Welcome to the Podiatry Blog of Dr Richard Blake of San Francisco. I hope the pages can help you learn about caring for foot injuries, or help you with your own injury.
If you are trying to prevent, or at least slow down, the development of bunions and hammertoes, these are 2 good products to use on some regular basis. I have attached my original post on conservative management of bunions and these should now be included.
Several days ago I saw a young man who developed peripheral neuropathy in his feet with level 7 pain secondary to chemotherapy for colon cancer. This is technically called CIPN or Chemo Induced Peripheral Neuropathy. His podiatrist made some great orthotics that helped some, and I added Neural flossing and Lidoderm Patch Rx on my first visit. The article below has a nice discussion of the problem and treatments. I have many other treatments, like Calmare, Neural Flossing, Quell, previously discussed on this blog.
This protocol was sent from a nice lady that could send me her MRI images clearly. Thank you for sharing the steps with us.
Hi Dr. Blake,
Here are the steps to send MRI Images from a CD through WeTransfer:
Load the disk into your computer and open it.
Select ALL the files on the disk, then right click and select "Copy".
Create a new folder on your Desktop titled "MRI Disk".
Open the folder. Inside the folder window, right-click, and select "Paste". All the files should now be inside the folder.
Close the folder. Right-click on the folder on your desktop then point to "Send to" and select "Compressed (zipped) folder". (On a Mac, right-click and choose "Compress".) This will create a compressed .zip file.
Click the blue plus sign inside the window on the left to add your .zip file.
You can choose to e-mail the .zip file to a recipient or create a link to the file. To e-mail, simply enter the recipient's e-mail and your e-mail in the corresponding fields. To create a link to the file, click the blue ellipses inside the circle at the bottom of the window and select the button next to "link".
The Plantar Fascia on the bottom of the foot should be as dark as the Achilles Tendon shown here.
The Plantar Fascia should be uniform thickness and density. Here it is seen rising up and with gray holes.
The slice through the bottom of the foot under the heel bone showing a bursae sac of intense inflammation.
This is the section that is at a right angle to the raised part of the plantar fascia seen above. The fascia above my arrow should be a solid dark fiber like the Achilles. In this image, it is showing 90% torn with the gray signifying fluid and scar tissue.
The image just in front of the last view looking more solid, although some irregularity and less density.
This is the initial image again in our series showing a section of plantar fascia separated from the bone.
A defect in the plantar fascia more to the outside of the foot. The arrow denotes the defect and is surrounded by intense inflammation probably a bursal sac.
Only slight irregularity noted in the plantar at this section, but see the inflammation is so intense it distorts the normal fat pad below the arrow.
This is really the best image of the problem. The patient's image shows the split partial horizontal tear of the plantar fascia seen as is there was a layer of Oreo cookie in the fascia. How do we know it is injured, the intense inflammation under the tear where the swelling is pulled downward by gravity. I would not want to walk on that heal.
This is the same image of the plantar fascia 1/8th inch further under the heel bone. It looks totally fine, so the tear is the 1/2 inch in front of its attachement into the heel. The swelling from infracalcaneal bursitis will travel all under the heel and the reason patients can not walk well. The plantar fascial tear protocol should be started. Plantar bursitis will take some work off-weighting the heel to transfer the weight into the arch.
I’m a dancer (mainly jazz/tap but also ballet) and I have been having pain in the ball of my foot. I first experienced it this fall (October-ish) when I was dancing a lot in my character shoes.
Then, it felt like stretching on the ball of my foot. After no longer using the character shoes, it got better. About two months later, it came back much worse and turned into more of an intense soreness underneath the big toe and second and third toe. This got worse on releve.
Ballet Releve on the weight bearing foot
I rested it for three weeks. This week, I have returned to dance while being mindful of it, and as I have gotten back into dance it has gotten bad again. BUT I have VERY important college auditions this week and next week!!! I initially had thought it was Metatarsalgia from my own research, but my dance teacher thinks it may be Sesamoiditis, and now I think it may be that? I’m not even sure if I can even see a doctor before my auditions, and would need to power through anyway unless there is a fracture. The only thing I’ve seen online to do with these injuries is rest and ice. If I had to dance on it, what are things I could do to help with pain and limit the risk of further injury? I definitely struggle on releve and it feels like a big bruise on the ball of the foot, but at least right now, I could mostly get through a dance call. Any advice would be very helpful! Dr Blake's comment: Get hapads, both small longitudinal medial arch and small met pads and try to protect the best you can!!
