heat, in general, over ice. Try gentle massage to the swollen areas, and gently move the ankle. I typically teach patients to use their big toe as a paint brush in the warm water of contrast bathing and attempt to paint the alphabet. Also, order a bottle of Neuro-Eze online. It is a good nerve topical medication. You massage a small drop into the area 3 times daily. I sure hope this helps. Rich

Sesamoiditis: Email Advice

Dear Dr Blake,

I am contacting you from Australia as I have been suffering from a particularly persistent case of sesamoiditis for the past 4 months. I read your blog and was hoping you may be able to help as I'm desperate for answers. 

I have tried all methods of conservative treatment, including custom orthodics, 2 cortisone injections (FHL tendon sheath guided by ultrasound) and 1 MTP joint capsule. I had a negative reaction to the second injection, with increasing swelling pain in the 1 MTP. My orthopaedic sports surgeon, decided it was best to have a investigative synovectomy with biopsy carried out to eliminate any potential infection/underlying inflammatory condition that was not appearing on blood tests or MRI. The biopsy yielded no results.

I have also been in a cam walker for almost 3 months, with 2 weeks of crutches included in there post surgery. I have been training in professional football. I am desperate to heal this condition and am reaching out to you for help as I feel my options here in Australia are limited, with little success this far.

I am particularly interested in ESWT and the specific modalities applied so that I may be able to request from a clinic here. I would also be interested to hear your opinion on PRP injections or Augment for bone healing, even though no fractures are present in my case (just a bipartite sesamoid, confirmed via xray and 2 MRI's).

I would greatly appreciate your assistance Dr Blake as I am a very active person and this condition has severely affected my quality of life and aspirations of becoming a punter in the NFL.

Yours sincerely,

Dr Blake's comment: I am honored you have asked me. I have no experience in ESWT or PRP or Augment for this condition, but I think that there is a place for Exogen Bone Stimulation to strengthen the bone. You have been in the Immobilization Phase for typically the time you would for a broken sesamoid, so the question is how to progress you to the Restrengthening and Return To Activity Phases. I am happy to look at any MRIs that you want to send me. The Pacific Ocean is not that big. I would have to assume the length of time is either from inadequate orthotic protection, a misdiagnosed small sesamoid fracture, or pain more from soft tissue with inadequate physical therapy. If everyone is happy that the bone is not broken, find out who makes the best orthotics in town or in the biggest town near you. See if a physio can evaluate you for bone, joint, or soft tissue problems. Ice Pack the area 3 times a day for 15 minutes, and do contrast bath each evening. Buy a roll of 1/8 th inch adhesive felt from Moore Medical (www.mooremedical.com) and with a tennis shoe 1 size bigger, and a good deep toe box, try to design a dancer's pad and arch support that when you walk and run there is no weight on the sesamoid (a slight overcorrection of the foot as a temporary design). Send me photos of your foot, inserts, anything and I can give you advice. Do you have swelling? Does the joint have good range of motion? When does it hurt---with joint motion, or just with pressure? Let's start analyzing. Best to comment on this post, but it you want more confidentiality, email me again. I hope this helps some. Rich

Patient's Response:

Hi Rich,

Thank you so much for your reply.  

From what I have been able to gather in my research, there are two different types of sesamoiditis.  One which is more related to a bony stress response, and the other which is more related to FHB and FHL tendon/ligament inflammation.  I think there's no doubt that initially it was a bony stress response, however I tend to think the sesamoids are now more reactive to the surrounding inflammatory soft tissue.  The MRI's reports detail tenosynovitis to FHB and FHL.

Dr Blake's comment: Tenosynovitis is an advanced, very sore, form of tendinitis and hard to get rid of. 

I was using a personal ultrasound device for a few days (ultrasound pro) which I bought over the internet, which has a low frequency setting.  I was using this around the FHL and FHB area, as well as 1st MTP.  It seemed to aggravate things for a couple of days and then settle down.

Dr Blake's comment: Ultrasound units that you can purchase are either for bone or soft tissue. The soft tissue ones are bad for bone healing, so you need to know which one you are getting. 

  So I have stopped this and am now only using the Melmak bone stimulator which my specialist recommended.  My specialist says its the same as an Exogen 4000.  Here in Australia you can't rent Exogen, you can only buy them for around $1,800.  So I am renting the Melmak for 1 month ($330) and doing 20 min per day treatment as prescribed. 

