Enneagram: The Sacred 9 Types. Which one are you?

Personality typing has been used for centuries and for many purposes. The best one I have ever found and used is called the Enneagram, or 9 Types. It was relatively unknown as a oral tradition until first written down in the 1950s.

What has this to do with a Podiatry blog? Your personality influences greatly how you exercise, how you respond to a doctor telling you what it wrong and what to do, how you deal with your injury, how you deal with others around your injury, etc.

It is actually hard to tell what number you are. Your close friends and family can tell easier. The number describes what your basic drive deep inside is (I realized how superficial I really was/am when first reading about it). It is part of a journey into healing yourself (we are all wounded to some degree), and it is helpful dealing with others.

I like the concept that if you had 9 people in a room with a single goal, if all 9 were a different personality type, all 9 would come up with a different opinion. So, if I tell 9 people with 9 different personality types the exact same thing, I will get at least 9 different responses. This has always been called the Art of Medicine, and the Enneagram can at least give you piece of mind that difference is fine. It is okay when some of my patients do not agree with what I say. People process what they hear, see, read, etc so differently.

So, what are the basics.

A) The Person is actually part spirit, body, and soul.
B) The 9 Types deal with the basic drive of the Soul (our deepest drive in life!!)
C) The Soul is divided into Mind, Will, and Emotion (Heart)
D) The 9 Types have 3 Mind Drives, 3 Will Drives, and 3 Heart Drives
E) These drives are us at our core, we can not change it if we tried
F) Each basic drive of personality has pros and cons
G) We grow as an individual by looking at these pros and cons and developing the ones, and suppressing the bad ones.

What are the 9 Types?
1 is The Perfectionist or Reformer (Will)
2 is the Giver or Helper (Heart)
3 is the Achiever or Success Driven (Heart)
4 is the Romantic or Individualist (Heart)
5 is the Teacher or Observer (Mind)
6 is the Loyalist or Trooper (Mind)
7 is the Epicure or Zest for Life (Mind)
8 is the Boss, Challenger or Leader (Will)
9 is the Mediator or Peacemaker (Will)

2 psychologists, who use the Enneagram solely in their practices, last year independently said I was 100% a 9. I always thought I wanted to be a 2 (great for medicine), or that I was a 5, but as I have read more and more, they are right and I am a 9. As you learn your number, you can see how the positive side and negative side affects your life. Without any further reading, look at the 9 numbers above. Can you think how each of these drives could make you great or break you down.

Can you see yourself, your friends or family, or colleagues as predominately one number?
This really has helped me in dealing with groups of people to see that there will be differences in opinion that are equally valid as mine.

We are One Number at our core, but each number has 2 strong wings that we can develop to get stronger or weaker (our choice). We can not pick our wings, as we can not chose our Basic Number. They are what they are. We can just grow with them. We could grow emotionally and perfect the good qualities of our 3 numbers.  See we can possibly be 1/3rd perfect people. LOL

Wings for Each Number are:
1 (Perfectionist) has 7 (Zest for Life) and 4 (Romantic)
2 (Giver) has 8 (Boss) and 4 (Romantic)
3 (Achiever) has 9 (Mediator) and 6 (Loyalist)
4 (Romantic) has 1 (Perfectionist) and 2 (Giver)
5 (Teacher) has 7 (Zest for Life) and 8 (Boss)
6 (Loyalist) has 9 (Mediator) and 3 (Achiever)
7 (Zest for life) has 1 (Perfectionist) and 5 (Teacher)
8 (Boss) has 5 (Teacher) and 2 (Giver)
9 (Mediator) has 6 (Loyalist) and 3 (Achiever)


The video below is a good start if you want to learn more. They tell you where to take a test, but I would check out some easy books (not too psychologically based) describing this topic. The video below had some other helpful descriptions.

Type 1 Perfectionist has beauty through organization, with slight stiffness
Type 2 Giver is friendly and pleasing
Type 3 Achiever reaches for the sunshine, strives for recognition through successs
Type 4 Romantic is unique, experiences richness in relationships, artist expression can be easy
Type 5 Teacher is passionate in pursuit of knowledge, finds identity in understanding
Type 6 Loyalist believes in overcoming fear by strength, and feels safer in groups
Type 7 Epicure appears passionate and lively, loves to fly high and look towards pleasures to come
Type 8 Boss is an attention grabber, prepared to face all competitors
Type 9 Mediator is happy and restful

 I sure hope this simple introduction was interesting enough to have you look into the topic more. As a good Type 9 I feel happy to bring this info to you, and to satisfy my personality wings, I feel great that I achieved this goal (Type 3) and supported by blog readers (Type 6). Have a great day!! Rich

eBikes: Are they for You?

As I turn 60 next year, and want to increase both my overall exercise, and my outdoor exercise, I am looking into one of these to help me in both area. I will have to combine Christmas, birthday, anniversary and father's day gifts together, but it looks worth it. Several people I know have one and just love it. Patty, are you reading this blog post, or should I give her more hints!!!!

Enjoy these beautiful Photos!!!

http://www.yiminghuphoto.com/portfolio/landscape.php

Post Calcaneal Fracture: Email Advice

Hi Dr. Blake,

     You helped me once before with advice regarding Neuro Eze cream for my feet.  If you don't mind, I had a question about peroneal tendons/muscles.  I broke both my heels 7 years ago and had plates/pins installed.  Over the years my feet have gradually become more and more supinated, to an extreme point where management with orthotics is impossible on my left foot.  I'm 5'6" and weigh 145 lbs.  It's occurred to me that I'm sore right where the peroneal tendons run, and I can't put my big toe on the ground.  I didn't start out this supinated.  Is it possible that I have a peroneal injury from the plate or accident that is making me more supinated?