Image that is the sesamoid being floated and that should take 80% of the pressure off. Ice also.
Many patients also will go into a removable boot for all non-dancing activities to rest it as much as possible. I linked to the Anklizer which is great unless you have a really thin ankle, and then you need a taller one to grab your ankle.
As you all know there are 2 givens in this post: I am not a surgeon, and it is hard to recommend anything you have no experience dealing with. So, that is the basis of our office recommending Arthrosurface for joint implantation if surgery is decided on to help the pain created by Hallux Rigidus. As of January 2018, I have not seen one patient present with the Cartiva implant, so please be free to comment below. Cartiva seems to be doing a great PR campaign, but the only comparison I could find between Cartiva and Arthrosurface was very heavily supportive of Arthrosurface. I am sure that the jury is out. I think all of these procedures do work when done on the right person. It is finding the right person. Doctors must rely on what they are trained in doing unless the doctor is dissatisfied with the results. Or, unless they are seeing patients from other doctors (our patients are so mobile so I follow patients from literally all around the world) that are getting fabulous results from another procedure. This is presently not happening with Cartiva. I would not believe a representative of the company, but patients who have used the Cartiva or the Arthrosurface are free to weigh in. I am hopeful this blog can inform people intelligently, but in some way, you have to trust what your doctor wants to do. At least now, you can pre-operatively ask if Arthosurface or Cartiva is right for you. Maybe your doctor has experience in both and prefers one over the other. That is what I am actually looking for. A doctor who has experience in both, and knows when to use either one (what are the implications to use one versus another). Wouldn't that even be a better post on my blog?
Arthrosurface Implant Left Big Toe Joint in one of my patients
After I give a cortisone shot, in this case for a left foot third intermetatarsal space Morton's Neuroma, I tell the patients that they may need 3 in total. We have to wait 2-4 weeks to get a strong sense of what each shot does, and then make our decision. The Golden Rule of Foot: Cortisone shots if attempted to bring down pain and inflammation should be done until 80% improvement is noted. This means you have accomplished the 0-2 pain level. You should not give more than what achieves that 80% relief. If the first shot gives you 20-75% pain relief, a second shot should be considered. If 0-20% relief is attained, you probably should not give any more, as it only works on pain produced by inflammation.
If you give a second shot, you can use the same rationale for determining if you need a third shot. Rarely, if ever, will you need a 4th shot, and I think 4-6 months should be the delay in deciding on that 4th shot. Typically, you get to 80%, and rest of the inflammation is helped with PT, daily ice or contrasts, NSAIDS, or topicals like arnica, etc. I am only talking about long-acting Kenalog 10 or Celestone Acetate. Never use Kenalog 40 in the foot.
Hi Dr. Blake,
I think it's been almost two weeks since the cortisone shot. I will say that I think it's helped but not nearly as much as I had hoped. If I had to put a number on it, I'd say it feels around 60% better. It's hard to say because one day it'll feel quite good, but it takes so little for it to start hurting again. One small misstep sets me back quite a bit. What I have noticed is that the little lump I can feel in the neuroma area seems smaller but is still there and causes nerve pain upon pressure. In addition, I often sense a general tingling throughout that area and in my third and fourth toes.
Also, there is something weird on my right foot I'd also like to talk to you about. I feel a similar little lump under the second space and have felt zinging a couple of times.
In any case, should we try another cortisone shot or move onto the next step?
Thanks much,
Dr. Blake's comment: Please schedule to see me for a second shot. See you soon. I will also look at the right foot.
This is an area of great interest to doctors and patients with osteopenia and osteoporosis. It is an epidemic to make our bones stronger, and prevent falls. It can help doctors discuss your fracture risk as you age, which presently affects 40% of postmenopausal women. My active patients want to stay active for as long as they can. The post I do tomorrow will discuss Vit D and calcium intake.
So, FRAX Algorithms (just love that word for some reason) will give you and your doctor your 10-year probability of having a fracture. Hip Fractures have complications and actually have a 20% death rate in the next 5 years. So, it can be huge to lower your risk and become more healthy. And, for some, they get to eat a lot more (when they have low body weight).
