Soft Tissue Injury Treatment and Running Shoe Concepts: A Lecture for the California School of Podiatric Medicine

Soft Tissue Injury Management: 

20 Golden Rules of Foot

                                        by Richard Blake, DPM

1981   We each ran 125 miles during that week

I am the goofy one above the T.

Patients present to your office with various injuries. These injuries have many general principles of treatment that I will call Golden Rules of Foot. These are rules I live by. This particular lecture focuses on soft tissue injuries, including sprains, strains, contusions, bursitis, and nerve injuries.

General Definitions:

• Sprain is an injury to a ligament

1. First Degree: overstretching of ligament
2. 2nd Degree: partial tearing of ligament (will see some ecchymosis/bruising)

1. 3rd Degree: complete tear of ligament (sudden swelling, impressive bruising seen)

• Strain is an injury to a muscle or tendon

1. First Degree: over exertion or over stretch of the muscle or tendon
2. 2nd Degree: partial tearing of the muscle or tendon
3. 3rd Degree: complete tear of the muscle or tendon

• Tendinitis vs Tendonitis: both acceptable spelling
• Tendinitis vs Tendinosis: Tendinitis is inflammation of the tendon (first degree strain), whereas tendinosis means their is some injury to the tendon (osis means condition of) not inflammatory
• Tenosynovitis is inflammation of the tendon sheath (peritendon)
• Stenosis tenosynovitis means that there is scarring along the sheath interferring with normal tendon function

• Contusion to direct trauma (single blow or multiple blows) to the body causing injury to skin minimally, and as deep as the bone and everything in between

• Bursitis is inflammation of bursae that protect bony prominences like posterior heel, lateral hip, etc

• Nerve injuries can be local to the foot or referred from above the foot or systemic like CRPS (complex regional pain syndrome aka RSD).

Patient with left foot CRPS!!

You also have acute injuries (like a sudden fall) and overuse injuries (from chronic repetitive motions) like most tendinitis.

Golden Rule of Foot #1: As you treat patients, listening to their stories, examining their injury, you should develop a checklist of treatments that could help them which include:

My Daughter In Law Clare in the San Francisco Marathon

1. Activity Level Allowed
2. Type of Anti-Inflammatory Measures Needed
3. Appropriate Stretches
4. Appropriate Strengthening Exercises
5. Any Bracing Needed
6. Dietary Help 
7. Shoegear or other Equipment Changes
8. Inserts to Purchase
9. Need for Testing (x rays, etc)
10. Followup Needed (office visit, email, telephone call)
11. Logs to Keep (training, stretching routine)

Golden Rule of Foot #2: 98% of all sports medicine lower extremity injuries are non surgical. Therefore, your skill set in non surgical approaches to treatments should be developed.

What are 7 General principles in Stretching?

How do I pad the removable boot for a sesamoid injury?

What is the best shoe for a patient's problem?

Golden Rule of Foot #3: With each office visit, you make changes appropriate to your checklist, based on the patient's response.

• Activity Level
• Anti-Inflammatory
• Stretching
• Strengthening
• Bracing
• Shoe Inserts
• Diet
• Shoes and Equipment
• Testing
• Followup
• Logs

Golden Rule of Foot #4: The 3 phases of injury rehabilitation that the patient goes through (sometimes in the wrong direction with 2 steps forward and 3 back) are:

1. Immobilization/Anti-Inflammatory Phase
2. Re-Strengthening Phase
3. Return to Activity Phase

You may have to take an athlete 9 months post injury who keeps hurting him/herself and place them back into the Immobilization Phase. Many times athletes who come into your office seeking 2nd opinions have never been treated appropriately for the phase they were in. 

What are the common ways you strengthen a body part? The various categories of strengthening are:

• Active Range of Motion (with or against gravity)
• Isometric (no change in length of muscle)
• Isotonic (weights--no change in amount of resistance)
• Progressive Resistive Exercises--variations in resistance (therabands).

• Functional Exercises--strengthening whole groups at once

Golden Rule of Foot #5: During the treatment of an injury, the athlete will exist within the 3 Phases of Rehabilitation at the same time, although primarily in one phase. The art world I love to dwell within.

Golden Rule of Foot #6: Any time you are treating a superficial soft tissue injury, remember that the true cause of pain can be deeper, or referred from elsewhere. 

This patient's Anterior Tibial Spasm was related to a bone spur in the front of the ankle.

Chronic Ankle Tendinitis (achilles, peroneal, etc) can be related to Cartilage issues

Bunion Pain can be related to arthritic spurs

Neuromas can be related to Low Back Issues

Heel Pain can be related stress fractures

So, always think deep or referred as you work on the soft tissue components. 

Golden Rule of Foot #7: There are 3 sources of pain that patients experience in an injury each with different treatments---mechanical, inflammatory, and neuropathic. Any injury can have all 3 components at one time, with one type primary. The primary source of pain may change during the course of treatment. Typically inflammatory pain is always treated, but mechanical and neuropathic pain ignored completely or inadequately treated. 

What are common treatments for each source of pain?

Mechanical??

Inflammatory??

Neuropathic??

Golden Rule of Foot #8: For an Acute injury, think PRICE.

• Protection 
• Rest
• Ice
• Compression 
• Elevation

PRICE is 5 individual components of treatment that must be changed or at least discussed with each visit.

Protection

• Develop a Pain Free Environment (0-2 pain level)
• How long is it needed? 
• What is the best form?

• Can strengthening be used to take it's place?