Dr Blake's comment: Thanks for the email. Since the supination is on both sides, you have to think first of mechanical causes. The most common is gradually peroneal weakening since the surgery somehow disrupted their normal function. You could have peroneal nerve problems, originating from your back, since you are supinating too much. Supination is one of the biggest causes of low back dysfunction. The plates also can be loosening up around the lateral side of your foot irritating the tendons, shutting them off from normal function. 

    On my left foot, there's a 3/4" inch gap between the big toe and the ground.  I've seen a lot of podiatrists and orthopods, and no one has mentioned the peroneals.  They've suggested options like calcaneal osteotomy and/or plantar flexory first ray osteotomy.  Do you have any other ideas for treatment?  (I used to bicycle a lot but can't use a cycling shoe now.)  Thanks so much for any advice.

Regards,

Dr Blake's comment: Please have someone tell us if you can get your heel straight to the ground. This video below may help you understand this.



I would not consider a surgery unless the peroneal tendon function is evaluated by a physiatrist/neurologist  and a physical therapist. The MDs will perform a Nerve Conduction Test with EMG (muscle test) and the PT will be more practical about muscle strength and function. A bone scan or MRI should be done if there is questions about loosening of the plate on the lateral side of your foot. Any surgery like this should be pre investigated with a fine tooth comb to understand why this is happening, not just how to fix it. The fix may be simple, and have nothing to do with surgery. I hope this is in your case. And, I hope this helps you. Rich

PS Please review all my posts on excessive supination, one of my most favorite topics, to get a strong handle on some of the conservative options, but also so you can ask those treating you the best questions. 

Infant's Shoes: Email Advice

Hi Dr. Blake,

I am currently looking to purchase a pair of shoes for my 14 month old daughter. I have not put her feet in shoes until this point, and I wanted to ask what good options would be? Thanks for any help! I love your blog!

Dr Blake's comment:

     Experts in Children's Feet (which I am not) say that if the child has had normal development (crawling by 8 months, walking by 12 months, no history of severe flat feet in family) then a flexible shoe should be used. The 2 best companies are Robeez and Stride Rite for this type of shoe. 

     If the child does have delayed crawling/walking patterns (my second one did not walk until 15 months), then a rigid shoe should be used. Stride Rite also makes this type of shoe. 

     I hope this helps your decision. Rich

Low Dose Naltrexone: Bright Help for Patients with Nerve Pain

This was an email I recently received. I have worked with her on the orthotic side of helping her nerve pain. The Hannaford based orthotics were definitely helpful, but she remained with incredible pain. I recently went to a nerve lecture regarding CRPS. At this lecture, the pain specialist mentioned Low Dose Naltrexone and sublingual Ketamine as great drugs for nerve pain. This patient definitely agrees with LDN. 


Hello Dr. Blake,

How are you?  Long time no see.

I would like to come and see you in August so that I can have my orthotics redone again.  I've been taking a drug called Low Dose Naltrexone and experiencing great benefit.  IT has almost no side effects – it's a glial cell modulator – and the neurologist I'm seeing has been very helpful. 

Dr Blake's comment: This young lady has been suffering years with nerve pain. I was so happy to open the email from her. I asked her to fully explain the dosage as best she could. Here was her response.

It used to be that people began with 1.3 ml and slowly went up to 3 and then 5 ml.  However, Kaiser now compounds it and makes it in 5 ml caps.  My doctor recently gave me 5 ml caps.  That was effective, but then I went up to 10 and found it even more effective.  I asked if I could go up to 15 and she was fine with that because it is such a safe drug.  I now take 15 with no side effects and now have incredible results.  I walked a mile on cement sidewalks tonight.  Watched a movie and walked a mile back with only a very mild pain sensation that occurred only near the end of the walk.

I took 5 for a couple of weeks, 10 for 4 more weeks and then began 15 about two weeks ago.  I'll stay at this level, probably.

She is Dr. Rubenstein – neurologist in pain management dept at Santa Rosa Kaiser.

Good luck!

HI,

One more thing:  Doctors are told that LDN should be taken at night.  This can cause the one negative side effect which is overly vivid and intense dreams.  My doctor said I can take the drug anytime – it's not necessary to take it at night.  I take it after breakfast and it works beautifully.

Dr Blake's comment: Please also see the wonderful video from Dr Chopra whom I first learned about LDN. 

Better Exercise not More Exercise should be our Mantra

As the summer winds down, and we settle in for a great Fall workout program, the following article highlights some of the key aspects of a smart and effective schedule. The highlights focus on what to avoid to stay injury free:

1. Too Much Too Soon
2. Poor Planning and Goal Setting
3. Wrong Workout Gear
4. Poor Exercise Form
5. You Don't Mix It Up
6. You Think Negatively
7. Poor Nutrition
8. Don't Rest Enough

After looking over this list, I am suspect in 5 of these categories, and at 59 years old, I am prone more to injury unless I straighten up my act!!!

http://www.sharecare.com/health/type-2-diabetes/health-guide/diabetes-smart-tips-guide/diabetes-exercise-mistakes?isEndPage=false&topicUri=type-2-diabetes&healthGuideUri=diabetes-smart-tips-guide


On a personal note, tomorrow August 7th, I am starting a personal 150 day program to get in shape and shed 30 pounds. I will try to use the advice learned from this nice article to stay focused with better cross training, a more positive attitude, better diet and amount of sleep (less blogging!!??), and a gradual buildup in my exercises.

Sublingual Ketamine for Severe Neuropathic Pain

I keep hearing about sublingual Ketamine for severe nerve pain flareups. All MDs that I discuss this with are reluctant to prescribe. Here at least is blog post from one pain specialist supporting it. 

http://painsandiego.com/2012/08/22/ketamine-iv-vs-nasal-spray-or-sublingual/

Motion is Crucial to Life: Enjoy and Keep Moving!!

This is my next goal to learn this!!! We all need challenges even though I have two left feet!!