Most of the links below get too scientific, but it is good to make you aware. You can challenge your doc or your parent's doc to see what FRAX says. The common risk factors include:
having a fracture as an adult
having a parent, sibling or child with a fracture due to some bone weakness
having low body weight
current smoking
taking oral corticosteroids
having poor health
having a low bone density
having rheumatoid arthritis
having previous hyperthyroidism
having poor depth perception
having tachycardia
taking alcohol 3 units/day
and also there are age, sex, race, and height factors
I hope the articles below are somewhat helpful if you are trying to get a grip on where you are going and how to make your fall risk less. Good Luck. Rich
I'm a female 37 y/o. I have a question about treatment for a recurrent problem with left accessory navicular after a sprain to ankle in April '17. Dr. Blake's comment: When you have a typical inversion sprain where your foot rolls to the outside, you should have all your pain on the outside. When someone has an inversion sprain and has some inside pain (medial side of the foot of the arch side or big toe side), you have to investigate. This is a Golden Rule: There should never be inside pain after rolling your foot to the outside. If there is inside pain, you must consider that something else has been injured in the sprain. That you possibly have more than one injury at the same time.
Seen two orthos and they want to keep in brace/orthotics, off feet if in pain and if worsens back to boot then consider cortisone injections, last resort surgery. Podiatrist made orthotics. Dr. Blake's comment: This is a bad area to have cortisone shots since it can weaken the tendon attachment causing further problems. Stick with PT, icing, contrast bathing, diclofenac gel, etc to reduce the inflammation at the attachment site.
Last time hurt was 12 yrs ago playing soccer was put in a hard cast then air stirrup, crutches. and PT, no break. No surgery. Was back to activities faster but took a year to get back to playing soccer. Dr. Blake's comment: This is definitely a weak spot if it took more than a couple of days to recover. One year tells me it is vulnerable, but you got better. Hooray!!
This time April 6th, 2017! tripped walking and inverse ankle roll but made my body fall on left (opposite side as I was initially falling)due to injury in right wrist and wanting to protect. No fracture on MRI/X-ray just soft tissue rupture w/some edema. Was put in camper boot for 8 wks and out of work couldn't walk w/o pain. Dr. Blake's comment: It is a significant injury if you can not walk on it. If the edema was in the bone, we have a long injury ahead of us. Started PT and got out of the boot in a week and learned to walk again w/o brace. PT focus on being able to walk again, balance on board, desensitizing foot due to being in the boot so long w/setbacks. PT did physical manipulation work which was the only thing helping me but PT stopped after 10 visits due to insur. Dr. Blake's comment: So, the typically 8 weeks of boot/cam walker is fine. You know you are doing okay, if the transition from boot to no boot is done with maintaining your 0-2 pain level. I assume it was. But, an injury to the posterior tibial attachment with or without the accessory navicular should be progressed from boot to custom orthotic and posterior tibial taping ideally. Slowly wean off the taping. I have attached my video to this taping. https://youtu.be/AcSSyBfFocE
Now it's 2 mths w/no PT and almost 7 mths later since the injury. Orthopedic surgeons want to do surgery now and remove the bone. I’ve been wearing custom orthotics since sometime in July w/ASICS cumulus. Tried to return to work Sept 15 (on feet as hospital social worker log up to 3-4 miles a day on feet) but it was too painful, had pain getting up from a chair, ended up limping barely able to walk, swelled up, back out of work. Dr. Blake's comment: Always need to know how to get you to that 0-2 pain level. When you went back to work, were you at 0-2. Were you walking fine without a brace, but with orthotics? Can you go back to work with a removable boot and EvenUp (on the other side)? At least you could wear the boot the 2nd half of the day. Do your orthotic devices need improvement? Can the above tape help you? Can you get an AFO for work to be able to rest the pull of the posterior tibial tendon, but still wear a shoe? The surgeon could be right of course, but you need to have all these things before you try to recover some accessory navicular surgery. You have a lot to do before surgery is to be done or considered.
Finally saw 6 mths wait-to-see sports medicine doctor at HSS Sept 21 and he prescribed me anti-inflammatory, PT, stationary bike, and rest for 6 wks, didn’t think ready for surgery that pathology does not merit the pain I’m reporting.Rested and iced swelling stopped and pain decreased so for back to walking with sitting breaks up to 2.5 miles.
