Inverted Orthotic Technique: Email Advice

Hi Dr. Blake! 

     I am a Certified Pedorthist out of Fort Worth, Texas. I have the opportunity to 
speak to resident podiatrists/physical therapists regarding foot orthotics. I am 

writing to inqure about how I can present your technique for the inverted orthotics. 
What I am in the dark about is who qualifies for these orthoses?

Dr Blake's comment: Thank you so very much for inquiring. Most podiatrists will use it when their initial orthotic device does not bring about the symptom relief and the pronation control combined. When the patient is still pronating on the device originally made, the Inverted Technique may help. Typically, most orthotics designed set the heel vertical to slightly (1-2 degrees) inverted. A standard 25 degree Inverted Correction gives the heel about 5 degrees of correction, thus over 150-200% more support. Someone like you, and the students you teach, will begin to see patients that need the technique right from the get-go. Many patients with moderate to severe pronation are started at 35 degrees, equivalent to a 7 degree inversion correction. Runners, who typically needed 5 degrees correction (25 degree cant) in their stability shoes, now need 35 degrees cant in their neutral/transition/minimalist shoes since the shoes give less support for pronation. However, pronation control is not the only reason to use the Inverted Technique. The varus positioning you get with the Inverted Technique helps many patients with frontal plane problems like Tibial Varum and Genu Valgum. 

 What conditions are indicated and which are contraindications? 
     I understand the simple rigid vs. flexible deformity, but which diagnoses have you come 
across that can benefit from this, apart from PTTD, unless that's the only one? 

Dr Blake's comment: It is really an understanding of pain syndromes that lead you to know about what matches up. When you watch someone walk, you typically can tell if their pronation is mild, moderate, or severe. The Inverted Technique, which ranges from 15 degree cant to 50 degree canting with medial column corrections and medial Kirby Skives, is for the moderate to severe pronators. And these pronators get into problems in many ways affecting the weakest link in the chain. What problems are related to pronation that I treat (you may ask?!! LOL)?

1. Bunions are increased with over pronation
2. Hallux Limitus/Rigidus pain is increased with over pronation
3. Morton's Neuromas symptoms are worse with pronation
4. Arch Strain is worse with over pronation
5. Lisfranc's pain is worse with over pronation
6. Cuboid pain, and instability, is worse with over pronation
7. Anterior Tibial tendinitis, and shin splints, are worse with over pronation
8. Plantar Fasciitis is worse with over pronation
9. Lateral ankle and subtalar joint (sinus tarsi syndrome) impringement syndromes are worse with over pronation
10. Achilles Tendinitis and Hamstring strains are worse with over pronation
11. Tibial Stress Syndrome and Fibular Stress Fractures are sometimes related to over pronation
12. Iliotibial Band Syndrome is sometimes related to over pronation
13. Lateral Knee Compartment pain is sometimes related to over pronation
14. Chondromalacia Patellae is sometimes related to over pronation
15. Piriformis Syndrome and Ilio psoas strain can be related to over pronation
16. Some cases of Low Back Pain are related to overpronation

The contra-indications to this technique are two fold. Most patients do not need it, because they have mild pronation, or are supinators, or poor shock absorbers, or their symptoms are related to limb length discrepancies. But, secondly, a contra-indication has to be the ability for the lab to design it properly. I have reviewed at least 10 labs, and most can learn, or do it well. But some, just do not get it. They typically make a painful over-exaggerated arch which hurts. When done correctly, the Inverted Technique, which emphasized heel correction over arch correction, is very comfortable. 

Also, is there a chart maybe that could show the different correction angles compared to the 
eversion angles that you find or is it all the 5 to 1 rule?
Dr Blake's comment: If you understand the eversion angles, and your measurement of 0-3 degrees everted is mild pronation in gait, 4-7 degrees everted is moderate pronation in gait, and over 7 degrees severe pronation in gait, we probably measure the same and the 5 to 1 is appropriate. I will try to do a series of videos on it soon explaining the various anti-pronation cast corrections.  

You can see all the cast corrections for the over pronators

     Is there a rule about the arch height change other than to make sure it begins to make its descent distal to the 

medial cuneiform for the first ray drop? That is, do you increase the arch or measure it pre-modification and add to/take away from any of that height? 
Dr Blake's comment: I am attaching a couple of posts on arch height. The arch height gradually gets bigger with increasing inversions, or adding a medial column correction, but a 15 degree inverted cast probably has the same arch height as a Root Balanced with minimal arch fill. You will see in my cast corrections video over the next couple of weeks how the arch gets higher. I will try to do that video for you first. You hit the nail on the head perfectly by saying that the most important thing is to make sure the maximal arch height is at the medial cuneiform to insure first metatarsal plantar flexion in propulsion. 

http://www.drblakeshealingsole.com/2010/09/inverted-orthotic-technique-determining.html


If there is a clear/ to the point document that I could show them, that would be great. Otherwise, I'll direct 
them to your blog. By the way, I am becoming a fan of the technique as I just recently had 
a patient with severe PTTD who has not been comfortable in anything (Richie style, Arizona 
gauntlets, UCBLs etc.). I made him some orthotics using your technique, along with the 
use of work boots to give extra stability, and he loves them!  Sorry for so many questions, 
but I was so excited from seeing the outcomes in that patient that I want to spread the word 
about this in an accurate/appropriate way. 
Thank you sir! 
Dr Blake's comment: I am just ecstatic it helped. Most of the readers will not know how uncomfortable, or just big, these other devices are. Being able to take a patient that most who put in a AFO, Arizona Gauntlet or UCBL, and make an Inverted Orthotic device work, is a wonderful gift to that patient. The Inverted technique also allows the most normal function of all those techniques, thus the best chance for good strength to be re-established. 