Doctors Constantly Use their Phones to Communicate with their Patients: This Doctor Lost Her Phone Temporarily

Ball of the Foot Pain: Eccentric Flexor Hallucis Strengthening may help

I have been corresponding with this patient for a long time after he injured his right sesamoid bone (forgot which one). The rehabilitation was long, but successful. This is one exercise I have never thought of or recommended that he felt was invaluable. Concentric strengthening of the long flexor to the big toe is to pull the toe downward (a standard exercise). This is eccentric strengthening of the same tendon where the toe is being pulled up while the patient tries to point the toe downward. Therefore, the long flexor (FHL) to the big toe is elongating while contracting which is the definition of an eccentric contraction. We use this technique all the time for hip, knee, and achilles/ankle problems, why not the big toe? You start with 2 sets of 10 reps, and gradually over time build up to 2 sets of 50 reps. Good luck and thank you to my blog patient!!!

Stretch those Hamstrings: The Curse of being Chair Bound

Most of us sit too much for many reasons. This wonderful video emphasizes this and gets us out of our pattern of being "chair bound". Do these motions to get your body more flexible very gradually and gently. There is no rush to be more flexible. Avoid pain and listen to your body. You may not be able to go too far, but a slight gain in flexibility over the next few months, with the development of a few new habits, may be all you need. I have always said "Movement is one of the Secrets of Life" and this video shows how prolonged chair sitting may be a curse. I personally love anything type of exercise I can do laying on the ground, sad but true. LOL 

Humor: Never Lose It!!

The work I do I think is important. Sometimes I think it is so important that I lose sleep worrying over my patients, and what I need to do, and whether I will get it right. Sometimes, this attitude is very counter productive, and I get grumpy, irritable, and begin to work my self to a quick grave. Podiatry is my passion, but passions can overwhelm you. Passions can break you down. When a good friend sent me this video about the Humor of Ronald Reagan, while he was the President of the United States, one of the most serious demanding jobs in the world, I had one of those ah-ha experiences. Never lose humor. Never lose your self humility. Get rid of that feeling of how important you are, just do your best every day. Relax more, enjoy your friends and family more. Set your priorities better (of course, I am only talking about myself!!) 

Blister Care: Brief Video Presentation

http://www.drblakeshealingsole.com/2010/12/blisters-body-glide-to-rescue.html

http://www.drblakeshealingsole.com/2010/04/general-principles-on-blister-care.html

Webcast: 2 Most Important Aspects of Orthotic Design for Heel Pain Treatment

Foot Sprain: MRI Needed

Hello,

About 5 weeks ago, I fell and the foot began to swell and turn to a purplish shade within about 5 minutes. I ended up in the E.R, being diagnosed with a bad sprain, and it was put in a splint for a week. 

Although I stayed off of it completely for that time, the swelling, pain, or coloring had not improved at all. In a visit to another orthopedist, he diagnosed it as a chip fracture, caused by tearing a ligament with the bone. He put it in a cam walker originally for 3 weeks. After those weeks, he looked at it again, but the swelling had not gone down very much, and the pain seemed to have increased, if possible. He said to leave it in the boot for 3 more weeks, later transferring it to an air cast, before beginning therapy.

 But now, a week before the follow up, the foot hurts more every time I put pressure on it. The pain is not in the ankle, but in the inside of the foot and the heel. The swelling has gone down a bit, but the bruising has returned, and the pain is becoming more unbearable. Is it possible more than one ligament has been torn and this may require surgery?

Thank you

Dr Blake's comment: 

     Thanks for the email. I hope you can get an MRI to really know what is going on. Typically when you are in the boot, the swelling does not get much better, but the pain does. Something is going on that no one knows yet. Try to experiment to see if crutches help, but push the health care system to get an MRI. I hope this helps. Rich

Bunions Self Care: A Video Discussing Non Surgical Options

I hope you enjoy this short video discussing the common treatments used in avoiding or preventing the need for bunion surgery. There are many posts in this blog discussing all of these points.

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I've been following your blog since January, and I see that you have a lot of great advice on how to deal with sesamoid injuries. I've been following the advice you provide to people in their posts, but I'm very frustrated because I have yet been able to heal my injury completely. I believe my situation is somewhat unique so I would be so very grateful if you would consider reading about my situation?? I apologize if its so long!!! (feel free to cut stuff out if you want to post it on your site)

About a year ago I had a job where I was doing a lot of walking, which is what I believe caused my injury. I remember one day coming home and not even being able to put any weight on both my sesamoids. I resorted to just walking on the sides of my feet. However, it went away for the most part after a couple days of rest. And although it continued to bother me intermittently, it seemed as if it was just a temporary condition that would heal with rest. Soon after, I got another job that didn't require much walking, so during daily activities I just remained mindful to wear shoes that were comfortable. 

But then 6 months later (December of 2012) the pain in my feet increased to the point where I was regularly having trouble walking pain free. I finally saw a podiatrist and was diagnosed with sesamoiditis. I resolved to rest, rest, rest. I started doing contrast baths, and I made several versions of dancer's pads which I wore in brook's addiction shoes and wore with custom made orthotics. I found your blog and followed your advice on icing. However after a couple months of resting and contrast baths, I failed to see any improvement. In fact, it felt like it was just getting worse. I finally got an MRI of my right foot since that one was the more painful one. The MRI showed that the sesamoid was inflamed and it was either bipartite or fractured. The thing is that although it was the sesamoid itself that was inflamed on the MRI, I also have just overall pain and stiffness on that whole metatarsal region of the foot and my big toe. The pain sort of moves from one region to the other, and doesn't always remain localized in one spot. Sometimes it feels like its the bone that hurts, other times, a fleshy part and maybe a tendon.  I was previously diagnosed with Reynaud's phenomenon, so my feet are very sensitive to cold and I made sure to soak them in hot water on the regular in order to maintain good circulation.

