Chronic Foot and Ankle Pain post Illness: Spiraling Out of Control

Hello Dr. Blake,

I came across your blog in search for help for a chronic bilateral foot/ankle/leg problem that I've had for over a year now in which I've had a hard time getting a diagnosis for. I was hoping that I could give you some information and you could possibly offer me your thoughts, as I'm desperate.

First, let me say that I'm 52 years of age and am 5'6 and 120 lbs.

During the Winter of 2016-2017, I experienced a very stubborn bout of diverticulitis in which I have prescribed Augmentin (4 courses) for 4 months. I was mostly bedridden during this time. Once I had recovered in early May 2017, as expected, I had a severe amount of atrophy in my legs. I proceeded to do a lot of stretching, mostly of the calves and began walking (in unsupported shoes, unfortunately) about a quarter a mile a day. On my second day of walking, I came home with discomfort in my feet, ankles, hips and lumbar areas which is unusual for me. The following day the discomfort had dissipated.

Within a week, I developed pain in the left foot/ankle, mostly in the front of the ankle (retinaculum area) as well as pain around the outside of the ankle (peroneal) which traveled a few inches up into my lower calf.  I immediately saw an Orthopedic who did x-rays and suggested that I stay off my foot and ice it. Over the following weeks, the pain began to worsen and I visited the local Urgent Care, ER, and my primary care physician. All thought it was a sprain and I was told to stay off of my feet and to elevate and ice.

A month later, I did go back to see the Orthopedic, as the pain had gotten worse and I was beginning to get the same pain in the right foot/ankle. He suggested visiting a Rheumatologist and offered me ankle sleeves and to use a CAM walker boot when making small trips around the house. He recommended remaining off my feet as much as possible. Oddly enough, during this entire time, I never had pain while walking but several hours later.

I went to see a Rheumatologist and all testing was normal. (RA, and autoimmune disorders)

At this time, I went to see a Podiatrist who did x-rays and said that I had a dropped navicular bone and very mild PTTD. He made me a pair of custom orthotics and I wore them 15 minutes, 3 times a day. On the 3rd day, my feet and ankles were in so much pain, I cried and could no longer wear them. I understand that orthotics have a break-in period but my feet felt like they were shattering while wearing them. He then suggested that I try a pair of PowerSteps to get used to and he'd build them up as needed. (See attachments) I began having more areas of my feet/ankles hurting and was getting terrible tightness in my peroneal muscles in which I began seeing a massotherapist.  

Over the past year, I've seen about 50+ specialists. Neuro's, Neuromuscular's, Rheumatologists, Vascular, certified Foot and Ankle Surgeons, additional Podiatrists, Spinal Surgeons, Neurosurgeons and the list goes on. I was MRI'd from head to toe, blood work, etc. I wouldn't be surprised if the total for all of those appt.'s and tests exceeded $300K. Nothing was ever found. Everything from spinal issues to neuromuscular diseases to RSDS/CRPS, etc. have been ruled out.

Dr. Blake's comment: I am sorry!!

During the past year, my legs have atrophied even more. I've tried PT on 3 occasions which always made my pain worse, so various physicians told me to discontinue therapy. (Land therapy caused mild swelling in the feet and aquatic therapy made my feet hurt worse in general)

What's strange is this all presented as outer ankle pain (peroneal) and went up the side of my calf a few inches. Within a month, the other foot/ankle and leg had begun to hurt in the same places.

I'm only "on" my feet about 30 minutes a day. My pain is still bilateral causing both feet to hurt, my sinus tarsi, achilles, peroneals and calves. Oddly enough, I've never experienced pain in my Post Tib around my inner ankle nor have my arches hurt terribly.

Since August of 2017, I gave up my ability to walk stairs, squat down to pick something off the floor and many other things that involve moving the feet and ankles. I find the best position when sitting is to have my feet flat on the floor, as this causes the least amount of pain. I can do these activities, but hours later, I'm in miserable pain for days.

This problem has also caused my knee to pronate inward and I've also begun to experience extremely tight muscles around my hip, groin and IT band that cause me some grief. I have no leg length discrepancy as confirmed by x-rays.

I see a Chiropractor for my hip which he adjusts, but unfortunately, the relief is short-lived. It tightens back up within an hour. I have had luck with Massotherapy in which she works with my feet, calves, and hips using cross friction techniques. Massotherapy has reduced the minor swelling that I have in my feet/ankles but returns upon use. The relief lasts the evening. I did try acupuncture, it did nothing for me except leave me with bruises on my legs.

I do have a pronation problem, more so on the left foot and the left is generally worse than the right. My ankle also rolls in as I walk. I have flexible flatfeet and my ankle slides inward but in no way goes anywhere near the floor. My arches aren't like a pancake, either. I can slide my fingers under my inner arch while bearing weight. (See attachments) I've had 2 MRI's in which no tears or inflammation were found, as well as an ultrasound of both ankles to look at the integrity of the tendons, ligaments, etc. Both of those tests proved to be normal. I can do a single heel raise on both feet with no problems during the act but increases my pain levels hours later. I've tried multiple shoes for stabilization and have noticed that slipping the shoes on and taking them off causes the symptoms to go through the roof.

Dr. Blake's comment: This is nerve hypersensitivity or allodynia.

I recently saw my original Podiatrist again who said that I've progressed to PTTD Stage 2. I don't know how this could be with next to no activity or walking in a year. Most of my appointments have been in a wheelchair.

My Podiatrist is in the process of making me a new pair of orthotics to help with the pain/stability. He used plaster instead of the foam foot boxes. He said these will stabilize my feet and not allow my ankle to pronate inward which he believes will help me. I truly hope so because the pair that I had last Summer brought me to tears within 15 minutes and I had much less pain back then.

I'm just so perplexed as to why all of my MRI's/ultrasounds have been clear, I can do single heel raises, yet have Stage 2 PTTD according to my podiatrist.

Dr. Blake's comment: You are probably just so much weaker, so your arch is lower now, temporarily until we can improve the strength. This is the key to me. With nerve pain, you have normal MRIs. See comments below. You may have to consider epidurals, sympathetic blocks, or Calmare Pain Therapy. Most start with orals like Lyrica.

Could atrophy be a contributing factor in all of this? (I have a very significant amount in my legs) Would gaining some muscle help my situation? I'd be willing to try just about anything but it's hard trying to find an exercise (or even strengthening) that can be done from a bed or while sitting without much foot/ankle movement.

Dr. Blake's comment: Yes, you were set up for this with the diverticulitis, and sickness in general, that started giving you symptoms from this atrophy. Every day that has passed that you have not had normal activity, you have gotten weaker and weaker and weaker. The question is how to reverse this trend. 

During my research online, it appears that most podiatrists use custom AFO's (like a Richie Brace or similar) along with stretching and physical therapy and have had good outcomes in Stages 2 and 3. I'm perplexed as to why my podiatrist didn't suggest this given my previous experience with his custom orthotics.