Went back to same PT for re-evaluation last wk finally once insur allowed and referred to acupuncturist says extra accessory navicular bone is jammed and other stuff around is locked and would help to consider trauma related to few times I hurt it and address either on my own or with a Therapist. Wtg to find out if insur. Will approve more PT or not. Saw acupuncturist today first time at the same facility and did cold laser since I was scared to start with needles. She thinks I need both and to address trauma. My goal is to resume all normal activities (job on feet all day) and get back to being able to do recreational sports/activities (hiking, soccer, tennis). I want to avoid surgery. I’ve been reading your blog so thanks for the info. and support when it can seem so isolating. I greatly appreciate any feedback. Thx Dr. Blake's comment: Since I had not answered the original email for 2 months, I asked her for any additional information.
Hi Dr. Blake,
Thanks for your reply. Happy New Year.
The update is I did receive 5 more PT sessions after insurance reversal of denial with the last PT session on 12/12/17 and the insurance denied any further PT treatment. I had a total of about 20 sessions of PT.
Dr. Blake's comment: Did you make some progress? Are they working on the overall strength of the area? I have attached my video on posterior tibial strengthening which must be done or you will still break down. This is you probably do on your own, but definitely, lay an ice pack for 10 minutes 3 times a day, and learn to tape for sure.
My sports MD prescribed me Diclofenac on 11/15/17 due to what my PT told the sports MD; 1. Lateral cuboid does not plantar flex, 2) lateral cuneiform does not plantar flex, 3) distal fibula does not translate.
Dr. Blake's comment: These can be all left over from the inversion sprain that the PT should be able to rectify.
The doctor's notes from this session 11/15/17 are attached for your review.
Dr. Blake's comment: His comments were pretty unremarkable. If one side of your foot is not working, the other side will work abnormally. It seems normal after and sprain and boot and rest that you need some PT to mobilize the lateral column. I am worried that I see no mention of re-strengthening the posterior tibial tendon, or any other part of the foot and ankle, and no mention of how supportive the orthotics are, and whether taping would be helpful. It is all a bit superficial.
My last appointment with sports MD was 12/13/17 and the plan was to return to work on 12/18/17 light duty at x 4 hours per day but my employer (being a hospital) does not offer light duty and referred me to the Office of Reasonable Accommodations. I am waiting for the paperwork to be submitted by my sports MD to my employer to see if I get approved for an accommodation although I'm not sure how they can accommodate me when the issue is being on my feet for extended period of time. Otherwise, I'm going to have to resign for medical reasons.
Dr. Blake's comment: Can you work with a boot on? I do not see why not? Or perhaps an AFO that stabilizes you, but can fit in a shoe, or just the tape the video shows may be all you need or a combination of things. Many of my patients, so they can get back to work, have them all: boot, AFO, custom orthotic devices, taping, and posterior tibial dysfunction Ankle Brace called Aircast Airlift PTTD Brace. Some days or hours you need more restriction, and some days less.
My next appt. with sports MD is scheduled on 1/30/18. He seemed to think I should try for a full year of PT and alternative treatments before I consider surgery.
Dr. Blake's comment: Sounds about right, since you have all the above mentioned stuff to perhaps try.
It will be one year on April 6, 2018 from the date of injury and mid-June 2018 since PT started.
Dr. Blake's comment: Like many patients, for many reasons, it is just hard to find the right things that work sometimes. I am assuming you did not know the joints are still jammed up, any info on AFOs, PTTD Braces, taping, and how to make your orthotics better.
I continue to use orthotics, go on the bike 20-30 min on level 3 (Keiser M3), to do alphabet with left foot, calf raises each foot, stand on each foot for 30 sec while holding other foot up., while seated stepping down with ball of left foot on piece of foam without moving legs. I attend weekly acupuncture but will likely cut back to biweekly due to insurance/OOP fees.
I have difficulty doing the calf raises more on my right foot.
Dr. Blake's comment: After doing the posterior tibial exercises for a week, you should know where you are on the right foot and where you are on the left foot. That can be really revealing. You start from the beginning with each side, making sure you can easily progress through an active range of motion, then with gravity, then isometrics, then level I theraband, and so on. The therapists will have the theraband, or else you can buy them.
I had stopped doing the towel, marble, side lunges, heel cord stretch, and ball roll underfoot, amongst other exercises.
Dr. Blake's comment: Why? Were they sore? Were they easy? Did you not know which were important?
My PTs said I could come back once a month out of pocket for a mechanization session and just do the exercises at home the rest of the time.
The PTs said the issue is my foot keeps reverting to an unnatural resting position after the mechanization as if my foot was still in the boot. She suggested physiological calming and to pay less attention to my foot as I'm no longer panicking worried I'm causing further damage when I have pain after being on my feet for a while but the pain still happens.