Posterior Tibial Tendinitis with Accessory Navicular: Email Advice

Dear Dr. Blake,

     I have been following your site for a few months now and I am blown away by your kindness and generosity in answering the questions of strangers. It is an amazing blessing that you are giving to others and the sense of hope I have received from some of your entries is enormous.  I also read that you recently lost some people who are close to you and I wanted you to know that I'll be keeping you and your family in my prayers.  I was touched by the video you posted on June 1st and will certainly forward it to others.

Although I'm in Boston and can't come to CA to see you, I would be happy to pay you for email advice, so just let me know what your policy is. I would also be happy to send payment along with copies of x-rays, MRIs, etc. if you think it is necessary. I spent a few days writing and editing this to keep it concise and "calm" so I don't come off as a crazy patient! Although we distance runners ARE a bit crazy :) 

Dr Blake's comment: I can not thank you enough for your kind words. I have never charged for this service, but hope it is worth more than what you pay. I have to deal with crazy runners all the time, and because I am a crazy basketball player/athlete, we tend to get along just fine. I am needing time to review another patient's scans that she sent (sorry Sue, but I am slowly getting to yours), so I may not be able to review for a while. You can definitely send.  

     I am a 26 year old female runner - I absolutely love running half and full marathons, and this fall ran a full marathon that made my dream come true- qualifying for the 2015 Boston marathon. I have had no foot pain in my past 10 years of running about 35-40 miles a week, every week, except for some mild pain when I was about 16  which led me to get custom orthotics (they have been great for over a decade with zero signs of pain! BUT I've been wearing the same running orthotics for over a decade). Through my career I've had some minor problems that always resolved quickly with PT and cross-training (knee, hip), but never anything in my foot. I did once have a really bad sprain in my right ankle (not my currently affected side) that took over 6 months to heal. I do over-pronate and have somewhat low arches, but I'm certainly not flat-footed. I am petite at 5'2" and 103 lbs. (so I don't think I have much extra mass that is causing problems). 

     Mid-April while training for another marathon, I started getting some tightness/soreness in my left inner arch. I did a lot of icing, took days off of running here and there, but continued to train. I successfully ran my 20 mile training run on April 18th with some tightness, but not really pain. On April 25th, I took a short 4 miler and had a moment of sharp pain near my navicular, and limped the last 1/4 mile home. I put myself on a running hiatus for a full week. On the 8th day, I decided to "test" running again to determine if I needed to call off the marathon and cancel my travel and hotel. I successfully ran 10 miles with zero pain. However, that night my foot was stiff and sore.  Since then, I have not run a single mile - 40 days so far. Obviously I chose to sit out the marathon.  I wanted to be very cautious and not make my recovery any longer than it needed to be which is why I stopped running completely.

     The pain in mid April- early May was initially  at the accessory navicular, although I didn't know what that was at the time. I could produce pain when I pressed anywhere on it, with stiffness more generally around the arch. Further down in the email I'll give an update on where the pain is now. At no point did I have severe pain - I don't think it ever went beyond a 3 on the 1-10 scale. 

      I have iced in an ice bucket 2-3 times a day all 40 of those days that I have not run, and I have been cross-training with zero pain (bike, elliptical, etc.). Like many athletes,  I tend to run through A LOT of pain (including a stress fracture once!), but something in my heart and mind told me to STOP when it came to this particular injury. My heart is broken without running, although I'm trying to keep it in perspective. Lots of prayer!!  It has been emotional but I am grateful that I can at least cross-train but I'm living in fear of "will this ever heal?"

     I am a researcher by training, so of course I got onto PubMed and downloaded every medical journal article I could find. I diagnosed myself (haha) with an accessory navicular and posterior tibial tendonitis. 

     I saw a general sports doctor at Prominent Boston Hospital #1 in early May (omitting name out of respect for the doctor/hospital) who was largely dismissive of my injury and seemed totally un-sympathetic, but he told me my self-diagnosis was totally correct after looking at the x-rays (PTT and accessory navicular). He tested my feet and said my foot muscles were super weak so PT would be helpful. I had to basically get on my knees to BEG him for an MRI, because I knew I couldn't sleep until I got it. I had been making myself sick with worry.  He was frustrated with me but finally prescribed one (I was in tears at that point).

     I then saw a foot and ankle surgeon at Prominent Boston Hospital #2 yesterday, June 4th, 2014, who was kind, sympathetic, and seemed encouraging. He thought that it might be time for new orthotics since I've run in mine for so long, and having ones with a medial post would help with my overpronation, rather than only supporting the arch with a wedge. He prescribed PT and said we could meet again in 6 weeks to see how things were and re-evaluate if surgery is really necessary. The idea of surgery plus 6-8+ weeks in a cast, plus all that rehab, totally terrifies me, especially given that I'm not in severe pain.

Dr Blake's comment: The chance of you needing surgery is probably 2%. 

     At the same time, I so desperately want to be a "real athlete" again, and if the surgery afforded me that, I would do it. He definitely had limited experience with patients with this problem (he was in his fellowship in foot/ankle surgery, but I found him to be patient, understanding, and deeply caring) but his supervising surgeon had plenty and he would talk to him about it. He looked at my MRI and x-ray and said he didn't see much that was concerning, except for a tiny bit of fluid around the PTT. He was expecting to see much more irritation around the accessory navicular, but it didn't look bad at all.

Dr Blake's comment: This is a good sign. When the accessory navicular is a problem, there is more fluid around and/or in it. Hopefully, you have posterior tibial tendinitis mainly. 

     When I got home yesterday evening, my MRI report was finally in my mailbox- would have been helpful if I had it before I saw the surgeon! Maybe I'm reading into it too much, but the report from the radiologist seemed worse than what the surgeon told me today (he didn't think things looked too bad).

Imaging results: X-rays of foot and ankle showed accessory navicular. MRI report for the ankle said:

1. 11 mm multiloculated ganglion cyst between the spring ligament and talus

2. Mild tenosynovitis along mid to distal aspect of posterior tibialis tendon, with mild tenodonitis at its insertion on a type 2 os naviculare

3.  Mild degenerative changes along the articulation between the os naviculare and navicular bone

Dr Blake's comment: This mainly shows tendinitis. The treatment of tendinitis is very conservative--PT, orthotic devices, anti-inflammatory, taping, and strengthening. The ganglion cyst and degenerative changes make this interesting. 