Dr. Blake's comment: Unsure also. The Richie Brace or AFOs can undersupport a painful arch at the same time letting the leg take some pressure. 

To reiterate, I can walk stairs and walk pretty normally when I have to. The pain appears several hours later and is quite disabling for days.

Dr. Blake's comment: What happens when your muscles are weak, but functional which yours are, that the joints sag a little bit more than normal, and this stresses the nerve endings. The nerves want to protect you so they hurt telling you that you have a problem. They are your friends in this regards. So, we need strengthening work of all sorts, as long as you can recover. Can you swim with floats at the ankles? Can you ride a stationary bike with the seat lowered so there is less stress on the ankle? Can you do active range of motion like ankle circles twice daily and then ice afterward? Were your original orthotics adjust for 25% of the original arch (if they have a deep heel cup they will still be stable but less irritative)? You really fit into the functional rehabilitation 6-week programs that they put CRPS patients in. The therapists who run these are great at teaching you when to honor the pain and when to push through the pain. We need short walks daily with ice afterward for the weight bearing. You may need oral medications to keep the pain down so you can exercise more. These would be the pain medications like gabapentin, Lyrica, Elavil, Pamelor, Cymbalta, etc. 

I've attached several pictures of my pitiful looking built up Powersteps that I've been wearing when weight bearing. I never go barefoot, even for a trip to the bathroom in the middle of the night. I've also attached pictures of my feet for signs of pronation. I don't know if I truly do have PTTD Stage 2 or perhaps a milder version or something completely different. I often wonder if atrophy could be a significant impact on my pain.

Dr. Blake's comment: I would blame this all on atrophy, forget the advice to rest some more, be on crutches, and move more. It may be an every other day program since you will need time to recover and need time for a pain specialist to get you on the right cocktail of meds. The meds are built up over time until you reach the desired result, then stabilized for 2 solid months, and then the process of slowing weaning off them happens. 

While I understand that you can't diagnose me through my attachments, if you have any thoughts or advice, I'd be grateful hearing them. I certainly don't want bilateral flatfoot reconstruction and feel after meeting with my podiatrist last week, I'm in a race against time due to progression. I'd prefer to try as many conservative measures as possible. If I lived closer, I'd make it see you but unfortunately, I'm in the Cleveland Ohio area.

Dr. Blake's comment: First of all, I looked at the photos you sent and saw a little pronation, worse on the left, but there should be no need for any foot surgery. Secondly, I hope the loss of Game 1 to my Golden State Warriors was not too upsetting to you. It was sad to see little LeBron crying over some of the calls. Look online for the organization of neurophysical therapists, and find a good pain specialist. In California, we would have you lathering up the noneuphoric cannabis!!

I absolutely love your blog! It's so informative and I think it's wonderful how you take the time to help others out. Had I known how to post this there, I would have.

I apologize for the length of this, it's been a tough year.

Dr. Blake's comment: I have added an article on Augmentin and muscle weakness. It could have been the dagger that broke your back. Not sure how long this weakness continues once you stop, but it could have added to the normal weakness of being sick. This is not uncommon. I wish you well my friend. Rich

https://www.ehealthme.com/ds/augmentin/muscle-weakness/

Thank you in advance,

The patient then responded:

Hello Dr. Blake,

I can't thank you enough for taking the time to read over my history and symptoms.

I recently received my 2nd set of custom rigid orthotics. (See above) They have good arch support, a deep heel cup and prevent my ankles from pronating. This is the first pair that I've been able to comfortably wear with reduced pain. The mild swelling that I had in the retinaculum in the front of the ankles, as well as the swelling on either side of the achilles, is now gone. This was within 24 hours of wearing them. I've been told the break-in period for these is an hour a day with a steady increase. I was told that if my pain increased to back off a bit to let my legs/ankles and feet recover.

Dr. Blake's comment: You are always dealing with 3 types of pain: mechanical, inflammatory, and neuropathic. I am glad you finally got some mechanical relief. 

Thank you for the information on nerve hypersensitivity. Not one physician could explain why wearing socks or shoes would increase the pain in my feet/calves. I've noticed that foot baths with jets increased the pain as well as when physicians manipulated my feet. 

Dr. Blake's comment: Yes, the nerve aspect of pain syndromes is not taught, or appreciated, by doctors and therapists in general. 

I have seen several pain management physicians and was refused any types of blocks. The only relief that was offered to me was a spinal cord stimulator in which my insurance company would not cover. As for medications, I have tried the majority that you have mentioned but were not well tolerated. Hopefully, with the use of these orthotics, they'll allow me to build muscle with a tolerable amount of pain. The past few days, I've been able to take short walks (5-10 minutes) with tolerable pain. (No sinus tarsi pain, arch pain, but calf pain which I'm assuming is due to a different foot position)

Dr. Blake's comment: In my mind, with weak muscles, strength, not an invasive procedure like spinal cord stimulator, is what you need. Many rejections to meds like Lyrica is because the doctors start the patient on too high of a dose. If you can research the starting dose of the nerve meds again, I can tell you where to start. 

I will try using the local pool with floats around my ankles, as well as a recumbent bike and ankle circles as my body permits. Thank you for this suggestion. Even though I'm within the Cleveland Clinic healthcare system, many physical therapists don't really know what to do with rehabbing feet/ankles. (My previous 3 visits proved this as I was pushed so hard with the "no pain no gain" attitude that I came home in excruciating pain on each occasion). I did look up the organization of neurophysical therapists and have found several in my area, thank you for the suggestion. 

Is noneuphoric cannabis CBD oil? If so, that is legal in Ohio and they make a lotion that I could try on my legs/ankles and feet. 

Dr. Blake's comment: Yes, CBD. 

When my husband and I brought up atrophy, all of the specialists said that atrophy doesn't cause pain. We were pretty confident there was indeed a connection. Thank you for confirming this. as well as it's connection to Augmentin.

Dr. Blake's comment: Here is an article discussing muscle atrophy to pain. It is so common!!

https://www.epainassist.com/muscles-and-tendons/muscular-atrophy
I do realize that this is going to be a long recovery. You're the first doctor that has instilled hope that there is a way out of this pain without surgical intervention. 

Hopefully, I can find some happiness in Game 2 tomorrow. The first game was a real nail-biter. They're both great teams but the Cavs only bought one superstar! On a side note, no one will ever compare to his Airness. His skill on the court was phenomenal, he had such grace, charisma, and class. That's something that seems to be lost in this day and age. 

Dr. Blake's comment: Too bad you have not had the pleasure of watching Stephen Curry through season after season as I have had. Unbelievable!! But Michael was also unbelievable. LeBron is a physical specimen and talent that may never come around again. But something is missing from his game, maybe a humanness that you see more than me. 

Thank you again for all of your help/advice and thoughts. You've provided me with hope which I haven't had in a very long time. 

I sent you a small Paypal donation this evening to help with your blog. You're a true gem of a doctor to help others as you do. I really admire you. 

