Fifth Metatarsal Fracture: Email Advice

Hello Dr. Blake,

   Thank you in advance for answering me and I will be happy to donate to
your blog.

 At the beginning of May of this year (2017) I rolled my foot and broke my
5th metatarsal. It is a slightly displaced avulsion fracture at the base.
I kept it in a soft cast non weight bearing for 4 weeks. After 4 weeks, I
felt I could walk on it while in the cast with out too much pain. After a
week I took it out of the cast and walked carefully. I wonder if this was
too soon, but I thought it was okay because I really had minimal pain.

Dr Blake's comment: This is considered appropriate as you want to stimulate mineralization and the fracture should be knitting well by then. And, you are creating and maintaining the 0-2 pain level. 

When I had a follow up xray 6 weeks after the initial xray, I was actually
surprised that there was no sign of healing and that it was still broken.
Somehow, maybe because of inflammation, I wasn't feeling the break at that
time. Over the course of the summer, I felt weakness in my ligaments and
like I had a 'dumb foot'. I have been trying to strengthen with a tensor
band and balancing. September 27th xray showed no healing in the bone.

Dr Blake's comment: Xrays reflect the amount of calcium in an individual area. Since the fracture area has high metabolism, typically there is alot of water in the area, giving the impression of poor healing. The Golden Rule is that xrays reflect the healing 2 months late, so they are poor indicators of what is happening right now. 

Now, almost 8 months later, I feel the break (tender), and the whole foot
feels sore and achy after walking on it for a half hour to an hour. It
feels great with no pain when I wake up in morning. I just had a CT scan
yesterday to see if there is any sign of healing. Will see surgeon about
results on January 8th. My questions....

Dr Blake's comment: The base of the 5th metatarsal typically bears all of our weight as we lift our heal off the ground. The fracture area can be healed, but sensitive, for 6 months after the injury. Things that help reduce the sensitivity are taping to stabilize the area, inserts with off weight bearing padding to float the broken area, icing and contrasts bathes to daily reduce inflammation, and pain free massage to move the sensitive tissue out of the area and de-sensitize the local skin nerves. I am always afraid, unless you are doing these things, an agressive surgeon will look at the CT scan and do surgery. But, of course, there is no guarantee you will need it, but these are options. Also, if we feel that he bone is slow, get a Exogen bone stimulator for twice daily home use. 
How long before I have to worry about Avascular Necrosis?

Dr Blake's comment: Were there signs of demineralization of the fragment? Since there is such good blood supply, I have never seen it in this area. 

Should I consider putting it back in the boot, or even using crutches
again? Will it make any difference at this point?

Dr Blake's comment: You have to create the 0-2 pain level environment. Some docs and PTs are good designing the padding, experimenting with taping, using PT treatments, perhaps stiff soled hiking boots, hike and bike shoes, etc. Can you send me a photo of the xray, honing down on the fracture? I personnally would not go back in a boot, unless off weight padding or inserts are not helpful. 
I received an Exogen in the mail today. I've heard it's never too late to
use it and can help 'non unions'.

Dr Blake's comment: Great!!!

Should I be concerned about ligaments that are not healing?

Dr Blake's comment: An MRI is needed to check. Definitely with a bad sprain in this area with ligament tears, orthotics and taping for one year in normal. Golden Rule it is normally better to break a bone than sprain a ligament. I know too little to really comment. 

I know surgery is an option if I am still not pain free in a few months
but I have doubts that it will heal from surgery. If such a simple break
doesn't heal naturally doesn't it seem likely that it would also have
difficulty healing from surgery?

Dr Blake's comment: If you do need surgery, it will be depend on what they do. Typically, they rebreak the bone, and put a screw across the fracture. They heal wonderfully unless you have some overall problem with healing: diabetes, smoking, obesity, vascular disease, etc. If you smoke, stop now. There are good studies showing the positive effect that has on surgery healing even if only 3 months have elapsed from stopping. If you have any question on bone health, get a Vit D3 level and bone density. 