     Other text on the report on foot and ankle: "normal alignment, joint spaces are preserved, no fracture is appreciated. The anterior ankle tendons are intact with normal signal intensity. Mild tenosynovitis along the mid to distal aspect of the posterior tibialis tendon. The tendon is normal in morphology and signal intensity, except at its attachment to a type 2 os navicularis where there is mild tendonosis. Normal fat signal seen within the sinus tarsi. The anterior and posterior talofibular ligaments are in tact. The anterior talofibular, posterior talofibular, and calcaneofibular ligaments are in tact, the deltoid ligament is intact. Deep to the spring ligament and overlying the talus there is a multiloculated ganglion that measures up to 11 X 6 mm in the axial plane. The subtalar joint is unremarkable. The articular cartilage throughout the midfoot is intact. The marrow signal is normal. There is no talar dome osteochondral defect. There is no acute dislocation, marrow edema, erosion, or cortical thickening. The flexor and extensor tendons about the foot are  intact, with normal signal intesity. No intermetatarsal bursitis is appreciated. No significant subcutaneous edema."

Dr Blake's comment: No significant change here. The ganglion is interesting if it is involved with your pain. 

     I'm thinking I might mail this report to the surgeon I saw yesterday so he can review it with the supervising physician (chief of foot and ankle surgery at the biggest Boston hospital) before my follow-up in 6 weeks. He reviewed the MRI and said nothing about the ganglion cyst, which I am in a complete panic attack about. I don't even know what this cyst is, but I assume it is horrible, terrible news. I'm avoiding googling it out of fear. 

Dr Blake's comment: Ganglion cysts arise from herniations of the ligaments from a joint. Sometimes they need to be removed. We always try injecting them and draining if possible. Some of them cause pain, most do not. 

     My pain these days: At no point since the initial onset of pain, up to today, have I been in incredible pain, thank God. I almost feel embarrassed that this has caused me so much distress, but I've been in very little pain this entire time. I can walk to and from work (about a mile each way), go about my daily activities, etc. with little or no pain. Cross training has been fine- no pain or stiffness during or after whatsoever.  The reason I have not run a single mile in 40 days is primarily because when I wake up in the morning, I have pain/stiffness in my foot for a few minutes. As an athlete, I take this as my body's message of "something is damaged," so I don't want to risk it. The  surgeon I saw yesterday said I could try some light running (but I refuse out of fear until I get my new orthotics). 

Dr Blake's comment: You are showing great wisdom at your young age. Definitely, this is an arch problem, and perfecting the orthotics first makes sense. Learn how to do some version of arch taping. I have the kinesio version and the low dye versions on my blog. These should be done with the orthotics for several months until your running is back up to normal. 

     The pain/stiffness upon waking is sort of difficult to localize and feels "deep" in my foot, but generally in the area of the navicular. Sometimes when I am sitting at my desk at work or get up after sitting for a while, there will be some stiffness in the arch, and there is often tenderness in the area of the PTT near the ankle  but more of an annoyance, not serious pain. As I mentioned, originally (in April/early May) I could produce pain on the accessory navicular when pressing it. Now, it is quite difficult for me to produce pain on the accessory navicular, and it almost never hurts. But the mild PTT tenderness, and particularly the tightness/pain in my arch upon waking, makes me worry. I am quite sure that if I went running, I'd spend the evening with a very stiff and sore foot. Right now, I mainly am limping during my first 3 or so  minutes out of bed, plus occasionally rubbing/flexing my foot during the day to test for stiffness/soreness. I'd say my pain on waking up in the morning is about a 3, the rest of the day I'm at a 0 or 1. Given this relatively low level of pain, it seems crazy to risk going through a major surgery. Honestly, if I were not a runner, I probably would not have even seen a doctor for this. But as an athlete, it consumes most of my thoughts, and makes me lose sleep! 

Dr Blake's comment: I have seen too many surgeries by great docs go wrong to say something but any thought of surgery  (if needed) should be 2 years from now. This means you do everything possible to avoid surgery. Again, the ganglion is a little unusual, and could be removed with minimal problem if we could prove it was your problem. Ganglion cyst are injected with cortisone all the time, but if placed too close to the posterior tibial tendon, could cause a rupture. If these things were easy a monkey could design a treatment plan. 

     I am scheduled to get casted for new Orthotics (the first appointment I could get for casting the orthotics is July 14, ugh!) and I will have my first PT session on June 16th (also the soonest I could get in).

So my question is... in your experience, do you really think there is a possibility of ridding myself of my PTT/accessory navicular pain with continuing rest, ice, and PT, even if 40 days off of running hasn't healed it?

Dr Blake's comment: Yes, orthotics with more support, a great strengthening program, icing, taping, activity modification, gradually increase running every other day with new orthotics (the new orthos should be more supportive and comfortable in the area of the accessory navicular), should all help. 

     Do tendons just sometimes take this long to heal? My concern is that if my accessory navicular is causing my PTT pain, how will I ever resolve it if I don't get the accessory navicular OUT of my foot? I guess I need to hear that other athletes out there in the world struggled with this for MONTHS but eventually returned to sport without surgery but plenty of PT and patience. The other part of me thinks "I had this bone for 26 years with NO pain, so what's to say I can't go back to being pain-free even if the bone is still in my foot?"  I dread a lifetime of just wondering when I'll need to have major surgery on this, and long for the days just a couple of months ago when I could easily run 40 miles a week, wear flip flops, go hiking, etc., without giving a single though to my feet. It seems like this came out of nowhere. I have been a serious runner for so long, with basically no change in what I was doing.  Do you think this very surprising finding of the ganglion cyst is related (a cause or a result?) of the navicular/PTT issues? Am I totally doomed?