Thanks again and Take Care,

Sesamoid Fracture Question: Can it Heal Conservatively

Dr. Blake,

First off, thank you so much for providing a forum for people to learn from you and share info about these topics that are difficult to find answers for.  I am a 42-year-old male (6', 175lbs) with a beautiful wife and 6-year-old daughter.  I have been an active, healthy person my whole life and the only health issues I have had have been minor self-inflicted injuries while doing activities that I love.  I am a former baseball jock but my current activities include mountain biking, snowboarding and walking our wonderful mini-poodles with the family.  All of which I do with passion and skill.

In November 2017, I developed what felt like a Charlie Horse in my left foot during the work day which caused me to have a limp that afternoon.  I did have some prior, minor discomfort in the left foot from what I thought was a strain from playing softball.  That night, when I was gingerly hopping up our hardwood, bullnose stairs barefoot, I stubbed my left toe to the point where it brought me to my knees in mid-air.  I knew something was wrong and my foot confirmed it by swelling up like a balloon.  The swelling extended past my ankle.  I implemented R.I.C.E. and canceled all activities for a while.

I will spare you the details of the triple misdiagnosis (first Xray was December 2017) over the next few months but my foot was actually feeling better through Winter 2018.  I went snowboarding several days, biked, walked the dogs a bit, walked to lunch - all very carefully and not through pain as much as discomfort.  After a slow increase in pain, another opinion was had and an X-ray was taken in March 2018.  It turned out "negative" although they put me in a walking boot and recommended an MRI.  The pain (and curiosity) held steady enough to get the MRI in April 2018.

At the MRI follow-up appointment (my first knowledge of the results) I couldn't process the severity as I had no clue the context: a "subacute mildly displaced ununited fracture to the medial sesamoid".  The gap between the broken pieces was .47cm.  Sesamoidectomy was recommended.  After the initial shock and research of sesamoid fractures online for a few days, the daily crying began.  What have I done!!??  The pain has increased greatly since that appointment as I now know exactly what I am up against.  I am now on crutches, working from home, immobilizing and basically going insane trying to figure out what course of action to take.  I am also now well versed in the pros and cons of surgery vs. conservative treatments.

So now that I have that off my chest, my primary question to you is... given the timeline, imagery, and gap between the broken pieces, is there any chance of avoiding surgery?  I have never really given the bone an opportunity to heal over the course of 6 months.  In fact, it felt like it was healing in January and February 2018 yet was already nonunion per the December 2017 Xray.  Is there any hope this can still heal by conservative treatment?  If the answer is yes or maybe, I will surely have follow up questions but for now, I'm looking to know if you have ever seen someone recover conservatively from a gap as big as mine? 

Please see attached images - they are pictures of pictures but if you need higher quality images I can provide them.  The December 2017 Xray is the image with no measurement noted, the .47cm image is the Xray from March 2018 and the April 2018 MRI is the side shot.

This has turned into a nightmare with the indecision aspect of it particularly taxing on my family and me at the moment.  Any feedback you can give is greatly appreciated.  Thank you so much for your time!

Dr. Blake's comment:
     I thank you so very much for giving me the opportunity to way in on this. The gap is very big so the edges will not go back together. When you stubbed your toe, you must have jerked it upward so that the pull of the tendon pulled the pieces apart. I wonder if it was a bipartite sesamoid, to begin with, and injury separated the two pieces. 
     I remember I had a young boy who did this supposedly in basketball, but it turned out to be separated from slamming on the brakes in the head-on collision with a fence. 
     The question really is it okay for you to function, once the inflammation calms down, with this is a non-union status. There is a chance for sure, that once you get this calmed down, if you can get it calmed down, that this will be pain-free. It will take you time, but I would try if it was my toe. 
     One of the key images you sent was the lateral (side view) from the MRI. What is striking, more than the x-rays is the lack of bone response in the sesamoid in two pieces.
This is very unusual that an injured sesamoid shows no sign of bone reaction throughout the sesamoid. Very unusual.  
    So maybe this is not a sesamoid fracture, but a sprain of a bipartite sesamoid. Good chance this could heal, and your body is already used to it in two pieces. Do you have any old x-rays of this foot? 
     In actually even the fibular sesamoid looks beat up and could be part of the problem. 
     The side view also shows the big toe dropped lower on the metatarsal then it should. Do you remember if the toe went up or down, you may have torn a ligament and have some version of turf toe? If you have surgery, it could be just to sew up a ligament. 
     Too many questions from my end to just say go under the knife, although that is my bent in life, and my bias that you have to accept. Has anyone evaluated for a ligament tear? Please mail me a copy of the CD on the MRI so I can review. The address is Dr. Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. There is not a charge for this. The next 2 months do what you can to create the 0-2 pain level with a boot, etc, and ask questions about the possibility of bipartite sesamoid sprain, tendon tear of the hallucis brevis, ligament tear, etc. Someone needs to at least entertain thinking outside the box. I hope this helps some. Rich
     

Sesamoid Fracture in a Young Athlete: Email Advice

Dear Dr. Blake,

     I want to thank you for all of the time and love you have put into your blog. It is by far the most comprehensive and detailed source of sesamoid injuries that I have been able to find. I was wondering if I could ask a few questions about my daughter because I would like to know if we are on the right healing path.

Dr. Blake's comment: Thank you for your kind remarks. I will be happy to answer them in hopes of giving you some guidance. 

     First, to give you some background, my daughter is a 9-year-old soccer player. She was diagnosed over a year ago with Sever’s disease, and despite our efforts to cushion her heels, the pain was quite severe. However, she continued activity and playing soccer through the pain, and tended to compensate for the pain by running on her toes.

Dr. Blake's comment: I hope now you understand how bad limping is. A child may not be able to describe the pain and use good judgment on what not to do, so I have to tell parents and coaches that as soon as they see limping, the child has to be pulled from the game or practice. 

    Flash forward to 8 weeks ago, she woke up in the morning with a very sore big toe after a week of heavier than normal activity. After x-rays and a referral to an orthopedic surgeon, she was diagnosed with a stress fracture of the fibular (lateral) sesamoid. The doctor’s recommendation was to get her in more supportive shoes, Superfeet insoles, and rest (no running, jumping, barefoot walking). After a week or two of this, and scouring the internet for advice, we added dancer’s pads and toe taping to the regimen. Additionally, we have been having her supplement extra calcium, vitamin D, and magnesium. With all of these modifications, her pain level was down to a 1 by her judgment.
Dr. Blake's comment: I would have put her in a removable boot, but I am glad you got the pain to 0-2 range for healing. The issue now is to keep an active child in this for the next 3 months to guarantee good bone strength. With a stress fracture, there is no visible gap of the fragments, which is an MRI diagnosis. This is very hard, but possible, to diagnosis on x-ray. I hope we are talking about the same thing. 

     At her 4-week check-up, slight healing could be seen on the x-ray, however, her pain had not changed.