Rest

• A 4 Letter Word for most of our patients
• Develop a Pain Free Environment (0-2 pain level)
• Activity Modification 
• Keep up leg tone, core strength, cardio 

Ice 

• Typically 96 hours post injury ice alone
• Then add heat in some form like contrast bathing
• Continue icing after irritation of injury

Compression

• As long as swelling remains (can be months)
• Pressure greater towards toes and less as move up leg
• Patient needs to be able to remove or loosen

Elevation

• As long as swelling remains
• Does not have to be above heart
• Ankle Pumps and Circles and Toe moving as long as not painful
• Super Elevation with body on ground and foot up on couch (especially after contrast bathing) once daily

Golden Rule of Foot #9: With any injury whether in the acute phase, subacute phase, or chronic phase, always attempt a pain free environment while rehabing (0-2 pain levels). This is the level of pain that a patient can have and still heal. 

This is how you determine the amount of protection needed, activity levels recommended, the need for icing, NSAIDs, etc. This is crucial in your treatment and the patient may or may not want to follow this. 

Acute Injury: Just happened (PRICE initiated)

Subacute Injury: 2 weeks to 3 months (with active treatment and cause reversal initiation)

Chronic Injury: Over 3 months

Golden Rule fo Foot #10: Rehabilitation is a balance between 0-2 pain levels and a gradual increase in Activity Levels. 80% better is your initial goal in treatment of most injuries. 80% better means you are back to full pre-injury activity level, and you are keeping your pain level between 0-2. It can take 4 times longer to go from 80% to 100% than it took to go from injured to 80% better. 

Golden Rule of Foot #11: With any injury (even if surgically produced), it is crucial to move as much as possible (highest level of activity within 0-2 pain) and begin strengthening the area as soon as possible. Our knee surgeons typically have a muscle stimulation unit on the patient when they wake up in the recovery room. 

Golden Rule of Foot #12: For any injury, seek 3 causes from the obvious to the "I am a great podiatrist" less obvious. This crucial in all overuse injuries, and still very important in some acute injuries. 

Law of Parsimony: The most common cause of an injury is most likely the cause now.

• Achilles Tendinitis--tight achilles/calf
• Plantar Fasciitis--tight plantar fascia
• Posterior Tibial Tendinitis--excessive pronation with arch collapse.

But constantly train yourself to look deeper!!! For example, a patient with a foot stress fracture doing an activity alittle more intense than normal. Initial cause of injury is overuse. You can stop looking. But, why a stress fracture vs tendinitis vs something else? 

Law of "Weakest Link in the Chain": If there is an abnormal overload to the body, the weakest link in the chain will complain first. If a patient who over does an activity breaks a bone, do not just blame it on overuse, look for reasons that they broke their bone vs not strain a tendon, and why that particular bone. I have typically found 4 or 5 reasons that an injury occurred and in helping those reasons can prevent further injuries in the future. 

What are some reasons that a runner who break their heel bone? Think in deeper and deeper layers.

Golden Rule of Foot #13: Podiatrists own the world of preventative sports medicine as we evaluate the causes of injuries, and make decisions to initiate cause reversals. 

Claim it!! But it takes time

How does a tight achilles give you metatarsalgia pain?

How does weak quads give you 4th or 5th metatarsal stress fractures?

How does excessive supination cause medial knee pain?

Which is more likely to cause achilles tendinitis: pronation without heel valgus or pronation with heel valgus?

Golden Rule of Foot #14: With any injury, look at the common mechanics involved for causality or aggravating factors. 

• Achilles Tendinitis--too tight, too loose, excessive pronation
• Plantar Fasciitis--too tight, excessive pronation
• Tibial Stress Fractures--excessive shock, excessive pronation with tibial torque

Golden Rule of Foot #15: The 8 common mechanical causes or contributing factors in lower extremity injuries that can be seen in gait or sport specific evaluations are:

1. Excessive Pronation
2. Excessive Supination (also called Underpronation)
3. Leg Length Discrepancy
4. Poor Shock Absorption
5. Tight Muscles
6. Loose or Weak Muscles
7. Improper Sport Specific Techniques
8. Miscellaneous Gait Findings

As we perform gait evaluation, and technique evaluations for specific sports, we look for mechanical problems that may need to be corrected. 

Still working on understanding the mechanics of mud running!!

We need to make sure this ballerina stays in neutral and does not over pronate (winging) or over supinate (sickling)

Cycling is one of those repetitive motion activities that we can greatly influence with subtle mechanical changes.

And then add other causes of stress/overload on that tissue to the mix.

Golden Rule of Foot #16: Besides mechanical causes of injury, there are so many other causes of injury including:

• Equipment Faults

• Training Errors

• Psychological Factors (ie. negative addiction, inability to appreciate correct pain levels, desire not to stop competing, etc)

• Dietary

This is why it is typically easy to find 3 causes of any particular injury.

Golden Rule of Foot #17: KISS rules!! It is okay to start slow in most cases, but the patient has to be with you on this (and most are). So much depends on the level of pain the patient is experiencing when you see them. 

K--Keep
I---It
S---Simple
S---Stupid

Golden Rule of Foot #18: For any treatment modality or area, develop expertise in treatments from Simple to Complex. 

Short Leg Treatment: Heel lifts to full length lifts to shoe additions

Orthotic Therapy: OTC to Custom Made to Speciality Orthotics

Anti-Inflammatory: Ice, NSAIDs, Contrast Baths to Physical Therapy, Oral Cortisone, Acupuncture

Golden Rule of Foot #19: Use the mnemonic BRISS for tendinitis treatment.