Dr Blake's comment: 3% of the population have accessory naviculars. Our sports clinic which is geared more towards rehabilitation, does one of these removals every 2-3 years. Probably on 1% of the patients presenting like you. So, I feel comfortable that your chance of needing surgery for the accessory navicular over the next 40 years, with high level sports is probably around 2% at most. That being said, the ganglion cyst is more likely a cause of problems and needs long discussions with your docs. We really do not know where you are, so after you get the new orthos, and after you need that they give great support, along with taping, begin running every day with your foot taped, while you start PT. It sounds like it will take until September to get a great feel of where you are going with this. Keep me in the loop. 

     Second, is it bad that I'm still doing the ice baths, 40 days later? Should I also be doing heat baths of some sort on it? I just want to make sure there isn't the possibility that I'm over-icing, if that is a thing!

Dr Blake's comment: Definitely I would have you ice pack 10 minutes only 2 times a day, especially after exercise, and do one session of contrast bathing each evening. 

     Third, although I'm sure the Physical Therapist I'm going to see will be fine (I live in Boston with good access to medical professionals), my assumption is that PTT and accessory navicular issues are rare. I doubt they will know much about a ganglion cyst in the spring ligament.  Is there any information I should bring him/her about which specific areas I need to be strengthening? I don't want to make it worse with PT! Are there additional types of therapy, massage, medication I should be trying?

Dr Blake's comment: The ganglion is something for you and your doc to work on, and to decide if it is related to your pain. There is nothing that the PT does for this. The PT should painlessly strengthening the posterior tibial tendon in particular, the rest of your foot and ankle tendons in general, and work on your core strength, cardio, cross training. They will also do anti-inflammatory modalities. Definitely run while you have PT to get an honest feel of how you are doing no matter what they say to do. 

     I am totally dedicated to staying away from running as long as I need to in order to get through this without surgery (though praying I will be able to run the Boston Marathon in 10.5 months!) but you can be honest with me if you think surgery is going to be the only true option to "fix" me.

Dr Blake's comment: It is actually unfortunate that you have any running goals ahead of you. They sometimes get in the way to common sense. I am hopeful with the taping, PT, new orthotics, and return to running goes smoothly. We will see if there are any glitches over the next few months. Keep me in the loop. Rich

     The one blessing in this is that it has helped me re-evaluate my focus on faith, family, friends instead of just running, and it has encouraged me to cross-train and strength-train more (which I almost never did). I am an obedient PT patient and will follow my PT orders religiously. I want to come out of this healthy and strong, able to enjoy my feet and where they take me well into my nineties.

Thank you SO much for your kindness, I am praying for hope and perspective on this since it has been very tough to keep the tears back during the past 40 days.

Sybil (name changed)

Boston, MA - Age 26

Nerve Pain: What to do next?

Hey Dr. Blake, 

I keep up with your blog and I'm so sorry for your recent losses. Hope you are ok. I'm having trouble with my foot again and wanted to ask your advice, if you are up to it. If not, I understand. In case you ARE up to it, here's what's going on...

I can't get the pinched nerve (the Big X in the pics below) to calm down. I've had it padded a million ways (not sure I'm padding it properly either) and when I take the pads off and take a full step, it's zinging me just as strong as when it first started. I have been able to walk on the foot with the pads but I'm starting to get blisters and callouses on the side of my big toe from walking all weird from the padding and trying to avoid zinging myself by stepping on the pinched nerve. I did not and do not ice like you suggested (3x a day). I can but I don't because...I don't know why. Lazy, too busy, etc. So if that's what I need to do before anything else, I will make it happen. 

Thanks, 

Terry (name changed)

Dr Blake's response:

Hey Terry (you know who you are!! LOL),

     Thank you for the concern. I have been in a fog, but trying to help you and others does help get me centered. Thank you very much.

     First of all nerve pain/abnormal nerve sensations can forget to shut off even when you protect them for extended periods of time like you have. The old saying is that "if you look at a nerve funny it will hurt for 9 months" is fairly true. When treating nerves should be addressing 4 areas---mechanics (which you seem to have mastered), anti-inflammatory (and ice 3 times daily is the easiest), nerve hypersensitivity (oral meds, topical meds, neural flossing, injections), and diagnostics (MRI with contrast, Nerve Conduction tests, etc). 

Please email me back on what areas you have done and could do in each of these 4 areas. Rich

And the response:

Thanks for the response! Wow, I had no idea nerves could take so long to calm down. 

Mechanics - I think I am doing this right if that means not feeling the pinched nerve "activate" while I have the padding on. Most of the time I don't. This past week I feel it even with the padding on. For the last 3 weeks, I have been extra active and on my feet for much longer each day than normal. 

Anti-inflammatory - I am not doing any at all. So I can begin icing 3x per day. Any other ways?? 

Nerve hypersensitivity - not doing anything at all. What should I do?? 

Diagnostics -I never had the swelling or the level of pain for this nerve that I did for the original injury so I haven't done any new diagnostics. I just have the old MRI and X-rays that were done before this new pain started. I am not able to get a new MRI right now due to financial constraints and a super high deductible. 

Dr Blake's comments:

     Mechanics: So right now stay where you are at and avoid barefoot if that is irritating you. Some of my patients during flares will go into already tested removable boots or hike and bike shoes, or something that always works, and stay in it for a 2 week period.

     Anti-inflammatory: Definitely we need to see how 10 minute ice pack on the bottom of your foot works first 3 times a day. You can add 2 advil or 1 aleve occasionally. You can also massage into the area arnica or traumeel. 

     Nerve Hypersensitivity: Go online and purchase Neuro-Eze and massage into the area 3-4 times a day for one month. Also, look at the blog for the video on neural flossing  (aka neural gliding). Do that 3 times a day. 