Dr. Blake's comment: You can not follow the progress on xray, which the healing shown lags up to 2 months from where it is. You can also not follow the progress on palpation, because the bone will remain sore to touch months after it has healed. I had a 16-year-old, who was back running 10 miles a day 5 days a week tell me the bone we still just as painful for another 18 months on palpation. You immobilize the pull of the toe bend, you off weight the area, for 3 months on average, and then you gradually increase activity again. During the 3 months, you work on both nerve hypersensitivity with nonpainful massage 2-3 times a day and inflammation part of the healing process with contrast bathing and icing. 

     The doctor’s advice was to continue as we were and come back in 4 more weeks. During the 7^th week, she noted a small improvement in pain. At the 8-week check-up, the fracture looked only very slightly better than at 4 weeks. The doctor’s advice was to continue for yet another 4 weeks or go non-weight-bearing in a hard cast. He recommended to just continue as we were as he is not a fan of casting a child in this case.

Dr. Blake's comment: So if you are following it by x-ray, you are going to be misled. Sounds like it is a fracture, although without an MRI it could be a bipartite sesamoid that is bruised. Your doctor sounds like he/she has good wisdom. What are you doing gauge the pain? Remember, palpation is not a useful tool. The improvement in swelling would be a good indicator. I think going the 3 months in the boot keeping the pain level to 0-2 is just fine. If she is walking in the boot for 2 weeks with a 0-2 pain level, she can start the 2-6 week course of weaning out of the boot into a shoe, orthotic, dancer's pad, spica taping, and cluffy wedge. The initial goal is to keep the pain between 0-2 and wean out of the boot. The goal is not to have it look better on x-ray or feel better when you push on it. 

So, given all of this information, I would like to ask a few questions:

1. How often is this injury seen in a child so young? I have read that the sesamoid bones ossify around this age, could that have something to do with her becoming symptomatic? Do children usually go on to complete healing, or are we looking at a lifetime of issues? Dr. Blake's comment: It is rare for kids this early, but I have found if they are wearing cleats with long spikes right under the sesamoid it can get beat up. Some people have really prominent first metatarsals plantarly (on the bottom of the foot) and are prone. Kids are just are vulnerable as adults to bone health issues, so evaluation of any dietary issues could lead to bone density issues. Therefore, it is possible for many reasons. As I am treating a patient, I like to look for 3 possible causes of any injury besides bad luck (called the Rule of 3). For sesamoids, this can be bone abnormalities, bone health issues, cleat placement or shoe bend issues, biomechanics of how she runs, etc. 
2. Since she is able to currently keep her pain level below a 1 as long as she is in her shoes, would you say that it is ok to keep her like that? Or would you recommend switching to a boot or cast? Dr. Blake's comment: I am sorry but I thought she was in a boot. Definitely stay away from the hard cast, so hard to rehab from. I would definitely spend 4-6 hours in a boot and orthotics for the next 6 weeks if she has not been wearing a boot. I would forget about more x-rays if you take a photo of any of the images seen them my way. I prefer an MRI if possible to make sure we are dealing with the correct diagnosis. I have had some patients where we thought fracture, only to have the MRI show soft tissue bruise or bursitis. 
3. I’ve read your advice for contrast bathing. Is this primarily recommended to help with pain and swelling (which she does not have), or will it also promote healing? Dr. Blake's comment: Yes, probably the best thing you can do if she is getting the right calcium and Vitamin D are daily contrast baths. It is a wonderful flush of the deep swelling that sits in the bone and makes it hurt longer than necessary. The deep swelling can actually cut off the circulation to the sesamoids and stop healing. So, contrast away!!
4. Our doctor said that he didn’t think a bone stimulator is recommended for a child her age, and also suggested that insurance would not pay for it. Do you think it is ok? How would I go about getting one, or access to one, without insurance? Dr. Blake's comment: Yes, exogen is for skeletally mature individuals 18 or over. Sorry, this not an option.
5. After having taken 8 weeks off already, what would be a reasonable time-frame to expect that she could be back on the soccer field? Dr. Blake's comment: The normal would be 3 months of some form of immobilization maintaining 0-2 pain, then 2-6 weeks weaning out of the boot maintaining 0-2, then a walk-run program of which she can do in her cleats building up to 30 minutes of straight running, then sport specific drills from the coach like cutting, pivoting, etc which usually is progressive in terms of the demands on the tissue. So, 3 months is the fastest from now. During this time, based on symptoms, she may need different cleats, different orthotics, better evaluation of her biomechanics,  getting an MRI, so you see what it takes to keep her in the 0-2 range. When you do it smart and progressive in terms of loads, you avoid re-flares which are so frustrating for everyone. Hope this helps some. Rich

Thank you very much for taking the time to read this and for answering my questions.

Sincerely,

Tip for Sesamoid Problems: More Shoe Volume

     I do not think I have really focused on this aspect of sesamoid injuries but many of my patients say that the volume of the toe box area is crucial to feeling better. By this I mean less material in the orthotic near the big toe joint, more width and height of the toe box area, even skipping the laces above the first metatarsal to have more room. I am one that loves Hannafords with a lot of cush, but sometime that works against me. It requires me to experiment when patients can not maintain the required 0-2 pain level due to too much pressure. 

Tip for Plantar Fascial Tears: Hoka One One Shoes

Hi Dr. Blake, got the HOKA shoes, and I'm loving them.  I can move so much easier in them, and very little pain (definitely 0-2 range).  I can also put both the right and the left orthotics in, which balances things out pretty well.  I feel like I'm walking more naturally, and I think my legs are getting toned too!  Anyway, thanks a bunch, and I'll see you soon for a follow-up appointment (the 8th, I think).  

Hope you are well!  

Dr. Blake's comment: These are shoes that roll through the forefoot, limiting toe bend at push off. This is valuable for many forefoot problems and, in this case, plantar fascial tears where you are limiting toe bend and the pull of the fascia for up to 6 months post-injury. 

Plantar Fascial Tear: Email Advice

Hi Dr. Blake,

     I had sent you my MRI disc back in January, and you confirmed what I had suspected for a while, that I indeed had a plantar fascia tear. I have to admit, I have not exactly followed your advice to the word. I did wear the boot, but only for 2 months...as it turns out, my dog had to have her third surgery in 7 months on her leg, and it was extremely difficult to help her with the boot on (she's a large dog, 70 lbs, and it required walking next to her on leash at all times, lifting her, etc.).

Dr. Blake's comment: Very understandable. I would have had you switch to Mountain Bike shoes with the cleat embedded into the shoe. Mountain Bike Shoes with Built In Cleats 

     I gradually weaned out of the boot over a few weeks. Things are not going as well as I had hoped. My foot still bothers me on a consistent basis, which I don't understand, because up until last week I hadn't even *tried* anything that should irritate it. 

Dr. Blake's comment: Were you able to attain the 0-2 pain level in the boot? You have to be in the boot for at least several months at that low pain level. If not, either go back into the boot or try the mountain bike shoes. Your orthotic devices should shift the weight into the arch and feel protected and soft under the heel. 