• B----Biomechanics
• R----Relative Rest
• I-----Ice or Anti-Inflammatory
• S----Stretching

• S----Strengthening 

Golden Rule of Foot #20: Treat what you see as directly as possible (and be persistant)!!  

• Swelling (work on reducing the swelling)
• Ecchymosis (evaluate for tearing--2nd or 3rd degree injuries--an treat with immobilization and strengthening, along with soft tissue mobilization to reduce scarring
• Stiffness (work on soft tissue and joint motions)
• Hypermobility (work on strengthening with protection as needed for activities)
• Gait Findings (Gait Evaluation is the key to understanding how the patient moves, and if there is problems with that movement)

The 2nd Part of this lecture is on Running and Running Shoes. Let us go to my power point presentations on these subjects.

http://www.drblakeshealingsole.com/2015/06/walking-vs-running-mechanics-lecture-in.html



http://www.drblakeshealingsole.com/2015/06/this-is-second-lecture-i-will-give-at.html

Mustard Seed Plaster with Tumeric for Acute Injuries

A patient recently told me of an old, much forgotten, treatment for inflammatory and neuropathic pain. This treatment is called Mustard Plaster. I love remedies like these. She said you take mustard seed oil and mix with tumeric powder into a dry paste. You must use latex gloves since it will stain everything and hard to get out. She uses it after an Acute injury for anti-inflammatory while sleeping. You put on the paste and then several socks to hold on the paste. Something to consider. 

https://en.wikipedia.org/wiki/Mustard_plaster#Uses

Low Impact Running for Hip or Knee Arthritis

Dr Blake, what can you tell me about this style and the shoes that help-- Newton, Altra, etc. I discovered advanced arthritis in my right hip and trying to prolong its life. Having a gait analysis next week.

Dr Blake's comment: This is a nice video below discussing low impact running to help slow down the stress on your hips. The basic biomechanical changes do not revolve around running slower however, unless you are going down a hill, which is sort of counter intuitive. The basic changes are to get away from heel strike (which may or may not require a zero drop shoe like Newtons or Altras). I can easily run midfoot to forefoot strike which my normal Asics. You need to actually focus on improving your stride rate to 85-90 strides per minute. A stride is the distance from right foot land to right foot land, or 170-180 steps per minute (right heel strike to left heel strike). As you increase your stride rate, you will have a natural pull back of the landing foot that gets you more on the center of your foot). This increased stride rate allows us to avoid over striding, which produces a jarring damaging force on our knees and hips. You can also see the videos on Chi Running on my blog which emphasize the proper mechanics of midfoot landing/strike.  Hope these principles help. Rich

https://youtu.be/gvp-8TYMuIk

Dr Blake's comment:
     So, to summarize:

1. Avoid down hills with a passion, and run slowly down them if encountered
2. Work on Chi Running Techniques to get more midfoot or forefoot land, avoiding heel strike
3. Find a Zero Drop or Neutral Shoe (both well cushioned but stable) that allows you to land on the midfoot or forefoot easier.
4. Gradually try to increase your stride rate with proper landing foot pull back to avoid heel strike. 

Foot Fracture: Email Advice

Dear Dr Blake:

     I had pain in the ball of my foot for awhile. finally went to the dr and he said i have two broken bones there. Since it started to heal he said just see how it is in a few weeks and if still not good come in for the boot cast.

Dr Blake's comment: So far the advice is good. The use or no use of the boot is based on creating a pain free environment. This is crucial to keep the pain in that 0-2 ranges where normal healing can occur. 

After he pressed on it its been more painful now then ever. i feel like i am walking funny to compensate and now my knee is really bothering.

Dr Blake's comment: I have done this also to sweet, kind, innocent patients that come to me for help. Most of the time it is just I do not know how sensitive it is when I am exploring. Your walking funny is called limping. Limping causes knee, hip, back pain, even to the other leg, so I would go into the boot if it stops you from limping. If you can not keep the 2 sides level with the boot, get an EvenUp (wonderful savior of spines!!)

What do you think is best to do…what about a shot will that help

Dr Blake's comment: No cortisone around a fracture since it can negatively effect bone healing. Get the boot, ice 2-3 times a day, and give it some rest. 

Its painful and feels like a heart beat of pain

Dr Blake's comment: That is the inflammation out of control. Hope this information helps. Rich
> ps im curious will ball of the foot pain cause back pain to ?

Accessory Navicular: Email Advice

Hi Dr. Blake

I have a son with accessory navicular and somewhat flat feet.  He is a 6 ft 8th grade, power forward and has been playing for many years.  Last year he had a hairline fracture of his fifth metatarsal and this past spring he rolled his ankle again and was in instant pain and we discovered it was related to an injury to his accessory navicular.  That foots accessory navicular five months later is slightly larger on the foot that was injured and was recently kicked in a game inflaming it slightly.  He dropped running cross country as he plays both aau and school basketball.  He uses voltaren diclofenac gel topically when it was acute.  He originally five months ago was in a boot for 5 weeks.

Dr Blake's comment: Due to the vulnerability of that bone to have flareups, make sure he is using taping when he plays, and ices daily for 20 minutes each evening every day religiously. 

https://youtu.be/e1JAewWT9Fc

He was told by a sports orthopedist to use Superfeet inserts which he played in today and they were fine.  He wears Adidas high tops which are good for people with flat feet.