     Diagnostics:Remind me what the old MRI showed since this is the best test. However, getting a neurological examination to look at the whole sciatic nerve (even the spine up to the neck) to have see if you are getting neural tension anywhere. Simply having a PT evaluate how you sit and lift, etc, to give you tips on posture and how to minimize the day to day stresses on the sciatic nerve can be helpful. 

     Please give me feedback. Thanks Rich

The patient's response:

Ok, thanks!! I will begin all of these suggestions ASAP. (I am icing as I type this!!) 

Here are the MRI results. The MRI was about 2 months before I started feeling this nerve pitch. Nothing particular happened that I am aware of that caused it. I was doing well and recovering from the original injury. But as you can see from the pics, this nerve pinching that's bothering me now seems to be right in a line up my foot from the original injury. 

MRI FINDINGS: Dorsally located subcutaneous nonspecific edema of the forefoot is noted. No stress fracture is currently noted. There are bursal effusions especially between the 2nd and 3rd, 3rd and 4th and to a lesser extent 4th and 5th metatarsal phalangeal joint. Subtle flexor tendon is noted third ray. These findings are compatible with bursitis, synovitis, and mild tenosynovitis without associated stress fracture. Phalangeal sesamoid ligaments appear unremarkable. 

IMPRESSION: 1. MULTIFOCAL BURSITIS, nonspecific soft tissue edema with no stress fracture noted. 

2. The Lis Franc ligament is intact. 

Dr Blake's response:

    All of the original MRI findings indicate inflammation, but does not rule out inflamed nerves (they can be hard to see, especially with the bursitis inflammation). If we get another MRI down the line, then the expensive one, the one with contrasts, should be done since it can give more information. Ask your doc about a 8 day Prednisone Burst to jump start the anti-inflammatory attack. Rich

Personal Reflection: God and me

In the last 2 months I lost 3 people very close to me. I have stared into the computer screen, but could not type for weeks on end. I was sent the below link from someone who believes in God as I do. Thank you Kenn. I have watched this and it brings me great peace. My sorrow seems a little less for now. You do not need to open if you do not want to, but it is one of the most beautiful videos about an interview with God. It made my sorrow softer. I pray it helps some of you. Rich

http://vimeo.com/8898059#at=0

Tips for Wearing High Heels to Minimize Problems

Here are some tips to create less problems for those of you that will be wearing high heels. 

http://www.idahostatejournal.com/vac/how_to/well-heeled-tips-for-picking-high-heels-that-are-better/article_8b8e6569-ce83-5aff-a7a2-5f063a31e450.html

Hallux Rigidus: Email Advice

Hi, I was diagnosed with hallux rigidus a year ago.

 I'm a 40 year old male that was fairly active doing things like running, triathlon, ultimate frisbee.  I've see 3 different doctors about my toe, all recommended surgery saying it was advanced, but I'm still on the fence. 

 At this point, I'm able to run 3 miles once a week with minimal pain the day after.  I'm using a morton's extensions and very stiff running shoes.  Besides the weekly run, I ride my bike.  I would really like to get back into ultimate frisbee but I'm pretty sure it's what caused the problem as it's much harder on my foot than running.  

 I'd like to come up with a plan on how to get back to playing ultimate frisbee, even it it means having surgery.   Should i just start playing and hope my joint self-fuses?  Or perhaps the hard answer is that my ultimate frisbee days are gone, if I want to still want to walk normally when I'm 70.  

 Any advice you could provide would be appreciated.  I live in the south bay and would be willing to drive up to see you, do you accept blue shield ppo?  Finally, I do have a soft copy of my xrays if you care to take a look.   Thank you

Regards,
Carl (name changed)

Dr Blake's response, 

     Thanx for the email Carl. Your ultimate frisbee days are over for now (hopefully temporarily), since it is just too hard to control the forces with all the cuts and uneven terrain. Typically, we get you comfortable at cycling first, then running, and then begin to introduce side to side stresses. The pain you have to avoid is the pain that comes on during a workout, that you ignore. And, any pain that begins to effect your gait can mess something else worse. Xrays are less important than MRIs and CT scans so I would progress your diagnostics to include these. Let us get a good 3D image of your big toe joint in 2014, and will be able to use these as baselines. Like any arthritic conditiion, you need to be icing for 10-15 minutes 3 times per day, no matter the workout, but especially as soon as you work out. This alone should enable you to do more. You need to learn spica taping and be great at it. This is for all your workouts. Most patients with Hallux Rigidus (less than 30 degrees of big toe joint dorsiflexion) feel better with dancer's pads, not Morton's Extensions so work on that. You will definitely need an orthotic to shift weight to the center of your foot and off the big toe joint. There are many times that athletes need a little different correction for cycling vs running vs ultimate frisbee so multiple pairs may be in order. Have someone measure the big toe joint, I have a video on that, to see exactly how much motion you have. It is hard, but typically doable to gain 20 degrees with anti-inflammatory, physical therapy, and self mobilization. So, if you are really 50 degrees (Hallux Limitus) not 30 degrees or less (Hallux Rigidus), that may help you. I hope this helps you some. Rich

Complex Regional Pain Syndrome: Email thoughts on possible/present treatments

This is an email I sent a patient, whom I just met, with 14 months of CRPS. The neural prolotherapy from Dr Lee Wolfer as described in my last post is helping greatly. She still has metatarsal pain so I am making soft Hannaford orthotics and sent her some of my other thoughts below. 