     One night last week I was sitting on my couch, and I thought you know what? I'm just going to give a quick run a shot. It was probably about .35 mile. I knew not to try anything crazy. I have attempted the same a few times since then, and it feels like I'm back to square one again. It doesn't necessarily bother me during the run, but afterward. My foot is still sore in the mornings (but that never really went away anyway), but it's not like PF pain...it's kind of just diffuse soreness that is more noticeable around the PF attachment to the heel...I'm wondering if this morning soreness something I'm going to have for the rest of my life? It also doesn't take as long to go away as it did at its peak.

Dr. Blake's comment: We use our general rules on time, but one person can be different than the next, unfortunately. You need to be so much better day after day before you can run. Your symptoms can mean that things are healed, but not strong. Day to day has to be good first with the boot or shoe before you can wean from the boot or shoe. Then you need to build up your walking so that you are at a minimum of 2 weeks, no pain, walking at least 30 minutes at a nice clip before you start a walk run. You probably should be wearing the boot or shoe during the day to rest the tissue, use the support the foot taping 5-6 days at a time, continue icing and try some contrast bathing to see how you feel. 

     I also noticed that, while the middle of my heel isn't sore to poke like it used to be, there is a spot that still hurts to touch, and I'm not sure why? (The spot I am pointing to in the photo.) Sneakers really seem to bother me in that spot, I have found only the crocs I use for the yard are comfortable. I have started to wonder if there is not something going on in conjunction with the tear...a nerve issue maybe? 

Dr. Blake's comment: That could be a possibility. You are pointing right to the plantar fascial attachment so that does not like unusual. You could have a plantar heel bursa. Those can be painful. Try to use the frozen sports bottle roll over the sore bottom, but do not roll into the plantar fascia tear. Only the direct bottom of your heel for 5 minutes twice daily. 

     I also noticed after every attempt at a short run, my calf gets really, really tight. I try rolling and using the stick and it doesn't seem to help at all. I know I didn't follow the protocol exactly, but I have been pretty careful, and I just feel so discouraged about the level of discomfort I still experience on a daily basis. 

Dr. Blake's comment: With plantar fascial tears, in the immobilization phase, I allow no stretching of the calf or fascia. The two weeks you are out of the boot, and feeling good, I allow patients to begin to stretch the calf, but still no the fascia. This can give symptoms of tightness, so do not be too discouraged. The next 2 months boot or shoe, ice twice daily, tape daily, stretch the calf as long as the heel is firmly on the ground three times a day. You can get PT so long as there is no stretch of the arch. 

     It is really wearing me down, I just want to feel like I have my life back again. I'm also having a heck of a time trying to find a doctor out my way, and I was wondering if you might be able to offer any advice in that regard? (I have seen 4 podiatrists in person, none of whom helped me at all, which is why I ended up finding you.) As always, thank you so much for reading and for your help!

Dr. Blake's comment: Check the members for the AAPSM (sports podiatrists) in your area!! Typically we can find someone. It is not certain that you say you are a sports podiatrist and practice a conservative meaningful approach. 

Pointing to the attachment of the Plantar Fascia at the Heel

Another email before I could respond:

Hi Dr. Blake,

     So sorry to bug you with another e-mail. I am really struggling with what kind of doctor to see. Two of the podiatrists I have seen previously were members of the American Academy of Podiatric Sports Medicine...and unfortunately, their advice was less than helpful. I thought I would make an appointment with a local foot and ankle orthopedic specialist...except the receptionist (pretty rudely) informed me he will only take on surgical cases. So, I made an appointment with their podiatrist instead, but upon finding this out my PCP told me it would essentially be a waste of time and that this particular doctor would probably prescribe a pair of orthotics and send me on my way. Should I be looking for a podiatrist, a sports medicine doctor who doesn't necessarily specialize in feet, or an orthopedic foot and ankle doctor?
Dr. Blake's comment: I am sorry. I do feel podiatry is the way to go for this. I would call the office of Dr. Stephen Pribut near DC. He is wonderful. Tell Dr. Pribut that I am asking you to see him or recommend someone close to you. My son played basketball in Wayne at Cabrini College so I know that is quite a distance. He may have the exact person for you to see. Are you in good orthotics? What shoes are you wearing? What are your running mechanics like? These are all questions we need answers to help you. Temple University has a podiatry school that may help. There used to be a Dr. Howard Palamarchuk, but I am not sure if he still practices. 

      Do you know anyone in the relative Philly area you could recommend? I am having such a hard time, and I have spent so much already on this issue, my resources are pretty limited...so I can't afford to pick the wrong place again. I also noticed that along with tenderness at that point in the photo from my previous e-mail, my foot is a bit swollen around the back of the ankle and the inner arch...not sure how much concern this warrants?
Dr. Blake's comment: These are areas that fluid from any cause can collect in. Probably not a big deal. 

As always thank you so much for your help!

Dr. Blake's response:  I will sit down this weekend and answer I promise. Rich

Hi Dr. Blake,

     Please take your time! Thank you so much for getting back to me. I somehow managed to forget to mention this...sometimes I will get a stabbing pain in that sore spot in the first photo, it comes in bursts of about 10-30 seconds, it is quick but SO painful. Feels like someone repeatedly stabbing a knife in that spot...and it happens randomly, sometimes even when I’m just sitting at my desk(???)...it happened yesterday after I finished mowing the yard, and I held my foot up thinking if I put it down the pain would be unbearable...to my shock it really didn’t make a difference. I’m not sure if this is a clue to what’s going on???

Dr. Blake's comment: When you tear the fascia, we want scar tissue to get in there and heal the injury. The scar tissue can get bound up in the local nerves giving you these symptoms. These should improve as you begin to stretch the fascia, but that is probably 3-4 months away. Good luck my friend. 

Thank you, Dr. Blake!!

I am attaching for the readers my Plantar Fascial Protocol we give patients in the office. 

https://www.drblakeshealingsole.com/2014/08/plantar-fascial-tears-top-10.html

The following is the patient's response to my questions and comments.

Hi Dr. Blake,

     I had sent you my MRI disc back in January, and you confirmed what I had suspected for a while, that I indeed had a plantar fascia tear. I have to admit, I have not exactly followed your advice to the word. I did wear the boot, but only for 2 months...as it turns out, my dog had to have her third surgery in 7 months on her leg, and it was extremely difficult to help her with the boot on (she's a large dog, 70 lbs, and it required walking next to her on leash at all times, lifting her, etc.).

Dr. Blake's comment: Very understandable. I would have had you switch to Mountain Bike shoes with the cleat embedded into the shoe. Mountain Bike Shoes with Built In Cleats

Is something like a Hoka One One an acceptable alternative? (I have an old pair I can try before buying new to see if they seem to help at all.) Dr. Blake's comment: Not as good, but you can alternate back and forth for the next 4-6 months. 

     I gradually weaned out of the boot over a few weeks. Things are not going as well as I had hoped. My foot still bothers me on a consistent basis, which I don't understand, because up until last week I hadn't even *tried* anything that should irritate it. 