Dr Blake's comment: Sounds great---good stability shoes, taping, arch support!!

Questions: are there other things that can be done for accessory navicular issues/syndrome?

Dr Blake's comment: Based on the extent of reflare, you can increase or decrease the mechanical support and anti-inflammatory measures. I always love accessory navicular patients to do posterior tibial strengthening as long as it is non painful. Sure, you can go to custom orthotic orthotics if the Superfeet are not enough support. You would have to see if he is walking and running whether he is still pronating. You can improve the taping by going to a good Posterior Tibial J Strap. You can get a Stromgren Ankle Brace and only use the inside strap (I have my patients actually cut off the outside strap that would pronate them. 

https://youtu.be/QP3Ud4d39dc

   Are Superfeet inserts what is best for this?   I say your wish list I. Ur blog and in always after him to not walk barefoot around the house and wear slippers.  He has been playing competitive basketball since 4th grade and this discovery/injury of this accessory navicular was just discovered in June of this year.

Any suggestions would be much appreciated.  He is a very good player, will be the captain of this 8th grade team, and would like to potentially play in college.   I would like to do everything I can for him to realize that.
Dr Blake's comment: Please comment on this post where he is now in regards to his injury. As long he is not limping, he can play. I hope this helps somewhat. Rich 

Thank you in advance for ur help Dr. Blake!

More Images from Our Pilgrimage in Spain on the Camino de Santiago

https://youtu.be/kH_rkoLqU4I

Straightening Your Back: Exercises for the Curves

Dear Dr Blake:

Great to see you yesterday.

Congratulations to you ~ new grandfather!
I love your grandson's name and it was really fun to see the pictures. Thank you for sharing those with us. 

Thank you for seeing my daughter and helping her with her pain. I would be very interested in any kind of exercises that you do find on the web if you end up searching for any. I know when she has time she'll also look as well. I never even imaged the pain in her thigh could have stemmed from the scoliosis!

See you soon, 

Dr Blake's comment: 

     Here are some of the videos that represent what I know. It would be wonderful to show this to a PT who can review here curves and decide exactly on the top 4 exercises. Typically there are 2 concaves areas in an S shaped curve that need to be stretched out, and 2 convex areas that need shortening by strengthening. I believe you can get faster results if you can do less general stretching and strengthening (although there is a role for that), and more specific stretching and strengthening due to your understanding of the individual curves. These videos do help you guys start understanding the process. I would love to watch you two do the partnered stretch in the third video, I think it could go viral if you make your own!! Hope it helps. Rich

https://youtu.be/9TWtrCmzaOw



https://youtu.be/H7ZC9t2VUO4



https://youtu.be/wmk5Mvz4pe8

Fascia: A Part of some Pain Syndromes we should not Ignore

This short note was sent to me by one of my blog patients. It is an area that affected my plantar fasciitis patients and my achilles/calf patients. I realize I have a lot of learning to do to understand this complex structure that covers every muscle in your entire body. 

Found this wonderful article on fascia after doing a home practice video with the instructor Jenni Rawlings. Wonderful and interesting.

http://www.jennirawlings.com/blog/2014/1/26/a-brief-primer-on-fascia-and-why-its-cool

Sesamoid Fracture: Email Advice

i have tibial sesamoid fractured too from running backward at high intensity, had small bump in my new shoes and broke my sesamoid and felt the pain immediately, i got MRI and seen at least 8 specialist... 

after 1year they told me i had fractured my sesamoid, i stilll have pain i went see a orthopedic surgeon and he told me he could remove a part of my non-displaced sesamoid fracture (a very small liquid is between the 2 part shown on MRI a month ago). so his idea is to remove the smaller part(about 45% of the sesamoid..) do you think its a good solution?

Dr Blake's comment: I have only seen one case of this which was unsuccessful, so my limited knowledge won't help. Alot depends on how healthy the joint looks when they go in there, so you have to trust the surgeon to possibly remove it all if appropriate. But, technically it makes sense. 

 he think the pain is coming from that sesamoid not healing completely. But i hesitate so much on getting the surgery im so scared the problem become worse.. 

Dr Blake's comment: The surgery to remove the whole sesamoid is very common, and 85% successful (meaning 85% of the patients say they wound have done it over again). So, since it is a successful surgery, most do not hesitate to do after 6-9 months of conservative care. The downside with this is you have to wear toe spacers between the first and second toes forever, and some form of dancer's padding/orthotic device, to protect the other sesamoid. And you have to get the abductor hallucis very strong. 

and another weird thing, when i walk in the sand its magical for my sesamoid pain, i cant explain why walking in grass and in sand help me and anything involving anyking of shoes or sandals or anything give me pain. I learned to live barefoot because thats truly helping me. when i stand on my sesamoid i dont have pain, but when i touch it i can get about 8/10 in pain also bent it cause pain. 

Dr Blake's comment: The hypersensitivity to the touch of finger or shoe is nerve pain that settles into some chronic problems. You need to work with NeuroEze, prescribed nerve creams, neural flossing, massage for desensitization, etc. 

But if i keep my feet flat i have no problem. One important thing in my case is i learned 1year after the acute injury that i had fracture because they didnt seen it on x-ray. then 1 year later i bought a MRI and they finally seen small crack in the sesamoid that is non-deplaced fracture. Another thing is that my feet now cracking all the time when i walk and it never been like that before the injury.