First of all Sally (name changed), it was a pleasure to meet you. Here are 2 links from my blog I would like you to see. 

http://www.drblakeshealingsole.com/2012/11/graded-motor-imagery-chronic-pain-tool.html

http://www.drblakeshealingsole.com/2012/09/complex-regional-pain-syndrome.html

My general thoughts for now and in the future:

1. Continue with the Wonderful Dr Wolfer and neural prolotherapy
2. See if Dr Wolfer will look into Calmare Pain Therapy
3. Consider adding low dose naltrexone 1-4.5mg/day
4. Have an Rx for sublingual Ketamine for flares if occur
5. Purchase Neuro-Eze and apply topically 3x/day
6. Get Hannaford orthotics for protected weight bearing
7. Continue Gabapentin/Cymbalta/Atavan for nerve stabilization
8. Start daily Graded Motor Imagery with laterality flashcards and Mirror therapy
9. Remember PT and exercise are crucial, PT you must start an exercise below pain level, and very gradually increase to restore lost function
10. May consider 50%DMSO cream (99.9% Pure) with other topicals
11. Vit C 500mg x 45 days or with flares
12. 30 min to 1 hour meditation per day
13. We await reading of the MRI CD
14. Consider sleeping with Lidoderm patches
15. Check Vit D3 level, make sure it is at 45-50
16. Consider Somatic Experiencing (decreases sympathetic response)
17. Consider gluten free diet, emphasize fresh whole foods, de-emphasize highly processed foods.
18. Do Neural Flossing 3 times per day
19. Increase Cardio--stat bike with weight on non painful area (like arch or heel). Exercise decreases glial inflammation. 

Hope this helps. Rich

Neural Prolotherapy: A potential help for chronic pain

Just saw a wonderful new patient who has a 14 month history of developing CRPS (aka RSD). This is a severe disabling nerve condition. She has had wonderful help from a Dr Lee Wolfer in San Francisco utilizing a new technique (to me) known as Neural Prolotherapy. The nerves exhibiting point tenderness to palpation are injected with small amounts of sugar water. I hope those suffering from chronic pain may be helped by reading this. 

http://drleewolfer.com/regenerative-injection-therapy-rit/neural-prolotherapy-npt/

Sesamoid Surgery: Email Advice

Hi Dr. Blake,
Four months ago I had a sesamoidectomy after 2 years after the onset of my pain.  My post surgery follow-ups were with the orthopedic's assistant who was pretty clueless about the recovery.  He ended up referring me to a physical therapist which has helped reduce the scar tissue and increase my big toe range and strength as well as helping me to stop walking on the outside of my foot as I had for 2 years. 

     But I am now at the end of therapy and I still have stubborn scar tissue which is somewhat tender to walk on. Also as soon as I began the therapy and strengthening and stretching the toe I began getting numbness and tingling in the toe.  It's pretty persistent, but the "toe curls" increase that sensation.  This may sound strange, but that nail seems to have slowed/stopped in its growth.

Dr Blake's comment: Surgery is an incredible event that your body must deal with. All bodies deal alittle differently, but overall the surgical area gets the majority of the blood supply for healing, some being shunted from other areas close by. The nail may be alittle poor on blood supply for a while, but should come back to life within the next year. 

    So I am curious to know what is "normal", how long these symptoms may last, if they may be permanent and what I might still do to promote recovery.   Thanks for any insight or experience you have in this area.  

Regards, Bill (name changed)

Dr Blake's response:

     Thank you so very much for the email Bill. You are on the surgical plateau from 3 months post surgery to 9 months post surgery. It can feel like nothing is happening. This is when you stop PT in general, and do your daily stretching, strengthening, scar mobilization with Blaine Surgical Scar Kit, Hallux Self mobilization (as described on my videos), anti-inflammatory measures like icing and contrast baths, and wear your protective shoe inserts. Continue to honor the pain, keeping between 0-2 pain level. The next big change will be between 9-12 months when scar tissue maturation occurs. You will see during this period that the exterior skin changes from red to white. You will gain some range of motion. Your gait (walk) push off will be better. 

     So, during this next 5 months, when nothing happens quick, be diligent on daily stretching, mobilization, strengthening, scar manipulation, anti-inflammatory, and protection. It is hard to do, but very important, and for some, crucial. Hope this helps some. Rich

     

Achilles Pain Flow Chart of Treatment

I am just beginning to experiment with various flow chart software to capture the complex nature of treatment of these lower extremity injuries. I apologize for any confusions as it is meant to supplement the information already in the blog on achilles tendon injury treatment. 

Webcam Treatment of Acute Ankle Sprains

I hope you enjoy this Webcam on Treatment of Acute Ankle Sprains. See the attached video below also. 

Plantar Fasciitis Treatment Flow Chart

Abrupt Severe Heel Pain needs MRI for diagnosis: Email Advice

Hi Dr. Blake,

I found your website while searching for a podiatrist in the bay area. I'm an ultrarunner (multiple trail 50ks, one 50 miler). I developed abrupt severe onset of right heel pain during a 14 mile trail run (running downhill) at 7 miles, finished up the run. This was 12 weeks ago now. 

Dr Blake's comment: Abrupt severe heel pain during a run is either heel stress fracture, plantar fascial tear, plantar heel bursitis, or Baxter's Nerve Entrapment. 

I did lots of icing, stretching, you name it afterward. I am very good about stretching, wearing the correct shoes, etc. I have continued to have heel pain ever since. Initially I took a week off of running, then went back. I run 3-4 times weekly, mileage is never more than 25-35 weekly. I have tried everything under the sun, including MLS laser, Graston/ART, E-stim, rolling, stretching, icing, changing my shoes (was in Pearl Izumi M2, went back to Hokas), heel cups, night splint,  plantar fasciitis cups, superfeet. 

Dr Blake's comment: When patients give me info about past treatment, it is important to know what treatments helped somewhat and what treatments aggravated. You have had treatments in the 3 important areas of heel pain treatment---stretching, biomechanical changes, and anti-inflammatory. However, without a diagnosis, we need the info on how various treatments effect the heel pain for the positive and negative. 

I have stopped running altogether, I'm going on my 2nd week. The symptoms have not gotten better, in fact it is getting worse. I did some research the other night and realize I may have injured my heel fat pad. When I displace the fat over my heel, my pinpoint tenderness, which is in the middle medial of the heel, goes away. I have started taping the heel (for fat pad syndrome). 2 days of that but have not noticed any improvement.