Dr. Blake's comment: Were you able to attain the 0-2 pain level in the boot? You have to be in the boot for at least several months at that low pain level. If not, either go back into the boot or try the mountain bike shoes. Your orthotic devices should shift the weight into the arch and feel protected and soft under the heel.

Yes, after the first week my foot adjusted to the boot and it really wasn't painful wearing it at all, which is also one of the reasons I felt it wouldn't be too terrible to wean out of it at 2 months when I needed to help my pup! Dr. Blake's comment: Your beautiful dog's photo did not transfer over. The boot did its job, but what you went into after was inadequate to continue the immobilization. It also could have been the orthotics, not taping, doing too much with the new found freedom. 

     One night last week I was sitting on my couch, and I thought you know what? I'm just going to give a quick run a shot. It was probably about .35 mile. I knew not to try anything crazy. I have attempted the same a few times since then, and it feels like I'm back to square one again. It doesn't necessarily bother me during the run, but afterward. My foot is still sore in the mornings (but that never really went away anyway), but it's not like PF pain...it's kind of just diffuse soreness that is more noticeable around the PF attachment to the heel...I'm wondering if this morning soreness something I'm going to have for the rest of my life? It also doesn't take as long to go away as it did at its peak.

Dr. Blake's comment: We use our general rules on time, but one person can be different than the next, unfortunately. You need to be so much better day after day before you can run. Your symptoms can mean that things are healed, but not strong. Day to day has to be good first with the boot or shoe before you can wean from the boot or shoe. Then you need to build up your walking so that you are at a minimum of 2 weeks, no pain, walking at least 30 minutes at a nice clip before you start a walk run. You probably should be wearing the boot or shoe during the day to rest the tissue, use the support the foot taping 5-6 days at a time, continue icing and try some contrast bathing to see how you feel. 

I can't even walk my other golden without pain, so I should have known better than to attempt a run, but I was having a "good" day so I thought I'd test the waters, and also I'll admit I was getting impatient. Dr. Blake's comment: In my world, we need to talk in terms of a consistently good week, over a run of good days, before attempting the next level of activity. That would have been a walk-run program as outlined in my blog. 

     I also noticed that, while the middle of my heel isn't sore to poke like it used to be, there is a spot that still hurts to touch, and I'm not sure why? (The spot I am pointing to in the photo.) Sneakers really seem to bother me in that spot, I have found only the crocs I use for the yard are comfortable. I have started to wonder if there is not something going on in conjunction with the tear...a nerve issue maybe? 

Dr. Blake's comment: That could be a possibility. You are pointing right to the plantar fascial attachment so that does not like unusual. You could have a plantar heel bursa. Those can be painful. Try to use the frozen sports bottle roll over the sore bottom, but do not roll into the plantar fascia tear. Only the direct bottom of your heel for 5 minutes twice daily. 

If it's an inflamed bursa, is it safe at this point to get an injection? Or should I avoid them indefinitely in that foot since it has a history of a tear and that would only further compromise the integrity of the plantar fascia? Before I used to have pain directly in the center of the heel (red circle), now it seems to emanate out from the sore spot into the side of the arch (yellow) and the actual heel has little to no pain...but I should be icing where the circle is? Dr. Blake's comment: Yes, that is where you ice. The bursae are under the heel. Are you having any pain there? Does not sound like a good idea to inject. Yes, I fear the plantar re-tearing some. 

     I also noticed after every attempt at a short run, my calf gets really, really tight. I try rolling and using the stick and it doesn't seem to help at all. I know I didn't follow the protocol exactly, but I have been pretty careful, and I just feel so discouraged about the level of discomfort I still experience on a daily basis. 

Dr. Blake's comment: With plantar fascial tears, in the immobilization phase, I allow no stretching of the calf or fascia. The two weeks you are out of the boot, and feeling good, I allow patients to begin to stretch the calf, but still no the fascia. This can give symptoms of tightness, so do not be too discouraged. The next 2 months boot or shoe, ice twice daily, tape daily, stretch the calf as long as the heel is firmly on the ground three times a day. You can get PT so long as there is no stretch of the arch. 

I have KT Tape, is that ok to use? Dr. Blake's comment: yes, there are many ways to tape with good results. Start with KT to see how it works for you. 

     It is really wearing me down, I just want to feel like I have my life back again. I'm also having a heck of a time trying to find a doctor out my way, and I was wondering if you might be able to offer any advice in that regard? (I have seen 4 podiatrists in person, none of whom helped me at all, which is why I ended up finding you.) As always, thank you so much for reading and for your help!

Dr. Blake's comment: Check the members for the AAPSM (sports podiatrists) in your area!! Typically we can find someone. It is not certain that you say you are a sports podiatrist and practice a conservative meaningful approach. 

Another email before I could respond:

Hi Dr. Blake,

     So sorry to bug you with another e-mail. I am really struggling with what kind of doctor to see. Two of the podiatrists I have seen previously were members of the American Academy of Podiatric Sports Medicine...and unfortunately, their advice was less than helpful. I thought I would make an appointment with a local foot and ankle orthopedic specialist...except the receptionist (pretty rudely) informed me he will only take on surgical cases. So, I made an appointment with their podiatrist instead, but upon finding this out my PCP told me it would essentially be a waste of time and that this particular doctor would probably prescribe a pair of orthotics and send me on my way. Should I be looking for a podiatrist, a sports medicine doctor who doesn't necessarily specialize in feet, or an orthopedic foot and ankle doctor?
Dr. Blake's comment: I am sorry. I do feel podiatry is the way to go for this. I would call the office of Dr. Stephen Pribut near DC. He is wonderful. Tell Dr. Pribut that I am asking you to see him or recommend someone close to you. My son played basketball in Wayne at Cabrini College so I know that is quite a distance. He may have the exact person for you to see. Are you in good orthotics? What shoes are you wearing? What are your running mechanics like? These are all questions we need answers to help you. Temple University has a podiatry school that may help. There used to be a Dr. Howard Palamarchuk, but I am not sure if he still practices. 

Before I received your reply I made an appointment with another podiatrist who is also a runner for next week. If that doesn't work out, I will definitely call Dr. Pribut, thank you!!! 

      Do you know anyone in the relative Philly area you could recommend? I am having such a hard time, and I have spent so much already on this issue, my resources are pretty limited...so I can't afford to pick the wrong place again. I also noticed that along with tenderness at that point in the photo from my previous e-mail, my foot is a bit swollen around the back of the ankle and the inner arch...not sure how much concern this warrants?
Dr. Blake's comment: These are areas that fluid from any cause can collect in. Probably not a big deal.

Ok!

As always thank you so much for your help!