Dr Blake's comment: The crackling is from fluid retention, either inactivity, chronic swelling, or both. It will disappear as your foot gets normal. The MRI makes me believe that the nerve hypersensitivity may be your biggest problem. Check out some pain management specialists who deal with peripheral pain syndromes, before any thought on surgery. My patient that had the unsuccessful partial sesamoidectomy finally got better with soft Hannaford orthotic devices with dancer's pads and a pain management approach. 

Its impacting a lot my life and tried everything i could, at this point i have 3 solution that i found could work:
1- Live on the beach 24/7 in a hut where i would NEVER walk on hard surface(dont have that $$$ to do that) Dr Blake: Sorry!!
2- Have sesamoid removed partial or completely
3- I never been in the boot, they told me its too late after a year, is it true? do you think if i put my feet in a boot pointing my toes downward for a while could fix my problem?? im thinking about trying this

Dr Blake's comment: When you take a pain management approach, you have to spend 3-6 months in a pain free environment (the boot may help in that regards), use topical and sometimes oral nerve meds, learn biofeedback and other desensitization techniques, and ice three times daily. I hope this helps. Thanks for your kind words. Rich
please come me back dr.blake you ARE the ressource on the sesamoid over the internet!!!!

Sesamoid Injury: Followup on Long Conservative Care

This kind young man, injured his sesamoid 3 years ago, had some ups and downs, has avoided surgery, and wanted my readers to know what he had discovered. Thank you. 

Hi Richard,

I hope you are well. I haven't been in contact for quite a while. Been trying to solve my pain and I think I got some results...fingers crossed...

Here's what really helped me I think:

• orthopedic soles made to measure by podiatrist.
• flat shoes (this model: http://www.adidas.co.uk/spezial), with thin and loose socks to minimize pressure (no thick socks like tubes etc.).
• no walking/running for several months. I basically used a car or a bicycle to go to office (with pedals under the back of my foot/heels level so no pressure on ball). This enabled me to stay pain free for several months in a row and I think it helped a lot. I think cycling is great as it enables you to do cardio workout without triggering pain.

I can now run 40 mins with my soles in good running shoes (Asics). Not 100% fixed but a big improvement compared to a few years ago....I hope this will help other patients, this injury truly is a massive pain (both physically and morally).

Thanks much again for all your work and assistance and don't hesitate if you want more details.

Best regards, 

Peroneal Tendinitis: Email Correspondance

 I have been suffering from peroneal tendonitis for four years now and I'm hoping you can shed some insight on how I can kick this thing for good! Originally, my podiatrist recommended motion control shoes to control the torque in my ankle: that was a complete failure. I rolled both my good and bad ankle twice in a matter of hours.
Dr Blake's comment: Wow, that was bad luck. Peroneal tendonitis stands be more from over supination (aka under pronation) than over pronation, so I am not sure why the motion control. Neutral, and some stability shoes, are great for this problem. My favorites are the Saucony Triumph and Brooks Ghost right now. 

After this my local running store recommended a support shoe instead. These shoes are usually fine for a few weeks, but as soon as they start to break in the underpronation gets worse and worse. It's a weird combination of feelings: like the arch support is so heavy that my feet aren't touching the ground on the inside, but also that the heel has worn out so quickly that I feels like it isn't touching the ground either. 
Dr Blake's comment: Look at the posts on lateral shoe wedging (which may be crucial), and common modifications of supination control. You can even power lace for supination protection. 

http://www.drblakeshealingsole.com/2011/08/supinators-orthotic-modifications-to.html

http://www.drblakeshealingsole.com/2012/10/shoe-wedging-to-stop-supination.html

I recently switched to a neutral shoe after the owner at another local running store was horrified that I was literally walking on the edges of my feet (and I have the ugly calluses along the entire edge to prove it). The neutral shoe has helped greatly. I feel significantly less later calf pain, but I can feel the tendonitis creep back in. It almost feels as though my feet slide from one side of the shoe to the other while I'm underpronating, and no amount of lacing can keep them in place. When I strike the ground evenly I have no pain, but when the edge of my foot hits the ground I can feel it right up the tendon.
Dr Blake's comment: This is why are supinators fall in love with shoe wedging and inserts that correct. Over supination is the most unstable and dangerous biomechanical problem I treat on a regular basis. You can even purchase some Red Sole Inserts from REI and other stores, and use masking tape and/or duct tape along the lateral under surface border, to straighten your foot until you get some professional help. When dealing with injuries, finding the mechanics that are causing or aggravating the problem, is vital. Or the problem is a repeating issue. 

I've also tried a lateral heel wedge to no avail, and a full over the counter lateral insole. Are there any other options or am I doomed to pain? I can't understand how one ankle sprain 4 years ago has led to such significant change in my mechanics, I always just grabbed any old shoe and had no problems before. 
Dr Blake's comment: Ankle sprains, where there is loss of ligament stability, can cause subtle and not so subtle instabilities that the body has to deal with. Besides the info above, start doing your Single Leg Balancing nightly (for it will take 1-2 years to get super strong in the protection of your ankle and probably now is a good enough time to start). 

http://www.drblakeshealingsole.com/2010/08/video-flatfooted-balancing-exercises.html

Foot Pain and A Higher Source

    I am having foot pain only. It may be from higher up. I feel it in my buttock too and some faint pain sometimes in my leg. I have a clean back MRI, though. Is it possible the L5 nerve impingement causing foot pain can be found in the hip/glute muscles instead

1. Dr Blake's comment: 
2. 
   

   For sure, you should read about piriformis syndrome, but the sciatic nerve can also get hanged up in the hamstrings or behind the knee. Rich

http://www.drblakeshealingsole.com/2013/12/sciatica-and-piriformis-syndrome.html

Sinus Tarsi Syndrome: Email Advice

The sinus tarsi is a canal that runs within the subtalar joint between the talus and calcaneus. It can give symptoms below the ankle in any of the 4 directions: back, inside, outside or top of the foot (this being the least). An injection of local anesthetic can be a diagnostic tool to locate the source of the pain. When the doctor feels confident in that diagnosis, they may combine cortisone with the local to get longer lasting relief. This patient seems to have gotten the diagnostic part with the initial pain relief post shot, so the source of the pain seems to be likely from the subtalar joint. 