 However, the condition of my feet began to decline, and in May I decided to quit my job because I felt like the stress from work, and the fast paced life I was living were causing increased stress to my feet. I wanted to make my feet my #1 priority. At that time, my doctor had told me to wear a boot on the right foot for a month, but by the end of the month, my foot didn't feel better. In fact, I was having new pain in different parts of my feet. Especially along the outside edge of my right foot, including the baby toe. Along with this I developed weird tingly sensations all over my foot but especially in these painful parts. By this time I was really fed up, and feeling very hopeless about my situation. I'm only 24 years old and having to deal with this for the rest of my life is not at all something I want.

After I got my boot off in mid June, I went out and bought new shoes by this company called Alegria : http://www.alegriashoes.com/  These shoes really seemed ideal because of how rigid the sole was. I paired these shoes with some insoles by a company called barefoot science http://www.barefoot-science.com/ which are supposed to strengthen your feet. I also proceeded to do strengthening activities by balancing and using latex bands. I started walking more and being more active which really helped encourage the circulation throughout my body, and in turn my feet.  I believe that wearing these stiff soled shoes really allowed me to carry out all these activities that were previously very intolerable. With these shoes I've been able to do more than I have in the past 7 months. Earlier this week I was actually able to do bikram (hot) yoga. (What I've noticed about my feet is that they are very temperature sensitive. And being in a warm, or hot environment seems to make them feel better. Especially being able to walk around and be active to encourage the blood flow.)

However, regardless of this improvement I am still struggling with just walking. Something about the movement in my feet while I'm walking causes more discomfort than standing and doing crazy balancing poses in yoga. When walking, I will sometimes still feel pain or stiffness in the Alegria shoes, but when I do, it is not quite as debilitating (like a 1-3). However, if I take these shoes off and try to wear other shoes (Even Brook's Addiction) or walk barefoot, my feet feel just as they did before. Walking barefoot a little doesn't cause immediate pain, but if I do it for longer than a minute, then my feet will hurt more for the next couple of days. I'm conflicted because although these shoes have provided a tremendous amount of relief, I'm starting to think that all they're doing is just covering up an issue that is clearly still a problem. It just seems weird to me that after wearing them for over a month that I still can't even step out of them to walk comfortably. A lot of my improvement has come from me being more active, so I'm starting to wonder that maybe I should ditch the shoes and push through the pain, in order to ultimately strengthen my feet and increase blood flow ( I don't really know how to tell the difference between good pain and bad pain. Its all bad pain for me). I've just already delayed a lot of things in my life because of this injury, and I'm feeling really impatient and eager to get back to doing all the same activities I used to do. Do you think that by continuing to just wear these shoes and avoid being barefoot, I will likely see improvement with my feet? Am I just being impatient, or do you think that resting may not be the best solution? 

I'd love to hear whatever thoughts you may have. Thank you so much for your time. And sorry again that this email is so long!!!!

Dr Blake's comment: Wow, where do we go from here? Reynaud's Phenomenon surely complicates things since you can not ice, like the rest of ice, so you need medications more to reduce inflammation. Most NSAIDS can slow bone healing, so you want to be cautious. I would still take 2 Advil 3 times daily to reduce inflammation and stay away from the warm water soaks (which may be allowing your body to hold on to the fluid). By my calculations, the MRI was in Feb/March, so any time you can get a repeat MRI to compare with the old one and see if any sign of healing is occurring. I will try to look into this shoe more, which sounds great, and weight bearing pain free is always better than non weight bearing. Sesamoiditis, even complicated with bi partite sesamoids, does not present like this so we are probably dealing with a fractured sesamoid. When a bone fracture seems slow to heal, then we have to think about bone health. What is your bone density? What is your Vit D3? Definitely your doc should be getting a bone stim. I like Exogen's ultrasound unit. 

     You need to create a pain free environment for the next 3 months. If that is with partial weight bearing with crutches, or with full time use of Alegria shoes, do it!! We need some weight bearing or the bones demineralize too much and there is problems. 

     Remember, anyone with a sesamoid fracture (diagnosed with MRI and bone scan) is a candidate for surgery. You do not have to suffer. Surgery is done when conservative treatment fails. Each patient is there own judge when enough is enough of conservative management. Just make sure at this point that your inserts/orthotics truly off weight the sore area, since it is crucial to avoiding surgery, but also crucial if you and your doc decides surgery is necessary. I hope this helps some. Rich

Generalizations in the Treatment of Athletic Injuries

I hope this short video helps you with the basic principles of treatment in athletic injuries.  

Ankle Sprain: Injury Advice

Hello,

     About 5 weeks ago, I fell and the foot began to swell and turn to a purplish shade within about 5 minutes. I ended up in the E.R, being diagnosed with a bad sprain, and it was put in a splint for a week. Although I stayed off of it completely for that time, the swelling, pain, or coloring had not improved at all.

     In a visit to another orthopedist, he diagnosed it as a chip fracture, caused by tearing a ligament with the bone. He put it in a cam walker originally for 3 weeks. After those weeks, he looked at it again, but the swelling had not gone down very much, and the pain seemed to have increased, if possible.

Dr Blake's comment: With a 3rd degree sprain with chip fracture, swelling is going to take 4 to 5 months to go down. It never goes down when you are immobilized, as the velcro straps above the ankle will prevent the swelling from going back towards your heart. You can help this with compression within the walker, elevation, massage, PT, acupuncture, contrast baths, and various salves. You will see the first real reduction in swelling when you can walk normal with the cam walker for 2 straight weeks. The second reduction in swelling occurs when you have been able to wean successfully out of the walker and are in the Aircast brace full time. 

   He said to leave it in the boot for 3 more weeks, later transferring it to an air cast, before beginning therapy. But now, a week before the follow up, the foot hurts more every time I put pressure on it. The pain is not in the ankle, but in the inside of the foot and the heel. The swelling has gone down a bit, but the bruising has returned, and the pain is becoming more unbearable. Is it possible more than one ligament has been torn and this may require surgery?