Dr. Blake's response:  I will sit down this weekend and answer I promise. Rich

Hi Dr. Blake,

     Please take your time! Thank you so much for getting back to me. I somehow managed to forget to mention this...sometimes I will get a stabbing pain in that sore spot in the first photo, it comes in bursts of about 10-30 seconds, it is quick but SO painful. Feels like someone repeatedly stabbing a knife in that spot...and it happens randomly, sometimes even when I’m just sitting at my desk(???)...it happened yesterday after I finished mowing the yard, and I held my foot up thinking if I put it down the pain would be unbearable...to my shock it really didn’t make a difference. I’m not sure if this is a clue to what’s going on???

Dr. Blake's comment: When you tear the fascia, we want scar tissue to get in there and heal the injury. The scar tissue can get bound up in the local nerves giving you these symptoms. These should improve as you begin to stretch the fascia, but that is probably 3-4 months away. Good luck my friend. 

That makes sense to me!

Thank you, Dr. Blake!!

I am attaching for the readers my Plantar Fascial Protocol we give patients in the office. 

Followup on Foot Fracture and Nerve Pain

This patient broke her toe and developed severe nerve pain afterwards. This post is also included on her original post of 4/5/18. This is a wonderful example of how active we have to be in our treatment to get the right healing plan working. 

Hi Dr Blake,

I wanted to give you and your blog readers an update...

I was worried after fracturing my toe (4th toe on left foot) I was developing CRPS because I have other nerve issues.  I fractured my toe on Feb 2 and the pain just got worse.  My foot turned ice cold blue and was like that for over a week plus my fracture wasn't healing and I was having shooting nerve pain/burning in my foot.  I am wearing a boot and have a scooter.  I did the following to try to heal my foot (which I found some of it on the blog from another reader):

• Went to a new anesthesiologist who just moved here from Cleveland Clinic and specializes in CRPS.  I was lucky to get a next day appt with her.  She was very nice and felt that it wasn't CRPS.  She did give me Cymbalta - which I didn't take since I am sensitive to medication.
• Bought a used bone stimulator and used it twice a day (based on recommendations from several doctors - including Dr Blake)
• Light massaging to increase the blood flow
• Putting leg up when sitting or lying down
• Started taking (all of these without fillers) each day:
• 1200 mg of R-Alpha lipoic acid
• 1200 mg of NAC
• 2000 mg of vitamin C (powder to mix in water with cranberry concentrate)
• 600 mg of Calcium Citrate (powder to mix in water with cranberry concentrate)
• 5000 mg of vitamin D
• Magnesium citrate
• I am taking some herbs as well
• Stinging nettle tincture (without alcohol)
• Horsetail (without alcohol)
• Comfrey tincture rubbing on skin over fracture and applying DMSO on top for better absorption.  I purchased Heiltrophen on Amazon - the bottle and dropper are glass which is important because DMSO absorbs everything.  I applied with clean hands and washed them afterwards without soap.
• I tried Dr Christopher's Syrup and Ointment for bone and tissue repair a friend recommended.  Tastes and smells awful.  Lots of stars on Amazon but I couldn't stand it to take it consistently.
• Mirroring 
• My friend let me borrow a mirror so I am doing some mirroring exercises I found on youtube.
• Went to Orthopedic surgeon (I wanted a second opinion in addition to my very good podiatrist just because the foot wasn't healing).  I was lucky that the orthopedic doctor for the feet of the US ski team had an appt.  Really nice guy - he just confirmed what my podiatrist had recommended)  He said I needed to be off the foot for 6 weeks and gave me a clearance for work.

So I am happy to say after 6 weeks on my protocol,  that the pain is almost gone from my foot.  I don't have the shooting nerve pain in my big toe and the burning is less.  I am able to walk very short distances without the boot.  It isn't keeping me up at night.  It looks like I am on a positive trajectory.  I think it will still be a while before I really feel comfortable walking longer distances and doing my normal routine but at least, it is getting better.

Thank you so much Dr Blake for your support and help.  

Hallux Varus after Sesamoid Removal Years Later

Hello Dr. Blake,

I have just spoken with your nurse/receptionist and she suggested I describe my foot concern to you.
I had sesamoid surgery on both my feet twenty-five years ago in Pasadena California.
Up until last summer, my feet were handling my everyday wear and exercise just fine.  
But, in the summer, I decided to wear a flat sandal with no side support.  In one month my large toe on my left foot began moving off my sandal!!!  At night I experienced shooting nerve pain from my ankle up to my knee, consistently for weeks.  I saw my podiatrist and he put me in a boot.  Had no other suggestions.  I then saw three prominent foot surgeons.  They all suggested “orthotics.”  
One of the surgeons gave me a shot of prednisone in the big toe of my bad foot.  
This did help with my nerve pain and foot discomfort.  

In caring for my foot I bought wide enough shoes to fully support the expanded width of my left foot and my disfigurement. 
I am athletic and always have been.  Since my foot alteration, I am walking with orthotics.   
One week ago, I was trying to make an appointment and was required to walk for at least 35 minutes in a sandal which has good support for both my arch and bunion area. Well, I thought.  I am normally paranoid to wear only a few pairs of shoes that work with my condition.   
The result was concerning.  My foot feels that it has become disfigured even more.  

I have been compensating for the past year, to not put full weight on my left foot.  Currently, I am having knee pain in my right knee.  I transfer my weight constantly.   I have taken a bad fall heading up the stairs because of my foot alteration. Every step I take is now is a concern to me.  

My question is are you a surgeon and do you know how to repair a condition like mine?  If not, do you know a surgeon who can which you recommend? 
I appreciate your time and consideration. 

Dr. Blake's comment:

     Thanks for the email. It sounds like Hallux Varus where the big toe moves away from the 2nd toe. If that is the case, surgical correction is necessary to realign the joint. Care has to be taken not to make the joint too tight, causing a limitus condition, and thus causing more of a problem. Send me a photo of your foot for this post to make sure we are talking about the same thing. Also tell me what sesamoid was removed many years ago. It makes sense that the fibular or lateral sesamoid was removed making it easier for this to occur. 
     Since you are 400 miles from me, and our surgeon (I only perform rehab), here is a list. My go-to guy in that area has always been Dr. Altchuler (Santa Monica) 310-451-8045. But, I have confidence in Franklin Kase (Burbank) 818-848-5583, Brian Hong (Oxnard) 805-988-3338, a member of my class Leslie Levy (Valencia) 661-254-0795 and Jan Tepper (Upland) 909-920-0884. Use my name as the referring podiatrist. After they exam you, you want to get two surgical opinions. They may be one, and then get the name of the doc they would have it done if them. Keep me in the loop. Rich

Further comment: Thank you so sending me the above photos. It almost looks like a breakdown higher up your arch, then typical Hallux Varus. This will take a good workup. Please get some 1/4 inch adhesive felt from www.mooremedical.com and apply to the medial side of the big toe when you are wearing shoes to push it over towards the second. Also, get an OTC arch support from Sole or Powerstep and begin to wear that it comfortable. Keep me informed. Rich

Foot Pain from Hamstring Stretch: Probably Nerve Irritation

Rich,

     Your treatment plan for the fractured sesamoid in my left foot is going well, especially since I got Dr. Jill's 1/4" felt met pads, which work better with your orthotics than the 1/8" felt I was using for months. I've been able to increase my weekly walking distance gradually to about half what it was before the injury, but last week I suddenly developed a new problem in the right heel which has immobilized me again.
Dr. Blake's comment: Thank you for that feedback. I will try to tell all my sesamoid patients to experiment with the Dr. Jills product, even with their orthotics. So happy you are off the long plateau you were on. 