 I have done everything I can think of to heal this...supplementation
(calcium, vit D, vitamin C, trace minerals, collagen), acupuncture,
osteopathy, physio.

Dr Blake's comment: Have not heard anything about taping (specifically for the fracture and surrounding ligaments, orthotics of some sort to off weight the bone at heel lift, icing and contrasts for anti-inflammatory, and of course, an MRI to look closer at the soft tissue. 

My main question is...can I be optimistic that I can still fully heal the
bone and ligaments 8 months after the accident?

Dr Blake's comment: I can only say from this far away that it is very rare that surgery is needed, although not impossible. Therefore, with those odds, try to work with my suggestions above, and see if they help. Good luck, and Merry Christmas. Rich

Thank you very much and Merry Christmas!

Sesamoid Pain: Email Advice

Dear Dr Blake,

I found your blog through a search engine and I have read stories on your blog, I feel positive that you may give me a proper advice. I have this pain below my big toe on right feet for almost 2 months since October 22,  developed during my sister in law wedding. I am not a sports person nor do running or dancing. After I return to Singapore, I felt my toe bone hurts very much. I have trouble walking and have to walk while dragging my feet to work. I ignore it for over a month. It is an on and off pain.

After one month of pain, I could not take it, I google about my symptoms and found out it may be likely is Sesamoiditis, which match my condition very well. I read other doctors advises such as stop wearing heels, take as much rest as possible, massage with ice and etc. It helps my condition however with my work nature that requires me to walk a lot, the pain came back. I am still thinking if I should go to see a doctor and do Xray. As I do not have insurance to cover the cost, this is a big dilemma for me. I am afraid it may take a toll on my finance. 

I have switched to a better support shoe and I am also looking for an arch support sole to help my feet to recover faster. Dr Blake, do you think I need to see a doctor? 

Dr Blake's comment: I am sorry for your dilemma. Unfortunately, everyone would tell you the same. Please see a doctor and get the right treatment. Severe sesamoiditis, as you may have, requires months of protection. You must create the 0-2 pain level environment quickly. See if you can find a doctor to put you on a payment plan. You have to treat this as a stress fracture with 3 months minimum of some form of immobilization. You could get adhesive felt from a supplier, and build a dancer's pad to off weight and put yourself in a flat stiff shoe, I use postoperative shoes to start the process. Experiment with spica taping, cluffy wedges, OTC arch supports to protect, immobilize and off weight. Good luck. Rich

Thanks for your assistance in advance.

Regards,

Sesamoid Healing Success!! Keep the stories coming in!!

Hi Dr Blake,

Merry Christmas and Happy New Year! I am thinking back on the year I’ve had and the sesamoid fracture from a few months ago. 

I am happy to report that other than some persisting swelling, I am living a very normal life and not thinking much about my foot at all. I took a trip to Southeast Asia last month, where I did lots of walking and climbing around ancient temples with no pain. I also played a game of baseball with my family recently and had a fun time running all the bases at full speed.

Thanks again for your blog and all your advice!

Dr Blake's comment: Here is the original posting from 3 months ago. 

http://www.drblakeshealingsole.com/2017/09/sesamoid-injury-email-advice.html

Ankle Strengthening with Resistance Bands.

This is an email from one of my blog patients who is trying to strengthen his feet due to severe pain. 

  Hello Rich, how are you?  I have been slowly getting better.  I have been using the ankle-foot maximizer (https://www.medco-athletics.com/afx-ankle-foot-maximizer#sin=34175) for foot strengthening every other day and have a question about strengthening.  There are 4 different color bands with this, yellow being easiest, then red, green and blue.  I am so glad I saw your video on not using the anterior tendon when strengthening the post tib!(https://youtu.be/QP3Ud4d39dc) This is what I've been doing in the evening 3x/week:

WARMUP:

BFST heat for 20 minutes

foot circles 20 each direction

foot dorsiflex and plantar flex 20 reps each

Then start with afx bands: (Yellow for a couple weeks then Red)

Plantar flex         Slight knee bend    

Eversion             Slight knee bend

Inversion            Slight knee bend

Eversion             Knee almost 90 degree

Inversion            Knee almost 90 degree

Dorsiflex            Both slight and bent

Plantarflexion Ankle with Knee Slightly bent

When I do the 90-degree ones, after watching your video I decided to keep my foot slightly plantarflexed by putting a 1" lift under my heel as to not use anterior tendon.  I have been starting with 2x10 on all 6 of these movements.  Next time do 1x10,1x15.   Next session do 2x15 until I reach 2x20 on everything and then move to the red band, which I did just the other day.