Dr Blake's comment: 30 years ago, in the infancy of sports medicine as a discipline, doctors and physical therapists were encouraging mobilization for ankle sprains, not immobilization. I definitely feel this needs to be tailored to each individual, but immobilization can lead to all your symptoms. When you sprain an ankle, you may have an obvious injury, and several less obvious injuries (minor or severe). Since you are having more pain, the obvious thing to do this next month is to get some other test your doc feels appropriate (MRI, bone scan, other xrays, etc) and to re-create a pain free environment (different boot, out of the boot, crutches more, or some obvious change in your activity). Typically with your injury I would have you in PT within the first week. The PT can successfully work on the swelling, find sources of pain, re-create a pain free environment, and give great feedback to the doc treating. Surgeries for torn ligaments, even with chip fractures, are done 9 to 12 months after the injury when the PTs can not find a way to get you functionally stable (where you feel a small crack in the road will cause a sprain). I sure hope this helps you some. Rich

Achilles Stretching: What if it hurts?

YouTube Viewer Asked:
What if your achilles gets irritated ?

Dr Blake's comment:

If you are doing achilles stretching exercises, and you feel that the tendon is getting irritated, you must back off. There are many ways to do this. You can try spending less time (say 20 seconds not 30 seconds). You can try going a little less deep into the stretch. You can use heat before (or massage) stretching. You can ice for 5 minutes after the stretch. Once you find the appropriate stretch that does not irritate, gradually increase the stretch over the next few months. Hope helps. Rich

Another YouTube Viewer Wrote:
I read that these stretches can be done with pain and can improve the pain.

Dr Blake's comment:

See my comment above. Pain is so subjective. Yes, pain between 0-2 on a scale of 10 is probably okay since you are stressing the tissue. However, your level 2 may be my level 5 and someone else a 0. We all have different pain levels. That being said it really boils down to you listening to your body and feeling what is good pain and what is bad pain. 25% of people are natural at this, the other 75% really do not get the idea so online advice has to be somewhat conservative. Hope this helps Rich

Sesamoid Injury: Email Advice

Hi Dr. Blake,

Your blog is the best resource I've found for sesamoid injuries. Thank you for giving me hope.

This has been a frustrating injury. I am a female runner, 29 years old, and I went to a podiatrist after feeling some pain in my left foot during plank and downward dog in Pilates.  After an initial mis-diagnosis, via an x-ray he found that I'd fractured one of my sesamoid bones. I went a month without running, but the pain didn't go away. I was even beginning to feel it when I walked up the stairs at work.

I decided to seek a second opinion, and went to see an orthopedic surgeon who specialized in feet and ankles.  He did more x-rays, and advised me that my fracture was worse. He then gave me an air cast (walking boot), and advised me to see him in 4 weeks.

After 4 weeks in the walking boot, I went back to the doctor, and he advised me to try walking without the boot.  After 3 days I was limping, and was in pain.  This was so frustrating because the entire time I was in the boot, I was pain free.

Dr Blake's comment: With sesamoid fractures, you need 3 months in a removable cast, followed by a 2-6 week gradual wean out process keeping the pain level between 0-2. There is normally no skipping corners with this tricky injury. 

I put the boot back on, and called the doctor.  His assistant advised me to leave the boot on for another 4 weeks, and to then see him again.

It was durning the second 4 weeks in the boot that I found your blog.  I was concerned that we couldn't really see the bones in the x-ray, and couldn't tell how I was actually doing. On the follow-up appointment with the doctor, I requested an MRI as you'd suggested in your blog, and had an MRI the following week.

On another follow-up appointment the next week, upon reading the MRI, the doctor advised me that the bone had healed, but that it had then necrotized.  Looking at the bone on the MRI, it was darker than the other bones.  What didn't make sense to me was that the bone would heal, and then just die.

Dr Blake's comment: That is typically a mis-read. The bone is inflamed for months and months even after healing, which makes it look darker on T1 images (bone is white), and whiter on T2 images (bone is dark). 

I read in another part of your blog that bone growth can be misdiagnosed as necrosis on an MRI.  Do you think this could be the case?   Should I have a CT scan done?  What is the difference between an MRI and a CT scan?

Dr Blake's comment: CT scan shows only bone anatomy in 3D, and MRI is great for showing soft tissue and fluid within the bone. I would just wait a minimum of 3 months for a followup MRI to see if these bone changes look better. MRI changes are much more predictable for this injury. 
I've been in the boot for 2 1/2 months now, and still feel tenderness and some pain if I land wrong on my foot. 

Dr Blake's comment: The key line is "if I land wrong". The sesamoid is going to be tender, especially if you land wrong, for months and months. This is not a sign of poor healing. This is the time to be designing a shoe insert that you are going to be wearing to off weight the sesamoid post cast. It is essential to weaning successfully off the cast. You place that insert in the boot also while you continue to wear the boot. 

 The doctor is suggesting surgery to remove the bone, but that makes me very nervous.

Dr Blake's comment: Average sesamoid surgery, which is done rarely BTW, is over 1 year after injury. Fight hard to save the sesamoid. It is important.

  I have a copy of my MRI, and am seeking a second opinion before considering going under the knife. My mom had a sesamoid removed, and said that she still has pain from the surgery after many years.  I'm not ruling surgey out, but I don't believe it will only have a 2 month recovery time that the doctor is suggesting.  If the bone is actually dead, I want to make the best decision that will lead to a pain free and active life.