Dr Blake's comment: Definitely switch to twice a day for the same 20 minutes. 

 I was hesitant to use this as I have been told I don't have a fracture as such and was wondering how much good it will actually do for a "stress reaction" to the sesamoid.  I hope it helps rather then causes a negative reaction.  Do you think these devices help with soft tissue/ligament and tendons? What about 1st MTP swelling?  

Dr Blake's comment: I love this device for building bone strength. A bruised bone would be helped as would a broken bone. For the soft tissue, due regular PT, icing massage, spica taping to limit the motion of the FHL and FHB, and contrast bathing daily for the swelling. 

The 1st MTP is still swollen (6 weeks post synovectomy) and range of motion it limited, although it improving as I'm doing some light rehab like picking up pegs and just ROM exercises.  I'm also doing some heat treatment like hot bath soaks, sauna then swimming pool.  I still haven't had a proper answer from the doctors I have been consulting here as to why I had such a negative reaction to the cortisone injection into the 1st MTP.  I think it was administered incorrectly and have not doubt it set my recovery back significantly.  At the time, the doctor commented - "oh that's good, I got more in than usual there."  I was told he got about 1.5mls into the joint capsule, which from what I can gather was too much.  Also, if there was any bruising of the articular cartilage it can really respond badly.  Would articular bruising show on an MRI?

Dr Blake's comment: Yes, articular bruising shows on MRI. Typically, when my cortisone shots irritate things, for whatever reason, it is 2-4 weeks before we are back to square one. And, in those cases, you never get any benefit from the cortisone, which I do not understand why.

Regarding the orthodics, these have been fitted by one of the best here in Brisbane.  He is the podiatrist for our professional sporting teams, although he didn't employ casts for my high arches.  Techniques include heal cups, posts from 2 to 5, dancers pad and arch support.  I have attached pictures of my inserts for reference.

Dr Blake's comment: Do they or do they not take pressure as you walk off the sesamoid? If not, modify!!!!

I have also contacted the radiologists who took the MRI's.  They are able to set up a web site for you so you can view the images online.  For this option I need to provide them with the following - name, location, provider number, specialty etc). We would then create an account for this doctor so he can log on.  If this doesn't work I can arrange to have the pictures sent via email, although these would be still images.  Would you mind providing the details so I can have QSCAN set up an account on our end?  I will also get copies of the MRI reports to emailed across to you.

Dr Blake's comment: Great, will do in the original email.

I continue to ice each night for 20 minutes which helps.  I have also just started (this last week) getting out of the boot more and back into my trainers with orthodics around the house.  I have also been taking silica as it's supposed to help with connective tissue strengthening (i.e. ligaments and tendons).  I am also taking glucosamine, fish oil, Vit D and calcium supps, in addition to a multi.  I eat a very good diet so I don't think there is anything more I could be doing nutritionally to aid in recovery.

I am seeing my surgeon on Monday (tomorrow) for another post op review and I will request another MRI to see how things are progressing and will keep you posted.

I am happy for you to repost this email on your blog.  Feel free to modify/amend parts as you see necessary.

Thanks again,

Plantar Fasciitis: A.R.T. and Graston to help move out the stubborn scar tissue

For any one that has suffered from plantar fasciitis, there are two important manual techniques that can really help. These techniques are A.R.T.(Active Release Technique) and Graston. These 2 short videos adequately demonstrate the techniques. Most Chiropractors and some PTs are certified in these techniques. So, if the going is slow, consider these techniques, designed to break down chronic scar tissue, as possible help for your sore feet.

Hallux Limitus: Email Advice

Hi Dr. Blake,

I discovered your web site a few weeks ago and have found it very informative and helpful.

I have had hallux limitus in my left toe for about 6 years and have tried many things to manage it.  These include NSAIDS, steroid injections,

orthotics (OTC such as Superfeet and Sorbothane as well as custom orthotics), carbon plates, stiff shoes.  In the past year or so, I've noted that

stiff-soled shoes don't seem to help as much.  My podiatrist suggested shoes such as Sketchers Shape Ups or MBT--I've tried these but they

seem to rock in the wrong place (still get painful movement in my toe).  On top of this, I'm having pain at the base of my other toes on both feet

(possibly Morton's neuromas?).

I have tried some of the suggestions on your web site with varying degrees of success.  Icing the joint sometimes helps, but at times increases the pain. 