Does this sound good?  Any recommendations or changes?

Thanks allot Rich, I hope all is well!

Dr Blake's comment: Almost my friend. The Plantarflexion of the ankle should be done first with the knee slightly bent, and then the knee at 90 degrees or so. The first part gets the gastrocnemius and the second part gets the soleus. The Eversion should be done with the knee slightly bent in both and the ankle first pointed (like in Ballet) and then the ankle at a right angle. The first gets the peroneus brevis and the second the peroneus longus. This the same for the inversion: pointed for the posterior tibial and ankle right ankle for the anterior tibial. You can actually add the third inversion exercise with the ankle pointed and the knee at a right angle to fire the soleus more. The dorsiflexion movement is only with the knee slightly bent. I hope this helps. 

Achilles Tendon Rupture: Email Advice

Dr. Blake

I'm 4 weeks nonop, recovering from a full achilles tendon rupture (approx 7mm) that was sudden impact and not degenerative or sport related, no history of weak tendons, very fit and active 45-year-old male, very clean diet, no drugs or alcohol.  Over the past four weeks, aside from the pain and frustration that comes with the injury, I've dealt with what I've perceived as incompetence and/or lack of care from hospital and ortho specialist staff.  I was in a splint from the er for 7 days, in a cast from ortho for 7 days, and currently, have on a walking boot with wedges in it.  I also ordered a Vacoped/ Vacocast that finally arrived.

Dr Blake's comment: This all sounds fine. You want to keep the achilles plantar-flexed, like the pointing of the foot in ballet, for the next 8 weeks. You will then slowly remove the wedges 1/8th inch at a time over the next 3 months as you get stronger. Start strengthening now by contracting the calf and pointing your foot in the boot. These are isometrics to be done three times a day. You hold a count of 6 seconds, relax for 4 seconds, and repeat 10 times per session. See if you can wear a muscle stim while you are in the boot on the calf. As you wean out of the boot, you have a month of vulnerability where re-ruptures occur. Avoid dorsiflexing over 90 degrees, and especially placing your heel in a negative heel position for this next year. As you wean from the cast, you need to make sure the step you are taking does not produce any tension in the calf. I typically work with a PT at this point who is seeing the patient once or twice weekly to manage the re-strengthening while I see the patient once a month to check strength gains and flexibility problems. I have seen both over flexible and too tight, but once recognized, easy to get back on track. 

I'm anxious to begin rehabbing, but currently exercising patience and caution.  I am willing to give 100% to the right protocol.  My problem is that I can't find any consensus on what is "right".  I'm hoping that your expertise can help ease my mind and that you can offer some help on my path to finding an optimal recovery.

Dr Blake's comment: Feel free to ask questions, and I will place everything in this post. 

Thank you in advance, any advice would be greatly appreciated.

Dr Blake's response: Thank you for your email. First of all, here is the link to one of the previous blog posts on the subject. 

http://www.drblakeshealingsole.com/2010/08/achilles-tendon-ruptures-surgery-or.html

And here are the rules of treatment from my book "Secrets to Keep Moving".