Dr Blake's comment: I would be happy to look at the MRI, but any elective surgery should get a 2nd opinion. Look at the AAPSM website for a fellow or member near you. These are sports minded podiatrists that typically share my anti-surgery zeal unless proven it is needed. Email me with your city and perhaps I can narrow your search. I hope this helps. Thanks for all your kind words. I think you you need to investigate icing, contrast bathing, orthotics, taping, bone stimulators, dancer's pads, etc. Rich

Thanks for all your help.  Your blog is wonderful, and has really helped me understand what is happening with my foot.

Take care,

Severe Foot Injury with CRPS and Possible Injections: Email Advice

 I received this email today 7/24/13. This patient is in very capable hands, with only some of the facts coming to my attention. My answers are only with great concern for the patient since it is impossible to really know what direction to answer some of the questions. Patients who develop CRPS truly suffer and need to trust their doctors. In my answer I give general guidelines, but they are only guidelines. Every guideline has exceptions, and individual situations sometimes demand taking risks. This patient is in an extreme situation where sometimes risks are worth it. So, in my answer I have many questions. I agonize over what is right.  

 I suffered a severely crushed foot one year ago today. All five metatarsal joints were fractured into many many pieces and soft tissue damage was severe. Surgery to repair them resulted in an external fixator for 8 weeks, hard cast for 2 weeks, boot for another 4 weeks ( non-weight bearing for close to 4 months). Temporary pin was removed 4 months later resulting in confirmed diagnosis of RSD/CRPS which I've been under pain management care, the surgeon's care and continuous PT.

     Foot developed severe arthritis almost immediately with osteoporosis now confirmed this week with MRI. The reason they finally did an MRI last week was because of the continued anterior ankle pain and stiffness that wasn't responding to PT and Massage therapy. I've complained about it repeatedly since I started weight-bearing last November, but no one paid any attention until last week when my foot surgeon ordered the MRI on foot plus one on the ankle. MRI confirmed a "partial thickness longitudinal split tear within the infra malleolar peroneus brevis tendon"..
Dr Blake's comment: This is tough since the peroneal tendon is along the outside of your ankle, and you describe the pain being in the front of your ankle. Also, get an ultrasound imaging of the peroneus brevis, since MRIs miscall this all the time. Let us make sure this is really a major source of your pain. 

     Surgeon immediately wanted to schedule operation to fix the tear then almost immediately remembered I was an active RSD patient. So absolutely "no surgeries" while RSD is active (which clearly could be forever). Even if RSD goes into remission and he could do surgery, it most likely would bring another attack of RSD (which is a horrible horrible disease). I still do not understand how or why the original MRI done when injured didn't mention this tear and the exact pain I have has been the same since first day of weight-bearing, so It didn't happen "latter on". I am also not convinced that this particular injury "may" be the main culprit of my RSD.
Dr Blake's comment: Unfortunately, CRPS can just develop with this scenario of severe injury and immobilization. And definitely you want to have more than one person say with certainity that your symptoms are related with this possible tear. And, if you need surgery, there are pre and post surgery protocols to limit the risk of another attack for RSD patients. 

    So -- he suggested cortisone shot which would not fix tear but "perhaps" would allow for asymtomatic pain relief until such time I could have surgical repair. I immediately said that I "thought" cortisone was harmful to tendons and ligments and he said "only if injected directly into the tendon or ligament -- he is injecting into the tendon "sheath" and that won't cause a problem he says.
Dr Blake's comment: If there is a tear, the cortisone will go into the tendon from the fluid around the tendon where it is injected into. I would be very nervous. Does cortisone going into your tendon cause a rupture all the time, definitely not. I am not sure the odds. 5% or 10%. Please ask the surgeon. You weigh those odds, with the odds of the shot helping you. Only your surgeon would have some idea. I can really only raise the questions, give generalizations, etc. Not a cop out, just reality from where I sit. 

    I am assuming it will be a long-acting cortisone. Also ice can not be used due to the RSD, so your "icing" after injection would not be possible for me. You also say I should be immobilized for 3 days - how??? Put in a brace or something? I saw your blog page where you say "never" inject long-lasting cortisone into a tendon or into it's sheath so now I am extremely confused/ worried/ and scared of more permanent damage as I already live with large level of disability with the RSD, the crushed foot, (and also my back was broken and I had a kyphroplasty to repair two crushed vertebraes).
Dr Blake's comment: Yes, do no harm. One idea is to inject long acting local anesthetic into the sheath, after 30 minutes of Synera Patch, and use an ankle brace to protect the ankle for the next 6 hours. This will tell you diagnostically if the peroneal tendon is the source of your pain. Be prepared for a 4 day flare of RSD which can be eased by the understanding that it will past, meditating, see if you can get sublingual Ketamine for the flare, and getting off your foot for several days. Definitely talk to the pain specialist and surgeon about how you will handle a flare post shot so you all have a plan. 

    Since my surgeon is actually "internationally" well-known as one of the best in the business today, I worry about constantly questioning him or telling him I read this or that that contradicts what he says to me, etc.
Dr Blake's comment: You have to feel that what you are getting done is the best. There are so many conflicting bits of information, that I constantly doubt my decisions, but at some point my patients and I have to make them. There is many rights and many wrongs. And, we all get tunnel vision in one approach. What does the pain specialist say? Does he understand about RSD pre and post surgical protocols? What are all the treatments for CRPS you are undergoing? Are you going to consider Ketamine Infusions? If you can get the CRPS calmed down, I would feel a lot better talking about injections, etc.

   " Short-acting shots normally are beneficial for 3 days and are used to quickly reduce inflammation. They are commonly betamethasone (6mg/ml) or dexamethasone (4mg/ml) formulas. Since even short-acting cortisone can cause damage/weakness to tendons, if given into tendon sheaths the body part should be immobilized for the 3 days. It is the long-acting shots that are the true healers when the inflammation is out of control, and normally what people are talking about when it comes to a cortisone shot. Long-acting cortisone shots should never be given into tendon or tendon sheaths (the covering of the tendon) since they are associated with tendon ruptures. It is important to keep the cortisone as far away from the neighboring tendons as possible." (excerpt from Dr Blake's blog).