The joint mobilization does help for short periods.  I have tried the spica taping too, but don't think I'm doing it correctly or else I can't limit the motion of the

toe enough.  I bought Yogatoes and find them beneficial.  I use either iboprofen or naproxen for pain when needed.

I would appreciate your input on next steps in managing my condition.  I've been told my surgical option is fusion, and I'm trying to put that off as long as possible

(I'm 53).  I have wondered if things like the dancers' pad you mention may be helpful or if there are other orthotic/shoe options I could discuss with my

podiatrist and perdorthist (I'm in Atlanta, GA area).  With shoes, I'm wondering if I should try a max motion control shoe like the Brooks Beast.  I'm neutral to slightly

overpronating with a moderate arch, but do have a prominent callous on the inside edge of my left toe.  I ask because early in my treatment, I had a perdorthist who put me

in the Brooks Addiction--this helped, but I realized over time I was walking on the outside edges of my feet and thought it may be doing more harm than good.

Thanks so much for your time.

Dr Blake's comment: 

     I agree with your fighting spirit, since undergoing a unreversable fusion seems too much. Glad you have found some things to help. Perhaps we can arrange that  you send your MRI, so I can see that if surgery is needed, perhaps cheilectomy or joint implant should be considered. These are not permanent, and can get you many years of a more comfortable joint if you are a candidate. Let me know what the dorsiflexion range of motion you have in this joint compared to the other foot. Since the same person measures it, the difference is almost as important as the overal amount. It is important to continue to perfect each technique. Try 3M Nexcare Waterproof tape for more support while spica taping. Definitely start using dancer's pads (get a roll of 1/8th inch adhesive felt from Moore Medical) in all your shoes. If you have stable orthotics, they can be added to the orthotic devices. Definitely ice for 10 minutes 3 times a day the top of the joint. Definitely go to the Brooks Beast for stability. In a month, let me know if this is helping. You can simply add a comment to this post. I hope it helps. Rich

Plantar Plate Tear of the 2nd MTP: Email Advice

Hi Dr Blake,

I'm desperate for advice.

 I'm 17 wks pregnant and after 10 mos of misdiagnosis and on/off pain, I was informally diagnosed with plantar plate tear of 2nd MT.

 My MD said since the pain has been present for 10 mos, the likelihood of it healing on its own is slim.  The joint is more lax dorsally than the uninvolved side and I have a mild hammer toe deformity. I started wearing a walking boot a week ago, and it provides almost complete pain relief.

 I am a physical therapist. Really want to avoid surgery. Does this sound like it could repair itself? Does it sound like a grade 2 or 3 tear?  Will have to wait to get MRI until after pregnancy. Thank you!

Alice (name changed)

Dr Blake's comment: 

     Sorry for your problem, and congratulations on the pregnancy. I have 2 wonderful unbelievable boys, and can not image life without them. You have a wonderful journey ahead. They will grow, but you also. 

     Only an MRI will tell us grade 2 or 3, with grade 3 being a complete tear of the plantar plate. Unfortunately, due to your pregnancy, you must wait. The walking boot is now your gold standard. It has proven you can produce a pain free environment for healing. You must use it on and off for 3 months, unless you can find a shoe that gives you just as much pain relief. Consider looking into hike and bike cycling shoes with rigid soles, or hiking boots, or getting a Bock carbon graphite shoe insole and see if it works in your athletic shoes. But, whatever you are walking in, we must create a pain free environment over the next 3 months to try to create a great healing environment. During that time, you ice pack the area from the bottom 3 times a day for 15-20 minutes. This daily program reduces the inflammation, both the acute (daily), and the chronic (built up over the last 10 months). Begin to experiment with Budin splints to get the right tension and decide if you put over the 2nd toe only or both the second and third toes. Sometimes, I will use the double Budin splint and place over the 2nd and 4th toes with the two loops. You will be wearing the Budin splint while you strengthen the area for 2 years. Some of my patients run marathons in these splints. 

     As the pain calms down, and you get into more normal shoes, if the Budin splint is not enough protection, then you need to experiment with Hapad Longitudinal Medial Arch Pads. 

The most important thing to do right now, and for the next 3-4 years is daily Metatarsal Doming Exercises. This will strengthen the bottom muscles probably 3 times more than they were, but it is important not to curl the toes. It can take the next 1-2 months just developing the ability to keep the toes straight before you actually dome. 