Dr Blake's comment: Typically heel fat pad injuries are chronic, but the lack of heel padding can lead to nerve entrapment, bursitis, or stress fracture/bruise. 

 My heel is swollen, which I believe is unusual for plantar fasciitis.  Prior to this injury, I was in great shape, no aches, pains anywhere. I did have a weird sensation to my 4th and 5th left toes starting about a month prior when I would run; felt like they were squished together, broken.  I have NO achilles pain, no dorsal foot pain or numbness, no arch pain.

Dr Blake's comment: The swelling is typically plantar fascial tear or calcaneal/heel stress fracture. MRI is crucial and definitive for the diagnosis. 

I am completely devastated by this injury. I run on trails, I don't pile on tons of miles, I stretch, get rest, take care of my feet. I am afraid I've done permanently damaged my heel fat pad. I am waiting to get into a UCDavis sports PM&R doc soon and will request an MRI. I did have an xray about 2-3 wks after the injury and no stress fracture was seen, they did see a small bone spur.

Dr Blake's comment: I would not get too excited until the results of the MRI come back. If the the MRI comes back negative, I would be happy to look at the images. If negative for tear or bone edema, which will both heal with cam walkers and time, then the doc soon palpate for a bursitis or neuritis. He/she can compare the fat pad on both sides. Keep me in the loop!!! Rich

I am not interested in cortisone injection as the research doesn't seem to show that helps much and if fat pad syndrome an issue, it could worsen it.

Do you have any recommendations? Would it be helpful to make an appt with you?

pam

Cheilectomy Post Op: Email Advice

Good evening, I had the cheilectomy surgery Nov 6 2013

Dr Blake's comment: A Cheilectomy (also known as an arthroplasty) is basically a joint cleanup of the big toe joint when arthritic spurs and cartilage damage is noted. Like meniscal repairs and cleanups of the knee, it may be the precursor of a partial or complete joint replacement. 

I was making good progress I thought. Recently, I am having a lot of soreness behind the big toe actually the entire toe is sore and nerve sensations are occurring.  I limp because of this soreness. 

Dr Blake's comment: If you read the post on Good vs Bad Pain, you are definitely in the Bad Pain side of things. What can you do to help this? Some common changes you can make are: daily ice pack for 10-15 minutes three times a day, learning spica taping, wearing a removable boot or another stiff sole shoe any time possible for the next several months, trying to make yourself dancer's pads to off weight, and going to PT for advice and anti-inflammatory treatments. 

 I went for my check up 6 months  he said to get some insoles for my sneakers but I  wear a 2 inch heel at work.

Dr Blake's comment: There is some many factors involved in finding a comfortable heel to wear. You definitely want to go shoe shopping. Try 20 different pairs of 2 inch heels and you will find some much more comfortable than others based on stiffness, padding, volume, flexibility, etc. 

  He said I was pushing my toe down causing pressure from wearing this small heel. He is a Orthopaedic surgeon for the foot and ankle.  I don't have much cartilage left by looking at my X-ray.   I am very active with weight lifting and stair stepping everything bothers my foot.  Further Surgery I don't think I want.  It's been 6 months and somewhat worse than 2 months ago for some reason.

Dr Blake's comment: When you are in a flare, which is very common for this and many surgeries during the first year, it is important to figure out how to get out of the flare as soon as possible. If that means a removable boot every weekend and evening after work for several weeks, so be it. If it means icing 5 times daily, and a good dose of oral meds, and shoe changes and physical therapy, so be it. See if you can begin to experiment and find what seems to help at least some, and then take the additive approach of finding multiple things. Hope it helps. Rich

Fibular Sesamoid Fracture: Email Advice

     I just found your blog trying to research sesamoid treatments and I wish I had found it sooner! I have been in a walking boot for four months to treat a fibial sesamoid fracture and I'm starting to get frustrated. Every visit to the podiatrist shows improvement on my x-rays, but I'm confused by the questions he asks about pain. He says that if it hurts the bone is moving, but how can it be moving when I wake up in the morning and it's been up and elevated all night long- and still hurt.

Dr Blake's comment: There are so many causes of pain after you hurt a body part, that blaming it on one specific thing may not be correct. The pain is most likely due to the swelling that collects in the area, that is a totally normal part of healing, but loves to sit there and interfere with movement and compromise the circulation and nerves. 

    I've been reading some of the posts and concerned about all the information that I haven't seen before, literally the only treatment has been this boot that I was told was to avoid having to do surgery- but not to remove, but to pin?

Dr Blake's comment: Unfortunately I have no experience with treating sesamoid fractures that have been pinned. It has always seem too small a bone to do something like that, but new technology is being introduced almost daily. I have only seen one unsuccessful surgery where the surgeon removed one half of the two bipartite bones. 

 The more I'm reading the worse this is sounding.
Dr Blake's comment: If you have been in the removable boot for 4 months, you have done everything right up to now. But, it is time to move from the Immobilization Phase to the Restrengthening Phase of Injury Healing. The Restrengthening Phase should continue your 3 times per day icing/contrast bathing, your Calcium and Vit D intake considerations, your protected weight bearing with orthotics and/or dancer pads and/or stiff soled shoes, a gradual strengthening program from the core down, and a gradual return to full weight bearing with no barefoot. 

 In the past month I swear it's been getting worse and the boot itself is driving me nuts and starting to hurt the other parts of my leg. Any advice?
Dr Blake's comment: Typically after 3 months in a removable boot, the negative effects of immobilization start to take their toll and pain syndromes develop. How to begin protected weight bearing without the boot is the next goal and many of your new soreness will abate. 

 My next appointment is in the first week of May and I'd like to sound like I know my options. 
Dr Blake's comment: Sorry, I just had some personal family problems that needed me so I am late with this response. 