The top 10 treatments for achilles ruptures are:

1.  Decide on surgical vs conservative treatment first

2.  Strengthening begins as early as possible with muscle stimulators or isometrics

3.  Strengthening of the achilles post rupture will take 2 years to complete

4.  Post repair (surgically vs casting) it is vitally important to find out if the tendon is too           tight or over flexible

5.  Control swelling as anally as possible with anti-inflammatory measures since it stops         the normal circulation for healing

6.  Strengthening goal (or you are not rehabbed!!) is 50 one-sided toe raises consistently,       however you need to start with the active range of motion exercises, then progressive         resistive strengthening like with therabands

7.  Deep calf massage started after the tendon is together

8.  Avoid any negative heel stretching

9.  Shoes should have heels or contain heel lifts and/or orthotic devices

10.  Orthotic devices are crucial with overpronators or over supinators

Sesamoid Stress Fracture: Email Advice

Hi Dr. Blake, 

I was wondering if I could get your input on my situation and whether I should pursue additional treatment for the hairline stress fracture in my left tibial sesamoid.

In February of this year, I started feeling an occasional sharp pain when training for sports and went to see a podiatrist in CT who took x-rays and diagnosed me with inflamed sesamoids. I rested/iced/took high strength ibuprofen for a while, but eventually decided to return to playing frisbee because the pain wasn't improving at all and it was my senior year (and we ended up making it to the National Championship game so I wanted to participate). After I graduated, I saw another podiatrist who took more x-rays and also said it was inflammation but thought I should be fine without orthotics or anything. Just continued rest.
Dr Blake's comment: Golden Rule of Foot: Create a 0-2 Pain Level for Healing. Rest however is very destructive overall in allowing deconditioning, swelling, nerve hypersensitivity, etc. I definitely want a more active approach to heal. 

After stopping all running and resting as much as possible for the summer, I still had pain and a lot of swelling. I saw my third podiatrist here in San Francisco and an MRI showed a hairline stress fracture in the tibial sesamoid (even though that spot never particularly hurt when pressed by any of the doctors).
Dr Blake's comment: Could be an over-read of the MRI for just bruising and inflammation. 

I have now been in a walking boot for 6+ weeks, semi-weight bearing with a crutch for the past 4. There is a pad on the bottom with a cutout for the sesamoid. The sharp pain is mostly gone, but I still get bouts of pretty severe swelling where I feel like all the blood is rushing and pooling in my foot. It gets red and hot and tingly. I also have noticed a general tingling when I touch the ball of my foot and big toe. I also developed more pain on the top side of my foot directly above where the sesamoids are and on the underside of my big toe where it meets the foot. Sometimes it feels like it is bruised there.
Dr Blake's comment: Pain, swelling, tingling, etc. that you did feel until after you went into the boot is probably caused by the immobilization and will get better once you leave the boot. Since your injury is so small, and we are not worried that it is a displaced fracture may be needing surgery, try to alternate environments with boot, hoka one one shoes, hike and bike shoes, and normal athletic shoes with orthotics and dancer's padding. 

To make matters more confusing, I am moving in three weeks and starting a new job right away in Hanover, NH. My podiatrist here hasn't really laid out a plan for me, except looking for a referral for me. I am worried that the walking boot may be causing more issues and the lack of PT or rehabilitation could be slowing my recovery. I am wondering what you think about my symptoms and response to treatment so far, and what my plan should be moving forward. I am also very willing to come see you in person since I will be in the area for the next few weeks.
Dr Blake's comment: Several weeks have passed since you emailed this, so you have probably moved. I hope the idea of alternating environments and daily working on the inflammation and nerve hypersensitivity is helpful. Good luck. 

I look forward to hearing from you and truly appreciate the time you take to help others like myself. Thank you very much!

Best,

Sesamoiditis: Email Advice

Dr Blake,

Thank you for the wonderful blog. If it wasn’t for your blog I would have had no idea to make any progress with my sesamoiditis.

The first podiatrist I went to diagnosed me with a fracture from the left foot x-ray, the second podiatrist (who is supposed to be the best in Denver) said there was no fracture on the x-ray and at my insistence ordered an MRI. The MRI also showed no fracture just inflammation in the bone and surrounding tissues

               -          This doctor has given me no advice on getting better other than insisting I                   get    an orthotic made from him and take a cortisone shot (which I refused)

                    Dr Blake's comment: Good for you. It is the long-acting cortisone that we           worry about in a joint. 

-          My pain started in mid-sept and I went to the doctors almost right away.

  I was in the boot for 6 weeks.