     Good luck and congratulations. Rich

Back and Foot Correction: Email Correspondance

This is an email from a patient whom has done well with her orthotic devices to stabilize her lower extremity, but now seem to be having problems. 

I have recently had an odd thing happen with my feet/orthotics. Over the last several months I have had increasing problems with my right hip/ITB. Rolling on the styrofoam roller helps but won't get rid of it. Used trigger point therapy in upper quads; that helped  but didn't get rid of it. Ended up with very sore muscle around fascea lata (sp?). Then hip itself got sore. Found that if I went barefoot, it went away. Did that (as much as I could) for a few days. Noticed that my left achilles was very tight and sore...maybe got stretched too much going flat-footed?

Of course I had to wear shoes but did better wearing the sandals, without orthotics.

A couple days ago, my lower back started to hurt so I tried to wear orthotics more.  In my work, I am on my feet for up to two hours at a time; sometimes it's only once a day but other days I do it a couple times, but with breaks in between. Yesterday, I hit a wall. My hips were so sore and then my left medial gastroc muscle started spasming. It  also seemed to come from the crease in my knee in the back. This feels a lot like what happened initially (which included my popliteus muscle), many years ago in my right leg, that lead to my plantar fasciitis. Which my orthotics seemed to cure.

Problem now is that if I wear any shoes at all, it is painful/difficult to walk using the affected leg, left one. Orthotics in tennis shoes of course are worse than wearing my sandals which have fairly good arch support but less than orthotics. But even the sandals make that muscle cramp. 

I am taking it easy, both with my back and my feet....using ice and naproxen.

The only other thing I had been doing differently just before this calf muscle event was trying to stay aware of not locking my knees. I thought I had licked this one years ago but last week a Pilates coach said I was still doing it. So I have been trying to keep knees slightly bent when I think of it.

I remember once you told me that my feet sometimes hurt, (it feels like the arch in my orthotic seems too high) because my back is shifting and there is something wrong up there, rather than my feet being the cause of that kind of pain.

I am wondering if you have any insights as to why I might be currently experiencing this increase of pain in my calf when I use any kind of arch support? 

Thanks

Hey Tina, sorry for your dilemma. One possible cause is that a branch of the sciatic nerve, coming off your back, going behind the knee into the calf, and finally the arch is irritated. You may have been slightly irritating with the knee hyperextension, and perhaps you have a slightly bulging disc.When these nerves hurt, it is hard to wear arch support which presses into them. I would see a physiatrist, like Dr Irene Minkowsky, to look at the whole neurological chain from spine to toes and see if there is a simple place to start treatment. I hope this helps. Rich

Hallux Rigidus: Email Advice

Dear Dr. Blake,  How very kind of you to give of your time and knowledge on your blog and actually answer all of us poor folk!

I will be brief.  I crushed my foot June, this year.  5 bones have healed, but I am not quite weight bearing yet, due to the trauma to nerves, tissue.  No bones were broken in my big toe but it is stiff even after several weeks of physical therapy.  My surgeon says it is HR and showed me a bone spur on top in x-ray which is, he says, the cause of the lack of motion.  The joint looks OK.  I have read that these spurs can result from trauma which it must have because I had full use of my toe before the accident.  The Dr. wants to remove the spur and some of the bone beneath it to give room for the toe to bend up.  If he sees that the joint is not in fact good when he does the surgery he would then do a joint replacement. 
1.   Is that the only way to remove this spur?  Is this a reasonable solution?

Dr Blake's comment: From trauma to surgery, this is too fast a progression. I would wait one year minimum before entertaining a surgical approach, unless the pain was out of control, and/or you have more information for me other then a bone spur and stiffness. Have the physical therapist continue to work on it pain free. Start doing the joint mob on the video below twice daily. Let me know how painful the joint is, and we can discuss spica taping, orthotics, shoe selection, Flector patches, PT modalities, topical meds, injections, dancer's pads, etc. 

2.  I will ask the Dr. and PT, but would like your opinion.  Am I making the spur worse working at increasing the motion with physical therapy, forcing the toe to bend more?  

Dr Blake's comment: Yes, gradually increase ROM pain free. If there was just scar tissue, PTs are wonderful at pushing through pain to achieve better motion. But spurs imply subtle cartilage damage, and need a more gentle approach. In this scenario, I never recommend pushing through pain (although I am sure that there are skilled practitioners who can do it). 