My podiatrist is a nice guy, but this is getting really frustrating, according to him I should have been healed by now.
Dr Blake's comment: You can ask any athlete if they continued to have pain when their injury was healed and the majority would say affirmative. You need to respect pain levels over 0-2 and increasing as you work out. You need to gradually stress the injured area to prevent flares. Working with a good physical therapist on lower extremity strength and flexibility at this time on a weekly basis will also get their regular feedback on activity levels permissable.

Dr Blake's comment:

     Thanks for the email. When you see him, ask the following questions.

1. Can an orthotic device be designed to off weight the sore sesamoid?
2. Can you go to PT to learn joint mobilization, spica taping, dancer's pads, foot strengthening, and anti-inflammatory techniques?
3. Can you get a baseline MRI to see where you are at, or CT Scan? There are many reasons to get a MRI other than healing of sesamoid for it can show if other structures are involved.
4. If he thinks you are slow at healing, can you get a bone stimulator?
5. What shoes, like hiking boots, can you wear to begin to wean off the cam boot?
6. Has he had cases like this that heal without surgery? This is check if he has a bias. 
7. Does he feel you can heal without surgery? If not, who should you see for a second opinion?

Typically, the next 3 months should be geared towards gradually getting out of the cast, developing a good orthotic, gradually increasing activity, gradually understanding good vs bad pain, and daily continuing to ice and contrast bath. Good luck. Rich

Peroneal Tendonitis: Email Advice

Hello Dr. Blake,

     I have had severe peroneal tendonitis in my left foot for over a year now. MRIs and Xrays were normal. After failing conservative treatment, we chalked it up to psoriatic arthritis and I've used a walking boot and crutches to get around in. Started meds for arthritis that have helped joint pain everywhere else, but foot pain still bad.
Dr Blake's comment: With negative MRI, and negative response to anti-inflammatory meds, you need to think nerve injury or mechanical (over pronation or over supination). 

     Now, recently (in January 2014), I started getting the exact same type of pain, this time in the right foot. This time around, the pain is accompanied by a loud snapping sound behind the outer ankle.
Dr Blake's comment: This definitely sounds like mechanical inflammation of the peroneal tendons. The peroneal tendons are easily irritated by limping. If you are favoring your left foot, you typically place more weight on your right foot on the outside, with only the peroneal tendons to protect and stabilize you. 

    The pain gets worse and worse each day when I try to walk and snaps almost constantly. Went to ortho doc and was diagnosed with intrasheath peroneal subluxation. He said the tendons are snapping over each other. He wants me to do physical therapy. 
Dr Blake's comment: Physical therapy sounds great. The therapist should focus on your mechanics---use an EvenUp on the right when you wear a boot/walker on the left, correct for any over pronation or over supination tendencies, and work to avoid over stressing your right foot. The PT will also help you with peroneal strengthening and anti-inflammatory measures. 

     I'm 25 and have officially lost my ability to walk, as it is too painful. I don't leave my house. I was a straight A nursing student and very athletic a year ago, I don't understand how a person can lose the ability to walk that fast. I don't understand how physical therapy will make the tendons stop snapping over one another? It hasn't worked so far.
Dr Blake's comment: I am sorry for problem. And, you should definitely get an MRI to get a baseline on what the area looks like. There can always be surprises. So, why do the peroneal tendons sublux? Typically, they hypertrophy from the overuse of limping and the tighter tendons snap on each other as they move across. If they dislocate anteriorly out of their normal groove behind the outside ankle bone, then we are talking surgery. But, typically then stay in their place. Hopefully you are experimenting with braces to stabilize the ankle. A back doc should also evaluate you for possible low disc central disc bulge which can cause bilatteral peroneal spasms/pain/snapping.

    Neither have custom orthotics helped me due to the fact that I also have type two accessory naviculars and taking pressure off peroneal tendons puts pressure on the tibial tendons and has been causing arch pain. 
Dr Blake's comment: In biomechanics, we call this Medial/Lateral Instability. It requires orthotics/shoes/braces that carefully help both tendencies---pronation tendencies and supination tendencies. You need someone skilled at addressing both in the same person!! The Fettig Modication of the Inverted Orthotic Technique is one version of an orthotic device that tries to address both motions.

    I went to another ortho person to see if he could do a groove deepening procedure that I've heard about, and he feels that it's "too aggressive."
Dr Blake's comment: Thank you to God that that doctor cared about you. You do not have surgery for subluxation. It can be fixed conservatively. I know when you are in pain, disabled, surgery can seem like a way out, but I would not do any procedure on you unless 2 doctors said you needed it, and a top notch physical therapist (with no financial ties to the surgery). 

    I've gotten so depressed from not being able to leave my house that I've considered suicide as an option, as I've lost my ability to walk and don't know what else to do anymore. I don't know why they wouldn't want to do surgery to fix a problem that's obviously not responding to conservative treatment.
Dr Blake's comment: Wow!! Please listen to yourself, this has only been going on since January (4 months). Check the AAPSM website for local sports medicine podiatrists in your area. Have your low back evaluated. Consider a brace for your better left side and a boot/walker for your right side now. See one or two physical therapists and see if they can point you in the right direction. Definitely see a psychologist to help you focus correctly. Nothing you have said waves red flags suggesting permanent disability. This is run of the mill stuff in a sports medicine practice, although there are many things I have no clue of regarding your case. 

    I'm also curious as to whether or not the subluxation in the right could have caused the pain in the left side as well, although the left side never made a snapping sound. Any advice would be greatly appreciated. I don't need both feet to work again-I just want the right one to stop snapping so I can go some places in crutches again or with an aircast. I've never been this worried before in my life :( Why wouldn't they want to do surgery to fix the subluxation when nothing else is working?
Dr Blake's comment: I hope my comments above have been helpful. Get the MRI, go to PT, back doc, consider a RollaBout for getting a round little. Email me when you have more info. See if a Flector Patch can be prescribed since you can wear 24/7 for a few weeks. We need someone to give you an old fashion muscle test to rule out peroneal spasm and grade your overall peroneal strengthen. You need to constantly work on the orthotic devices to get them right. Good luck. Rich