Hey Dr. Blake I wanted to ask. I had experienced some strain on my left foot and saw a podiatrist today. According to the doctor it was deemed a congenital left sinus tarsi syndrome. I had been experiencing a strange pain on that area for 2 weeks. Its like tender muscle which wouldn't go away and hurt with my work shoes which are slip-resistant rubber-soled shoes provided by the company. I have a job that consists me of being on my feet a lot. I know for a fact that the work shoes I had 2 weeks ago on a Tuesday was the cause of the strain on my left foot and that weird pain because the shoe got wet by the rain and the work shoe I had was of the steeled-toe kind which is a bit heavy. I hadn't had my superfeet inserts in them because I hadn't gotten pain before only when the shoe got wet. I initially had seen a general doctor 2 weeks ago and was given a ankle boot, a soft shoe and 800 mg ibupropen to be taken 3 times daily as needed with pain. Still the pain came. So now today Friday 10/2/15 I was able to land an appt with a podiatrist to get a thorough observation. She gave me a cortizone shot which at first relieved me of the pain when I walked but in the afternoon around 3pmish, I felt my left foot inflamed due to the shot I think. I even had lunch and took one tablet of ibupropen and I still feel it. I had tried to ice the area for 10 min and I still have it. I was told I'd be fine to return to work normally but I feel like the shot made it worse seeing that it feels more painful to walk. I was also given a new ankle brace to wear to replace the old one, but again feels like I can't walk a normal stride on that left foot. Do you have any recommendations? I did email the doctor about this too. Thanks. 

Dr Blake's comment:

It can take the cortisone up to 2 weeks to really work (if given in the right spot). Unfortunately, the shot can be irritative and cause more pain for awhile (typically only 4 days). Ice for 4 days post shot, and see how the symptoms go. By the time you read this you should be at the 2 week point, so I hope you are doing much better. Sinus tarsi is a pronation produced problem, and many braces are actually designed to pronate us. So, if the brace does not feel great, remove, and find another or just limit your activities. Hope this helps some. Rich

Accessory Navicular: Email Advice

Dear Dr Blake:

I strained my accessory naviular syndosmosis 8 months ago. MRI showed no PTT tears and very minimal bone oedema. I am in orthotics and some days are pain free but some days I get an ache around the area or more proximally up the PTT, pain 1-2/10 max. I can cross train, row and cycle but am doing no impact activity. My orthopaedic surgeon told me that if it was going to settle it would have done by now and that the next step to consider is surgery (he recommended a Kinder procedure). Given how much better it has got and fairly positive MRI results I would like to think that conservative treatment could work for me but lack guidance as to how to go about it. Should I be considering surgery at this point? Can delaying surgery affect how successful the outcome is? Many thanks in advance. 

Dr Blake's response:

     Doing surgery now is like recommending preventative surgery. I have not heard you talk about strengthening exercises. You need to gradually, and pain free, strengthen the PT tendon, and other tendons/muscles that support your arch. You need to maximize the amount of arch support you get from your othotic devices. You need to do posterior tibial taping for all your athletic activities. Hope this helps. Rich 

http://www.drblakeshealingsole.com/2012/11/posterior-tibial-tendon-dysfunction.html

Achilles Tendon: Cortisone Shots Near Them are Risky

Hi Dr. Blake,

I am hoping you can give me some advice: 

I was training to do an ironman triathlon this year. Last year I did my first ironman and I have done a couple of half ironman. This year would have been my second Ironman. I have always been pretty active. 

This year I started feeling pain at the back of my heel. At first it was only painful in the morning and the pain would go away after a few steps. One morning it was more painful than ever and I even had difficulty walking. I also had a little very painful bump at the back of the heel. I took two weeks off from training and took iboprufen everyday. The pain did not get any better so I went to an orthopedic surgeon to see what I had as I wanted to get back to practice as soon as possible. I knew the ironman would have been out of the question, but I am hoping to race again the end of january 2016. 

According to the doctor I have an overuse injury. Inflammation where the achilles tendon connects to the heel. He took an xray to rule out bone spur and gave me a (long lasting) cortisone injection to the back of the heel. (I attached a picture of the back of my heel. The injection is placed next to the label on the picture. You can still see the brown spot where the needle went in.) 

It has been about 3 weeks since I had the injection. After about a week and a half after the injection the pain is almost completely gone. The doctor said that he didn't inject the achilles tendon and that I have nothing to worry about because it's my first injection in that area. He says it's okay for me to start running as long as I don't do sprints and hill running for now. 

My question is; is it okay for me to start running and what are the chances to rupture my achilles tendon? Both the orthopedic surgeon and my physical therapist say I have nothing to worry about, but I am still very afraid I might rupture the tendon. 

If the cortisone did go into the achilles tendon, does it always weaken the tendon? And when will the tendon be back to normal strength after the cortisone injection?