3.  Is there more a podiatrist can do for me? 

Dr Blake's comment: See my comments above on taping etc. The best you can do is gently get the joint moving, while creating more and more activity painlessly which will stretch out the soft tissue. Gradually advance your activity from walking to running etc. As you attempt more activity, treatment options come up from your podiatrist, PT, etc as you try to do the activity and not produce a pain response over level 2 on the pain scale. You are advancing from the Immobilization Phase of Rehabilitation, through the ReStrengthening Phase, into the Return To Activity Phase, and this all takes good individualized thoughts to help you through. I sure hope this helps you. Rich

Thank you,  Jill (name changed)

Coalition: Painful Problem poses Difficult Decisions

Dear Dr Blake

I have a calcaneo-navicular coalition that has caused me pain over the past 6 months. I am 32 years old, and up until 6 months ago have never had an issue with my feet, despite being an avid gymnast, and then runner. I used to do upwards of 50 kms per week.

Since March 2013 I have stopped running – there was one day where I was walking around barefoot all day, without my orthotics/supportive shoes  (I have had orthotics all my life). Woke up the next day and was in pain.   Since March I have had pain when walking. 

I had an MRI and bone scan, and they revealed there is a coalition with some irritation of the bone at the site of the coalition. I had a cortisone shot nearly 2 weeks ago and it has taken away a significant chunk of the pain but I can still feel the stiffness. 

Thank you for your blog –I am currently icing my foot now after reading it. 

My question is – I would be happy to take another 6 weeks off running if I had a 2^nd shot – just to put this whole thing to bed.  Do you think that is a good option?

The other option according to my surgeon is resecting the coalition but he thought the cortisone would work.

Thank you

Dr Blake's comments:

     Thank you so very much for the email. I think you are doing well, and would limit the cortisone shots as much as possible. If you need them to avoid surgery, go for it. You would do another cortisone shot to reduce to the pain to between 0-2, and this has already been done. There is no reason to do more now. There is no reason to consider surgery either, for this may be an isolated incident. Typically, orthotic devices do well for CN Coalitions, so I would see how the next 6 months to a year goes. I like my patients to be able handle reflares when they occur. If this area flares in 2 or 3 months, you will be very discouraged, if you do not have a plan to reduce the pain quickly. Typically this means removable boot, icing, taping, activity modification and NSAIDs. Do you have all this? Do you know how to do a great low dye? You need to be a great foot taper!! See the videos below. I hope this helps. Please give me some followup. Rich

Ankle Pain Unknown Diagnosis: Email Correspondance

Dr. Blake,

Over 2 months ago I started experiencing some pain in my left ankle after yoga. Got it checked out. I was told tendonitis/sprain. I did RICE for 4 weeks. Then put it in a boot for 2 weeks. But it still didn't heal.

About a week ago, a new doctor told me I have posterior tibial tendon insufficiency. My pain is also in the surrounding areas, on both sides of my ankle. She told me to get some shoes (I used to wear flip flops 99% of the time) and I also got an orthodic inside (New Balance). 

http://www.drblakeshealingsole.com/search/label/Posterior%20Tibial%20Dysfunction

I'm 23 years old, relatively healthy and fit, and haven't been able to workout in over 2+ months. Now, after doing the smallest things (i.e. driving, stairs, etc) my ankles start hurting. Both my left and right hurt now.

I am confused and frustrated, and don't know where to turn next. I've seen 3 doctors and the pain still isn't gone. Can you give me some advice? I'm happy to return the favor in anyway I can, please help me, this has me really down, please e-mail me back.

Thanks,

Dr Blake's comment: 

    First of all, you need to verify the diagnosis. MRI is a useful tool to help in that direction. I am hopeful you just bruised the back of the ankle, or something else minor, that may take time but will heal completely. Without the MRI, there are too many possibilities to give this much further direction. You are still in Phase I of Rehabilitation without a solid diagnosis. Phase I is the Immobilization/Anti-Inflammatory stage. Use ice twice daily around your ankle for 15 minutes and do one formal contrast bath every evening. Place yourself back in the boot, you may need a lot for the next 3 months, for any situation that produces over level 2 pain. Remember to create a pain free environment as best you can keeping the pain between levels 0-2. Read my blog post on Good vs Bad Pain and memorize. I hope this helps. Rich

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html