 I had zero pain in the boot 

Dr Blake's comment: Yes, you get injured and you do what it takes to create the 0-2 pain level for healing. The secret is to figure out how to keep it as you wean out of the boot and into normal activities. But, you achieved the first part well. 
  My left ball of the foot still feels swollen and makes it uncomfortable to walk on barefoot

Dr Blake's comment: For most bottom of the foot problems, no barefoot walking until you have been completely fine for 2 months. The removable boots never get rid of swelling, and in fact, the velcro straps can trap the swelling in the foot by slightly cutting off the venous return back to your heart. 

 I use Dr Jill’s dancer's pads and high-arch over the counter orthotics.

 I bought Hokas and have been pain-free in them. I am able to walk for 30 minutes in them.

Yesterday I tried a spinning class and unfortunately I am feeling a bit of discomfort today ( I can’t tell if it is good pain or bad pain)

Dr Blake's comment: Spin should be fine. Initially do not get off the seat, and lower the resistance a little. Also, ice right after, and one more time that night for 5-10 minutes. 
 I do contrast bath 2-3 times a week

Dr Blake's comment: If you are swelling, contrast baths starting at one-minute heat one minute ice for 20 minutes, along with pain-free massage and perhaps some PT to remove the swelling. 

 I am naturally too pronated and my ankle rolls inwards

Dr Blake's comment: If your orthotics center your weight, then they are helpful. If you assess how you walk through them, see if you think you should have a higher arch. 

-          Questions for you

How do I get back to activity? I haven’t worked out in 11 weeks and I feel very unhealthy. I tried swimming but my work hours are crazy and it isn’t possible to swim other than the weekend

Dr Blake's comment: Typically it is mixture of impact (walking and advancing to a walk-run program), non-impact (elliptical or spin or stationary bike without the sesamoid on the pedal), and cardio (swimming is the best mixed with some spinning)  The spinning class gave me some pain – should I try it again? Yes, see above.  I am very unclear on how I try to get back on my feet and normal again and the doctor is giving no guidance

Dr Blake's comment: When you hurt your foot, you need to restrengthen your foot, but also condition your legs and core. Many people need the advice of a PT or trainer or both, to get the deconditioned feeling out and get powerful again.   What physical therapy exercises should I try?

Dr Blake's comment: Try to find my description of the well you make to float your sesamoid when weight bearing. Typically four books of an equal height slightly offset to stand on with the sesamoid in a hole or floated. Then you can do your two positional calf stretches, your toe raises (start two feet only), your single leg balancing,  ankle therabands, knee extensions and flexions, and other core work.  I still have swelling but prior to the spinning class had zero pain, is it normal for swelling to stick around? Yes, see above, but you must work on it. 

I feel really depressed all the time with the lack of physical activity and the inability to wear normal shoes to work (I bought some vionics recently and will try them once this bout of spinning class pain subsides)

Is there a doctor in Denver, CO that you would recommend? I need someone who doesn’t try and force me into cortisone shots. 

Dr Blake's comment: I have heard good things about Dr Stephanie Parks. Let me know what you think. Rich

Any help and guidance from you would be much appreciated.

Thank you!

Podiatry Question #2

I hope you enjoyed the first question several days ago. These are meant to educate, but also to test your knowledge. Sometimes there is more than one way to answer, but I need to give you my personal best answer from a podiatrist viewpoint. Hope you all survived Thanksgiving. It is the start of an energetic and blessed, but exhausting, month towards Christmas. I love the Holidays. 

Podiatry Question #2: When we help patients through a rehab process, what pain level do we try to keep them at? 