     Before starting a hike, I was doing a standing hamstring stretch with leg elevated onto the tailgate of my truck (I had already done my other stretches, including the "wall" stretch for calves). Toward the end of the stretch, I flexed my toes back toward my knee, and when I set my foot back on the ground (wearing heavy hiking boots and orthotics as always), I felt a sudden sharp pain in my heel.
Dr. Blake's comment: This is nerve irritation at the end of the sciatic nerve branch that feeds the bottom of the heel. The sciatic nerve is most stretched, and potentially irritated, with the hip flexed, the knee straight, and the ankle bent. Maximum stretch. It only takes slightly bending the knees or not pulling up the foot towards your chest, or both, to relax the nerve. So, you irritated the nerve deeply. 

Here similar situation with hip flexed, knee straight, and toes pulling up towards knee

     I had no idea what was happening and went on with my hike, being super-mindful about walking slowly, taking short steps and trying to focus weight away from that heel and onto the arch and toe, meanwhile just feeling discomfort in the right heel rather than outright pain. But the next morning when I woke up, I couldn't put any weight on that heel without bad pain.
Dr. Blake's comment: Have you a history of sciatic on that side or any low back or spine in general issues? These can be the first low grade irritation, that makes the sciatic nerve grouchy, but the stretch does you in. Nerves love motion, not prolonged stretches. 

     I ALWAYS wear your orthotics with the heavy boots, except when in the shower, and I've been really good about stretching, so this new problem really stumps me. The pain is under the center of the heel, and gets worse as the foot flexes and the back of the leg stretches (e.g. when doing a "wall stretch"). You say on your blog that PF develops slowly, so I initially thought it might be bursitis. But I don't do anything that results in impact on the heel - all I do is walking. And the pain seems to have been triggered simply by a routine stretching movement.
Dr. Blake's comment: Yes, see my video on neural flossing, get some Neuro-Eze to massage 3 times a day, avoid  low back, hamstring, or achilles stretching until it is better. Lift everything with your knees bent. Soak in warm water to see if it helps. Give me feedback within the next 2 weeks. 

I've been doing the ice bottle roll combined with mild stretching for a week with no improvement. I understand these things are sometimes tough to diagnose, but in any event I haven't had good results with our local podiatrist and thought I'd run it by you first. Feel free to post to blog if desired.

Thanks,



https://youtu.be/E0E60NpOSHg

One Sided Anterior Pelvic Tilt

As a podiatrist, I treat pronation or supination or short leg syndrome, and other causes of the pelvis becoming dropped on one side with its resultant hip and back problems. This is a good video talking about a left sided pelvic drop around the sacro-iliac joint and 3 exercises to help that. When I examine these patients, I initially do not know if the left side is dropped or the right side raised. If the left side is dropped and there is noticeably more pronation on that side, the left side is probably dropped. The body loves symmetry of motion and as I work on correcting the asymmetry at the foot, a PT, trainer, osteopath, or chiropractor will be working on raising the left side so that it is symmetrical with the right in the end. This is an easily observed problem, so one can easily to follow its success. Of course, the problem can be from acute trauma where the SI joint gets stuck up or down, or from chronic asymmetry of the right side of the body working different than the left. Both can lead to back, pelvic, and hip problems. Again, this is very common, and normally easily treated, at least logically treated. I have also attached two other videos which bring up good, but difference thoughts. I carefully reviewed these videos to make sure the exercises were safe for you. https://youtu.be/Pf-4SSI_obQ This may be a good starting point also. When you watch the video, I would be recommended just working on the dropped side that is anterior rotated to bring it back up. You can do the double side just to sense the differnce between the 2 sides. https://youtu.be/93p5YXdYF40 This is also a wonderful look at self assessment and several corrective exercises. Remember, start easly and there should never be pain. The last exercise shown should be fluid with no holding positions. I hope these help. https://youtu.be/pQA1IadG51Y

Nerve Pain flared with Removable Boot

Dr. Blake,

I have been following your blog for years and have a question about neuromas. Mine was under control for 5 years (with custom orthotics, met pad, wide shoes) until I was in a boot for PTT on the other foot and it flared. Since then I've not been able to get ahead of the irritation/inflammation cycle. Twice I've irritated it to a new level, most recently trying acupuncture. Before the acupuncture, I could wear Birkenstocks in the house without symptoms but now even standing for a short time will bring on symptoms and only elevating my foot keeps the symptoms away. Shoes, tight socks, sleeping (I now wear a Birkenstock at night), driving especially, all irritate it. I have had two cortisone shots which didn't help (I was told at least one was not long-acting).  

My question is at this point even if I was to do nothing that irritates it ( which I guess would mean keeping it up all the time), would the scar tissue around the nerve decrease in size? Also, does Neuro Eze work to shrink the nerve or just help with symptoms? At this point, it seems like my only options are some kind of intervention, cortisone, alcohol shots or surgery. What would you do in my position? Thank you so much

Dr. Blake's Response:

     Thanks for the email. It sounds like you irritated the nerve, more than caused inflammation (since the shots should have helped an inflammatory problem). It could have been the unevenness to your spine of the boot that caused a sciatic nerve irritation affecting the foot. I would approach it this way for the next month. 

1. Neuro-Eze topical three times a day as a non-painful massage
2. Neural Flossing three times a day.
3. Experiment on removing the met pad which can irritate an irritated nerve. 
4. Try contrast baths with 4 minutes warm and 1 minute cold alternating for 20 minutes twice daily
5. Avoid the bend at the toes with the boot on the neuroma side with orthotics, or a mountain bike shoe with a flat bottom, or a Hoka One One shoe (they have a couple of versions that are wider in the front). 
6. Avoid barefoot (try Oofos sandals or Halfinger sandals for home)
7. Avoid shots and acupuncture on the sore foot. Acupuncture on the opposite hand or earlobe can be considered. 
8. Look into a 2 month trial of Quell. 
9. Try a scooter to off weight at home and museums if the other side can take the weight. 
10. Since it appears to be nerve pain, consider seeing a pain specialist for oral intervention (at least an evening dose of Lyrica, etc.).
11. Create an environment for May of 3-4 level pain, and find out what you can and can not do. 
12. In June, we will try to increase your activity, and lower the pain to 2-3 consistently. 
13. You make want someone to really evaluate double crush syndrome, and fully examine your spine (low back to neck). The trigger of the foot pain can be anywhere up the chain, including hamstrings, piriformis, cervical neck discs, etc.)

Hope this helps get you thinking. Rich