    Since your "blog" page is from May of 2010, I am wondering if the cortisone issue has more recently been rethought and would appreciate any updated thoughts you may have. I really have encountered so much conflicting information, I feel like just giving up any hope of returning to how I was before the accident.
Dr Blake's comment: This is still my thoughts, and there has been no change in cortisone makeup or tendon anatomy. I would focus right now on getting a possible local anesthetic shot first as mentioned above, if your pain specialist feels that a shot can be safely given with perhaps sublingual Ketamine, to prove you may be a candidate for peroneal injection. Only then, should be again weigh the odds of cortisone into a tendon sheath. I hope this helps you some. Answering an email like this always makes me feel small, humble, somewhat stupid, and unbelievably touched with a sacredness. Thank you. Rich

Posterior Tibial Tendinitis: Brief Video Discussion on Treatment

Morton's Neuroma: Email Advice

Hello Dr. Blake,

      I recently came across your blog while trying to better understand my diagnosis of Morton's neuroma in my left foot. I noticed you are in San Francisco and was hoping to set up an appointment with you, since nothing I've done seems to help the pain.

      I began noticing a strange sensation in my foot last September, but didn't take any measures to treat it until December 2012, when it began to feel significantly worse. In summary, I had 3 cortisone shots but still experience a lot of pain and would like to find out if I am a candidate for surgery, as much as I'd like to avoid it.

      For a very detailed account, here are the steps I've taken so far:

 1. I went to see a chiropractor first, since my mom thought it might be similar to her foot pain, which he treated by working on her back. With minimal observation, he thought perhaps I had a metatarsal sprain or pulled tendon and suggested daily ice an massage.

 2. One month later when the pain got worse, I set up an appointment with a podiatrist and got an x-ray to rule out a stress fracture. When I saw her she confirmed that it was actually Morton's neuroma, and suggested 3 cortisone shots over the course of 3 months in addition to wearing only shoes with orthotics.

 3. My first cortisone shot was on Feb 13th 2013, and after about 48 hours I estimate that it felt about 30% better. Actually, she injected two shots - one between the 3rd and 4th metatarsal and one between the 2nd and 3rd. She said the injection included Marcaine (0.25% plain), Kenalog 40, and Dexamethasone 4 mg/ml.

 4. On March 20th, I had my second round. Again, I noticed a 30-40% improvement, so I really felt like I was on my way to recovery.

 5. On April 22nd, I went back for my third round, but she decided not to give me the third shot, suggesting that it would go away on it's own.

 6. A month later, when I still felt some slight discomfort, I made another appointment because I was afraid to resume my normal activities or wear other shoes without orthotics. On May 21st, she gave me a third round of shots. However this time, it seemed like the injection made it worse and it seemed like almost a week before I could put equal pressure on both feet.

 7. When I told my podiatrist that I was still in pain, she ordered an MRI, but I declined because I have very minimal health coverage, not to mention that I was very frustrated with how casual she was about the treatment. She said it was very common and very easy to treat.

 8. Since June 4th, (this email was received July 21st) I have been going to regular acupuncture appointments twice a week. I definitely seems to help with pain management, but it does not feel like a solution. The pain now seems to vary day to day, depending on what activities I am doing. All this to say, I feel pretty desperate for your help because I don't know what else to do besides surgery, and I would like to avoid it at all costs! If possible, please let me know if I can set up an appointment with you. Many thanks, Susan (name changed)

Dear Susan,
     Thank you so very much for your email. With your health insurance issues, I will try to minimize visits. You can call the office any day at 415-353-6400. But first, here are my thoughts for your to think about. 
1. You have definitely had adequate cortisone, which each last for 9 months, so are in there working right now. 
2. What does cortisone do? It controls swelling around the nerve that is all. So, even though the cortisone is working, you can still have nerve pain which is not inflammatory. 
3. Continue to work on any remaining inflammation however by putting your foot on an ice pack for 10 minutes 3 times daily.
4. What can be the cause of the residual nerve pain? Typically it is mechanical pressure and nerve irritation from above the foot. 
5. How do we work on the mechanical pressure part of the nerve pain? You change the weight bearing on that part of the foot. Here we are only limited by our imagination. We have so many choices, and you need to find out what excites the nerve and what does not.
6. Part of the mechanical fix is always inserts/orthotics which are carefully designed to take pressure away from the sore area. This insert is the staple of the treatment. But, staying away from tight shoes, too high heels, shoes with poor padding, and shoes with too much flexiblity should be done. 
7. Many times I will use a removable boot for awhile, with an EvenUp on the other foot, to rest the area while allowing the patient to walk. You can get the Anklizer at Amazon.com relatively cheap. 
8. Avoid barefoot for sure, find a clog or sandal or slipper that does not irritate you at home. 
9. Check my blog and online for Hapad Adhesive Felt Longitudinal Medial Arch Pads. I use the Small size on most patients, and there is an art to applying and adjusting. However, if you are not afraid of making mistakes, you can move them around, thin them, cut them shorter or narrower, to individualize the design for each shoe. I love these. They can be put in any shoe that orthotics do not go into, even heels and sandals, and may even be better than the orthotic you have.
10. I do love Acupuncture for this syndrome. Acupuncture works at the nerve layer of this injury, and can be very helpful. 
11. For your money, I would see a neurologist/physiatrist next. You really need to get their advice on whether this nerve pain is coming off your back (even if you have no back pain), and if they recommend nerve drugs (oral or topical) to help you. I would at least understand the concept of double crush--type into the search engine on this blog. 
12. Definitely get a bottle of Neuro-Eze. For $30/bottle, you rub a small amount into the area on top and bottom of your foot for 1 month, along with everything else. It is homeopathic, a concentration of L-Arginine, a natural amino acid. 
13. Take this one month at a time. So few patients need surgery that you are not close to that right now. I hope this gives you some focus for the next month or so. Rich

Plyometrics for the Distance Runner: Fitness Tips from Personal Trainer Lisa Tonra

PLYOMETRICS for the Distance Runner - JUMP for Faster Race Times and More Energizing Runs!