When rehabbing athletes and non-athletes, working them through the various landmarks of recovery from injury, you must keep them between the 0-2 pain levels which are considered a healing environment. Initially, that may mean needing crutches and a boot, then various forms of taping or braces or orthotics, then some limits on what shoes they can wear, etc. But, in the pursuit of keeping the pain within 0-2, the patient learns what is needed to help them fully recover. I see so many patients spend too much time waiting for a test to be done, with no attention being made to the amount of pain that they have. Every day with high pain levels causes more muscle compensations and weakness to develop, more possible nerve hypersensitivity, and more gait changes to avoid pain. It may be impractical for some reason to reduce the pain this much, but when you do not, you are always delaying the process of complete recovery. I just had a patient that needs her dislocated 2nd toe fixed surgically. This will be the only way to completely eliminate her pain, but I am trying various shoes, taping, Budin splints, icing, and activity modification while the long process of finding a surgeon and the right timing in her life comes along. We must have that as our mantra: Keep the pain down between 0-2. Compromise is needed at times, but we should look for ways to lessen the compromises when we can. 

Podiatry Question #1

I created this blog to teach. I wanted to teach my patients first of all to be smarter in the rehab course, and perhaps to prevent injuries in the future. But, I also created this blog for podiatrists, podiatry students, and all in health care with an interest in feet and biomechanics and overall health. I am in my 6th year of teaching the podiatry students at Samuel Merritt University’s California School of Podiatric Medicine. They are wonderful, and I am blessed. I am starting this series of questions with the hope they will all know the answers by the time they graduate, or even as they begin their practices. Many of these questions will be for lay folks, sports store personnel, coaches, or just students of good health. I will ask the question, followed by a photo to gap the answer by some space, and then the answer. Shall we begin?

#1   When treating tendinitis in any form, what mnemonic is commonly used to think through the possible treatments?

Answer: The mnemonic B.R.I.S.S.  Biomechanics  Rest.  Ice.  Stretching.  Strengthening. These are the 5 key components to treating all types of tendinitis. Of course, there are so many other treatments of tendinitis out there that have helped, but BRISS gets the process started. The Biomechanics are concerned with the forces that caused the injury, and the forces that can be changed to help the injury. Rest is a four lettered word for everyone, especially top level athletes in competition, so we tend to shift the attention to Activity Modification. We need to rest the area, but we need to cross train. Ice is universal for Anti-inflammatory measures, but we are getting better at knowing when to ice, and when to heat, when to use contrast bathing. This also applies to anything that decreases the inflammation including oral medicines, injectables, topical, prescription or OTC, physical therapy, or acupuncture. Stretching is key to relaxing the tissue, and many tendinitis cases do not get better until you can find the way to stretch that makes the area feel better. And finally, Strengthening, is so crucial. We must assume that any tendinitis is caused by weakness of the tissue, or surrounding tissue. Start strengthening to some degree the day you hurt yourself. 

Post Bunion Surgery Suggestions from a Patient

Dr Blake,

Hi, things are really progressing for my toe! Pain is about 0.5 and it’s becoming more and more flexible. I’m in normal shoes with dancer pads—seems to be a good combo at this stage. In a few weeks, I’ll try some orthotics again. 

Anyway, if I had feedback for other patients it would be: 

• Go to Defcon 4 of a healing program for yourself—it won’t get better unless you’re really doing the work. If you do the work, though, it will get better. 
• Contrast baths are much more effective than just icing. Do it front of the TV at night. Easy.
• Physical therapy to strengthen muscles and loosen up the joint. This really works.
• Self-mobilization 3x per day works wonders. 
• Elevate whenever possible.
• Protect your toe from bumping into things with a toe guard or shoe.
• Wear a post-op shoe when you sleep to protect it from injury at night. 
• Take your time and remember that you’re injured—whenever I started feeling better I went too far with my movements and set myself back.
• No pain meds—for me that would just mask injury and not give me feedback about progress and possibly further injure the toe without me knowing.
• Lose weight to put less weight on your foot.

Rehabilitation Lecture at Samuel Merritt University

https://drive.google.com/file/d/0BwmEZgwJ3YN7Z2UwUkFLZHJoTGJnMzhQSThsc01rRVp3UDJR/view?usp=sharing

Ankle Pain with Email Advice

Hello again, dr Blake

I hope you are well. I am sorry to bother you once again. I am sure you are a very busy man. Since last I contacted you, I can report that I have gotten hold of the exogen stimulator, and taking Vitamin D and Calcium supplements (right foot sesamoid problems).