I hope you can help me out. 

Ps. I am a 34 year old male and haven't run since the injection which was 3 weeks ago. I would like to start running again, but only after I am sure the tendon is back to normal strength

Dear Triathlete:

     I am not a proponent as you know of any injections near tendons. I think some patients can tolerate, and others it causes weakness. Since you have already had it, I would recommend taking the next 3 months off from running, and focus on the other parts of the triathlon. Surely there is work to do on your swimming and cycling. With cycling I would not get off your seat until December 1st, and work on form mainly. Is this overkill? It maybe, but you always should err on caution. No negative heel calf raises also which place tremendous stress on the achilles when the heel is dropped lower than the ball of your foot and you raise up from there. Sorry. Rich The article below substantiates this caution. I have had too many athletes tear their achilles when the doctor said the shot was not going into the tendon, only a neighboring bursae. Chalk it up to a learning experience, many races ahead of you with a little caution now. 

http://orthoinfo.aaos.org/topic.cfm?topic=a00147

Achilles Tendinitis: Yes it can get better!!!

This email is from one of my favorite long distance patients. I treated her for achilles tendonitis last year with activity modification, icing, stretching and strengthening. The email shows that this basic approach was successful. She also found a wonderful video on self deep tissue mobilization of the calf, but not to be done if your knee cartilage is suspect at all. The technique requires your knee to be too bent forcifully for too long. But, given good knees, and given a calf or achilles problem, you may want to add this to your regimen. Another example of how I learn more from my patients than medical seminars some times. Rich

Hi Rich;

I meant to make a follow-up appointment with you for earlier this spring, and I got caught up with stuff and never did. Part of the problem (if you want to call it that) is that my Achilles was feeling much better... which meant I wound up putting off making an appointment to see you.

I think I don't need to make another appointment at this time, but I thought it would be good to send you an update.

I kept up with my calf stretches regularly (and heel lift exercises not-as-regularly but still every so often), to where my Achilles no longer bothered me. I stopped wearing the support boot at night. I also felt like I could finally start pushing off with my left foot and I didn't feel any sort of strain.

The big news is that I ran the Mountains 2 Beach Marathon (from Ojai to Ventura) this past May, and qualified for the Boston Marathon! Not only did I BQ; I did so with 5 minutes 12 seconds to spare, essentially guaranteeing a race spot by being able to register during Week 1 (with the rest of the "fast runners"). I have a friend of mine who only made her qualifying time with a spare 100 seconds, who was shut out for the 2016 race because the cutoff was 2 minutes 38 seconds (I assume you know how that two-step process works for Boston).

I have registered and been confirmed to run Boston next April. I also won the "Boston 2 Big Sur" lottery so I will be running the Big Sur International Marathon down in Monterey a week after that.

Things got a little dicey after the marathon. Just a few weeks later, we took a vacation to Grand Teton and Yellowstone, where we ran two half marathons. Since we were doing a lot of hiking and also some camping, I actually didn't stretch as much as I should have... and so June/July was a little concerning because my Achilles tightness came back. I restarted working on them with diligence, and the issue has resolved itself now.

Now that I no longer feel gimped, I find that being able to push off with healthy feet/legs has made a tremendous help in my speed. This past weekend, I ran the inaugural Yosemite Half Marathon, and had I been suffering from Achilles tendinitis that course would have had me howling in pain; the course is 10 miles of downhill, with a leveling off/rolling streets for the last three miles.

However with my healthy Achilles, I was able to just remove my brakes altogether. I finished with a time of 1:40:51.9 and broke my previous PR by 10 minutes. My husband joked that I should put an asterisk on it because it was a gravity-assisted course, but I also came in first in my age group... THAT's legit, since everyone else in my age group also ran the exact same downhill course.

One quick question. A friend of mine forwarded me this video, and I'm wondering what you think. It makes sense; it's essentially like having someone press down on your knots while you try to work them out.

http://mobilitymastery.com/learn-the-one-stretch-that-relieves-plantar-fasciitis-shin-splints-achilles-pain-heel-pain-and-compartment-syndrome/

Cheers!

PS: Sorry about the Giants. The A's sucked this year, too.

Morton's Syndrome: Email Advice

This is an email received. High Arch Feet (aka Pes Cavus) by their structure place inordinate loads on the metatarsals. And, the nerves near the metatarsals can be daily crushed and irritated. Changing the mechanics first is crucial to help this syndrome.

Dr Blake, I urgently need your advice. I plan to walk the south island of New Zealand starting at the end of this year. I have pain in my foot like Mortons Neuroma and very high arches to the extent that I sometimes lose my balance. I have always used arch support insoles with a metatarsal pad. I think I need orthotics for this walk but I'm not sure there's time to get them made. I would also like your advice about protecting my feet during the walk. Could you help me? Thanks 

Richard Blake

You definitely have time to get new orthotics and break them in. Tell the provider that you are willing to pay for a Rush order. You can also experiment with longitudinal medial arch Hapads, but as a metatarsal arch. You go to Hapad.com. Use the right on the left side. I have photos on my blog at drblakeshealingsole.com. You must get the mechanics to off weight the sore area, combine icing, and perhaps a cortisone shot to decrease the inflammation, and you should be much better. Hope this helps. Rich

Of course, my latest photo of my grandson Henry Ellis Blake only 7 days old, and the cutest baby ever!!