5K, 10K and half-marathon runners! Looking for faster race times, a greater sense of 'ease' with your run and greater running efficiency? It's time to step (or hop) it up with plyometric training!

Plyometric training helps runners recruit muscle fibers in the most efficient way. Plyometrics are based on the principle that a muscle's Stretch-Shortening Cycle (defined as an active stretch, or eccentric contraction of a muscle, followed by an immediate shortening, or concentric contraction of that same muscle) can create much more power than a normal muscle contraction. This is because the muscles are able to store the tension from a stretch for a short period of time - causing the muscle to react like a rubber band. The better your muscles are at producing force against the ground quickly, the less time you spend on the ground. Plyometrics help the hip and lower extremity muscles transition from their eccentric to concentric contraction more quickly, thus producing more force against the ground. Now we're moving fast!

As a rule, distance runners tend to recruit and use more Type I (aerobic, slow twitch) fibers. But when speed work is incorporated into your routines, more of the anaerobic, Type II fast-twitch fibers are recruited. Part of improving your ability to run is maximizing muscle recruitment. The more muscles recruited, the more ability you have to produce force against the ground and the faster you’ll go! However, the goal is ALSO to recruit as few muscle fibers for the task as possible. It sounds contradictory, but the more muscles you recruit, the more oxygen they require, and this can lead to decreased running economy. So we have to be picky with our fiber selection! Running economy is all about using oxygen efficiently. Our goal is thus greater recruitment of those explosive fast-twitch fibers, which use less oxygen. More bang for the buck from a muscle perspective!

NOTE! In addition to good overall strength in the major muscles of the hips (gluteals and hamstrings) and thighs (quadriceps), it is CRITICAL that you have adequate strength in your calf muscles and flexibility in your ankles for the plyometric drills. The biggest calf muscle (gastrocnemius) usually contains a larger proportion of Type II fast-twitch muscle fibers, and responds well to traditional strength training. 

Beginners should start with calf training basics: 

1. Heel raises: holding onto a counter top, squat rack or other sturdy surface, raise and slowly lower your heels until you reach fatigue. Use a weight amount such that you are completely fatigued by 10-15 repetitions. This weight can be simply your body weight, or you may hold small dumbbells of equal weight in each hand. You may also try lifting one heel at a time, with or without added weight. More advanced exercisers may use the same exercise but increase the weight amount used, such that fatigue is reached by 6-10 repetitions. Everyone should complete 2-3 sets with a 1-minute rest interval between sets.

This basic exercise is well worth the time invested: more Type II fiber recruitment  in your calves equals better ground force reaction time, less overall body fatigue and a better race time!

Once you've achieved good basic strength in the calves, it'll be time to move on to some basic Plyometric drills.

Beginning runners can start with stair climbing (two stairs at a time if you're able), two-footed hopping in place, or short bursts of running uphill. Each activity should be performed for 45-60 seconds per bout.

More advanced runners can try the following:

2. Ankle hops: With feet hip-width apart and heels elevated, balance on the balls of your feet. Bend your knees, place hands on hips, and repeatedly hop forward, pushing off and landing only on the balls of both feet. Stay on the ground as little time as possible between hops and never let your heels touch the ground. For variety, you can try hopping backward. Reps: Start by hopping 10 yards, building up to 20 yards. When you're ready add a second and third bout of 20-yard hops with 1-minute rests between them. This drill will strengthen EVERYTHING below the knee, but especially the Achilles Tendon, shin muscles, calves (see above), and the flexor muscles that support the ankles.

2. Squat Jumps: Stand with both feet hip-width apart and place your hands on your hips. Tilt your hips back and bend your knees, leaping straight up as high as possible. Land softly with both feet  in the same spot. Bend your knees to absorb the impact. Reps: Begin with one set of 10 jumps in rapid succession. As you get stronger, build up to three sets, each set separated by a 1-minute rest. This drill will strengthen all of the muscles, tendons, and ligaments from the waist down. Efficient!

In a nutshell: plyometrics work primarily because they strengthen everything related to your feet and ankles. They make all of the muscles, tendons and ligaments acting on your ankles stronger and more powerful, helping you to become "stiffer" (a good thing!)

How tired should you feel with this type of workout? In general you should finish any plyometric workout just as fresh as when you started. If you feel unduly fatigued you likely did too much. Keep the repetitions low enough so that each rep is a quality rep. With regard to rest intervals, rest at LEAST one minute or long enough to be at 100% for your next attempt. 

As with ANY athletic program, make sure you check with Dr. Blake about proper footwear and the need for corrective orthotics. Bring any new (or existing) foot and ankle injuries, or muscle/joint pain to his immediate attention.

Best of luck! And here's to your next personal BEST race time!

About Lisa: 

Lisa Tonra, a twenty-year veteran of the fitness/wellness business, holds credentials from ACSM, NASM, and BASI Pilates and is currently a Physical Therapy graduate student. She specializes in injury 'pre-habilitation,' prevention and recovery for all sports-related and overuse conditions. Lisa can also design, implement, coach and monitor fitness routines for all recreational athletes, fitness enthusiasts and beginning exercisers. Her philosophy is a simple one: "There is a (sometimes hidden) fitness enthusiast in all of us! It’s good to set a short-term fitness, health or lifestyle goal to get yourself up and moving, but challenge yourself to take the longer view of 'training for life.' What are Your Body Goals? I can help you achieve and maintain them, and do it injury-free!" 

Visit Lisa's personal website here: http://yourbodygoals.com