However, I am not writing about my right foot metatarsal problem now. Unfortunately, I have a more acute problem with my left foot. 

Originally, after my running injury 2 years + ago, I ended up with very bad pain in both feet. The pain got so bad that I ended up using a wheelchair for 4 months. About a year after I was diagnosed with sesamoiditis in the left foot after MRI (oedema in both sesamoids). I suspected that I actually had had a sesamoid stress fracture in the left foot too and that it was healing ok. But I also had strange aching pain in all of the left foot and continued difficulty wearing shoes and tight socks. This pain got better very slowly but seemed to get worse every time my right foot metatarsal pain flared up, and I focused on offloading that with more "flat walking". I mentioned it to several doctors, but it seemed to be written off as pain connected to my forefoot-issues. But all the time I had a feeling that while my pain level matched the diagnosis of my right foot, it was not so with the left one.

About a month ago, my left hind foot had gotten quite painful again, and then I felt a sudden stinging pain at the back of my ankle/over my heel. It then felt like I shouldn't place weight on my heel afterwards. In the following week, the pain got worse. After negative x-rays and being written off by my doctors once again, I decided to pay for an MRI myself. This was the description I got:

"Mild tenosynovitis in peroneus tendon sheaths with possible small longitudinal spilt of peroneus brevis tendon distally to the lateral malleolus. The tibial posterior tendon is a little thickened distally against the attachment to os peroneum. Very mild tenosynovitis in the flexor tendon sheath." I have excluded the rest of the description, which was of normal findings.

I have read a lot about these tendons afterwards, and today I was at a physiotherapist with diagnostic ultrasound expertise. He confirmed that it looks like a split right below the malleolus, although a very short one. I have a history of 2 ankle fractures and following sprains (with a major knee injury after 1 sprain) in the left foot since my childhood, so I am thinking there might be a connection there. 

My question to you now would be, what now? I feel that the pain gets very bad with any weight-bearing at the moment. I tried offloading with crutches for a week, but my right foot cannot handle the additional weight. I also have gotten some new pain in the ankle area of the right foot. It doesn´t feel nearly as serious as the in the left, but I suspect some inflammational tendon issues there too. I have used a wheelchair at home for 10 days now, and I feel a lot of pain reduction when offloading the feet.

I read that some use cortisone to get rid of the inflammation, but others say it can damage the tendon more. I see some statistics that look very bad for conservative treatment of tendon split, and that many end up with surgery. Others claim that conservative treatment could work well, after all. Do you have a position on this? Or any advice on how long to offload the foot, before attempting to walk again? 

Dr Blake's comment: I need you to send me the MRI for review, at least a copy. Your symptoms do not match the findings of the MRI. If the physio tests the tendons, do they hurt? You can try resting the ankle in an AFO custom made at a local brace shop. They are prescription items. I see these split tears in some, with absolutely no pain in the area, and no pain on the contraction of the tendon against some resistance when you are testing the strength. I think for some people they are normal variations of that tendon--to not present like a hold piece but to present as multiple strands. Yes, I do not like cortisone for tendon inflammation as there can be some weakening. The 9 classes of NSAIDs could be tried first to find one that works well. Ibuprofen in one class, diclofenac in another, Celebrex in another, and so on. It sounds almost nerve tension, so consider neural flossing, Neuro-eze gel massage, and neurological eval by a doc or neuro PT. Hope this helps some. Rich

Hope for a response from you, yet again.

Kind regards,

A Podiatrist's Look at Knee, Hip, and Low Back Pain: Lecture at Samuel Merritt University

This will be my lecture to the 3rd year podiatry students this Thursday.

https://drive.google.com/file/d/1hyeborJsdbAHiF8EbHvlpGwTATzDMIJr/view?usp=sharing

Calmare for severe nerve pain: More news

https://www.clinicaltrials.gov/ct2/show/NCT03322007?term=scrambler+therapy&draw=1&rank=2

A Pilot Trial of Scrambler Therapy for Pain Associated With Pancreas Cancer - Full Text View - ClinicalTrials.gov www.clinicaltrials.gov A Pilot Trial of Scrambler Therapy for Pain Associated With Pancreas Cancer - Full Text View.