Our Camino de Santiago in Northern Spain

Here is my first attempt at sharing our wonderful trip walking 12 days 189 miles along an ancient pilgrimage route in Northern Spain called "Camino de Santiago" or the Road of Saint James. It was an incredible trip with no injuries to report. Our shoe fitting at REI proved paramount to any success. My wife Patty and I trained for 15 months, with long walks almost every weekend. Since I am not a walker, so initially 3 miles seemed a lot. We gradually built up to 18 miles, although nothing can really prepare you for 16 miles a day, day after day. My wife and I used a travel company called MacAdventures to arrange our hotel stays (always nice) and baggage transfer (so only a day pack). It was incredible to accomplish through exercise something great, have hours to meditate (I spent a day alone thinking of my dad who passed last year), experience a deep rooted Spanish cultural tradition, meet people from all around the world (some who will remain friends), be in nature with incredible diversity of landscape, enjoy great food and wine everywhere even in small villages, and have time away from life, great but forever hectic (and this was a remarkable break from normalcy shared with your fellow pilgrims). What we learned is vast, but one special point rings loud. Everyone has their own Camino which is very special to them. It does not matter if you walk, bike, or even drive the Camino. It does not matter if you use taxis and buses at times. It does not matter if you have a back pack or a day pack. It does not matter if you do it all at once, or in sections (we did Stages I and II of the Camino Frances). It only matters that you experience what the Camino has in store for you and be open to what it teachs. My wife and I each had our own Caminos, yet we have an incredible shared experience. We are eager to finish the remaining 311 miles to Santiago de Compostela or just Santiago, but it may be in a few years due to family circumstances. 

CRPS: Email Advice

Hi Dr. Blake,

I am hoping you can offer us some advice as we’re getting pretty desperate.  My son (13 years old) suffers from CRPS.  He has had pain for over 5 years, but the severe pain and hypersensitivity (and other symptoms of CRPS) for the past 2 1/2 years. We have tried prescription pain medications, lidocaine infusions, traditional Chinese remedies, physiotherapy, light therapy, psychology, and most recently neuroprolotherapy (he went into shock).  He is barely sleeping, attending school less than half time and losing touch with friends, etc.  (spiralling downhill and I worry about depression).  I know you ask people to be concise but I’ve attached a description if you have time to read.  Any advice you can offer would be VERY VERY mush appreciated.

Thank you so much,

Dr Blake's comment: 
     Thank you for sending the summary that I read. I am so sorry for this injury. Definitely see if you can get the 10 treatments of Calmare Pain Therapy in the nearest center. I am sure it is not 100% successful, but it is non invasive, and has great successes. Neuroprolotherapy seems very good, but this is with sugar water injections only. I am not familiar with the Ozone injections that gave your son his problems. Find someone for normal neuroprolotherapy if the Calmare gives suboptimal results. Every good pain management specialist that treats this has a topical cream they like. This is so important to find one that you can gently rub in to the tissue for desensitization three times a day. This has to be a daily fix no matter what else you are doing. I guess IV Ketamine Infusion is next, but I am not sure at what age they would start at. I sure hope this helps some. Rich

Sesamoid Injury: Email Advice

Hi, Dr. Blake, 

My 12 year old daughter plays year-round soccer at a very highly competitive level. In early June after coming back from a tournament weekend, she complained of her foot being sore and not able to bend/flex her big toe very well. After asking her more questions, we find out that her foot had been slightly sore when she pushed in on the ball of her foot with her fingers for a couple months. However, now it was sore to walk and her flexion was limited. 

We took her to a podiatrist. MRI revealed inflammation and a bipartite sesamoid. He said it didn't appear fractured because of the clean lines. She was in a walking boot for 4 weeks with no pain. Then, she started wearing her custom orthotics in all shoes. We kept her out of soccer and pretty much all other running activity for another 2-3 weeks. She had little to no pain. We then slowly started her back into soccer wearing her orthotics in her cleats. She would only playing at 50 percent effort/time for a couple weeks and slowly increasing that keeping her discomfort level below a 3. After each practice and game she did an ice foot bath. We also were spica taping her foot all day at school and at practice in the evening and games. All the while she was doing foot strengthening and stretching exercises. A couple of weeks ago she was able to go at 100% effort with very low discomfort. We continued to ice bath after each practice and game, but because of the little amount of discomfort, we discontinued taping. Last week she mentioned it was getting a little sore with pressure again and this weekend at the end of her game she was in a higher level of pain than she had been in several weeks. 

Ugh! Will this ever go away and will she be able to be back playing regularly at her level of soccer? She's only 12 and the podiatrist doesn't do cortisone on children her age, which is fine. And, I don't want to resort to surgery. 

We are struggling with really knowing what her pain level is because she has a hard time determining when she has the "ok" kind of pain and when it's "time to pull back kind of pain". Her podiatrist told us/her that a low level discomfort is normal. 

Please help this mom who jumps to the conclusion that her child will never play soccer normally again! 

Dr Blake's comment:

     First of all, you are to be commended for the great and thoughtful course of action. Unfortunately, there can be many bumps along the way and you need to use the same common sense with each one of them. Children do have a hard time in general distinquishing good and bad pain, so typically parents must team with the coaches to pull the child when limping. I have found that bipartite sesamoids can fracture, but this does not sound like a fracture due to her good early return to soccer. This years advice though would be 100% spica taping while playing, removing any cleat under the sesamoid, making sure the orthotics have good arch support and great dancer's pads, and icing twice daily during the season. If you ever get an xray, please take some photos. Hope this helps some. Rich