Calmare in the news:  https://njmonthly.com/articles/top-doctors/alternatives-to-opioids/2/

As Addiction Rises, Doctors Seek Pain-Relieving Alternatives to Opioids njmonthly.com Doctors seek new paths toward pain relief amid an epidemic of addiction and death.

Calmare Therapy
Four months after a botched podiatric surgery, Ridgewood resident Marilyn Green started to experience intense pain in her right foot. She was diagnosed with reflex sympathetic dystrophy (now largely known as complex regional pain syndrome type 1), a neurological disorder in which pain from damage to the soft tissues and/or peripheral nerves can spread to other parts of the body. Leery of narcotics, she self-prescribed a combination of B-complex vitamins and exercise that had proven beneficial to her mother after a case of shingles. The treatment offered some relief, but the gnawing pain persisted and began to spread. Green came across an article describing a rare procedure known as Calmare, designed to treat neuropathy, the nerve damage and concurrent chronic pain that can arise after chemotherapy, a shingles outbreak, or surgery. In cases like Green’s, says Michael Cooney, a chiropractor who is one of the few practitioners in the state to use the therapy, “we think there’s a hypersensitivity that’s developed within the pain center of the brain.” The Calmare device uses electrodes to move what Cooney calls “a no-pain signal” through the area of pain in order to “reboot” the brain, so that it’s no longer aware of the pain.

Cooney treated Green with 10 sessions of Calmare, and she is now pain free. “When I went in there, my pain level was at nine,” she says. “On day five of the treatments, it was down to zero.”

Calmare is effective only on true neuropathies; it appears to offer relief ranging from 6 to 18 months or longer.

Fat Pad Atrophy: Email discussion

This patient has fat pad atrophy post cortisone shot one heel and sesamoid area other foot. Here is a discussion we recently had regarding a procedure to move the fat pad placement and inject stem cells to encourage fat regrowth. The doctors are up in Pittsburg, Pennsylvania. I have reviewed the MRI for her noting tremendous scarring of the fat pad at the heel called panniculitis. 


Hi Dr Blake,

I wanted to get your opinion on this procedure. I have lost fat on the lateral side of my left heel as well as under my big toe (same foot) due to a cortisone injection for plantar fasciitis and sesamoiditis. Unfortunately, I haven't found any shoes that help or inserts, taping, etc. I've been doing a lot of research and found 2 doctors performing the Foot Fat Grafting. They're married, the wife is a podiatrist and the husband is a plastic surgeon. It seems like they've had good results for far in their pilot and research study.

What are your thoughts, do you think it's worth trying? I'm only 28 years old and the pain is unbearable. I just want my freedom back.

http://footfatgrafting.com/index.html

https://www.ncbi.nlm.nih.gov/pubmed/27391833

https://www.podiatrytoday.com/can-autologous-fat-grafting-help-address-fat-pad-atrophy-patients-diabetes

Thank you!

Dr Blake's comment:

      I reviewed and found the articles interesting and hopeful. They would, of course, recommend it if you went there. You would need a doc near you to followup, and hopefully, someone independent to think your pain is from the fat pad atrophy also. But, it sure makes sense. Rich

Thanks, Dr Blake. I've had one doctor say it'd atrophy but then others haven't. It's hard because I hear so many opinions, a lot of "plantar fasciitis" but I have the scarring in my heel fat pad that is shown on the MRI. They will do ultrasound prior to the procedure to confirm the thickness 

Dr Blake's comment: 
     I read their reviews. Also, see if you can talk to one of their patients. 

I spoke to one of the patients yesterday and it sounded promising, she only had it done 3 months this ago so hard to say if the fat stays and if the stem cells from the fat help with new growth of the fat pad

Dr Blake's comment:
     I was thinking the same, but as long as we get good results probably does not matter!

They are doing a volunteer study for the heel which I'm going to apply for so it's free. Worth a shot. I'll keep you posted in case it might help others.