Dr. Blake's comment: I guess that means you stiffen up your foot. It probably fatigues out. That is why in the middle of the day if you feel this, and can throw in a brace, boot, AFO, you can essentially rest it for a couple of hours. Then you can remove the brace, etc.
Although the mechanization can be quite painful at times she has been able to get my foot to release or whatever the word is and was even able to set up an obstacle course and I dribbled a soccer ball after in the same session without pain but a week or so later the foot reverts.
Dr. Blake's comment: That can be only a strength issue since you are definitely improving, but your orthotic devices and the amount of strength you have cannot maintain supporting you. But, that is definitely the best news you have told me and makes the possibility of surgery less and less. Get really strong, better orthotic devices if possible, and you may lick this.
My balance has improved and ability to pivot and step up and step down. At close to 2 miles I get pain from walking. Riding the subway is difficult and painful when holding onto the bar when the movement of the train is pushing against my body and I'm trying to maintain my balance. The cold weather has been very painful for my foot so I double layer my socks.
Dr. Blake's comment: The 2 miles is the fatigue of the tissue setting in. Taping alone, even before you are stronger, should raise that bar. It is sort of fun playing with different taping, different braces, different orthotic modifications, and have the patient report back how that helped or did not help.
I'm hopeful I will be able to return to full activities including day hiking and hopefully pick up soccer. My acupuncturist thinks I'm making some progress with acupuncture, cold laser, and tens. She suggested to ice for 10 min when in acute pain after being on feet a lot then follow with heat.
Dr. Blake's comment: At least, if the pain is located at the navicular, ice pack for 10 minutes 3 times a day, whether you hurt or not at the time, should reduce some inflammation significantly after 75 to 100 times, so get started.
Any input would be helpful at this point as I'm unsure if this is even a reasonable time frame to heal and I need to just trust my body to heal and do the exercises.
I really do not want to do surgery as it is unclear to me how this would resolve the problem at this point and appears might create other complications and challenges I would rather avoid.
Dr. Blake's comment: I can find nothing that seems like it needs an operation at this point, so follow the advice above, and from the sports doc, and PTs. Ask them to perform a good foot, ankle, and leg strength test on both sides and see what it shows. Tell them I want particularly the differences in the anterior tibial, posterior tibial, peroneus longus, and peroneus brevis. Thanks and Good Luck. Rich
Thank you for your time.
More info from the patient:
Hi Rich,
My apologies for not using or inaccurately using proper terminology and omitting info. you asked for.
Just to clarify, I rolled my left ankle inward but stopped my body from falling that way and made myself fall outside due to avoid the risk of falling on right wrist.
Also, I did the transition from boot to ASO brace, to taping to just orthotics as per Ortho in about 3wks. At first, I was wearing an old NB shoe that was too over stabilizing + the ASO due to it being able to fit the brace and was closer in height to cam walker boot. When I got my orthotics I also got the ASICS cumulus sometime in June or July. I preface this to say I could not use crutches due to the wrist and had to use a cane on the left side which I got a week after injury. BTW I’ve both ASO and aircast braces got after was put in a boot (initially using a flimsy store wrap right after injury referred by the pharmacist) but haven’t used ASO or air cast since the Summer.
I’m beginning to think didn’t get clear enough instructions from providers as no one has mentioned returning to brace or taping and only suggestion was gradually increasing time on feet.
One Ortho said might’ve to go back to boot but that was in August but I didn’t go back to him or other Ortho who seem to just want me to go for surgery. Podiatrist made me orthotics but haven’t been back I didn’t get a good impression he could do anything else.
From what I’ve been informed by providers all along is that the range of motion has not been an issue.
I’ve been doing some of the strengthening exercises for posterior tibial tendon as you suggested in video and walking backward on a treadmill then w/o treadmill, and toe raises on a weight machine at PT.
Ar home I continue to do the exercises instructed by PT; alphabet, heel raises, stand one leg, the ankle dorsi/plantar, eversión and inversión exercises.
I stopped standing calf stretch, resistance bands, side lunges, marble, towel, ice baths bc I wasn’t told to continue last time I asked but will check again this week to get a full list of what should do now.
Perhaps, I wasn’t clear but PT had been working on to get the left foot to mirror right foot at rest and not have my foot overextend to the outside when doing the eversión exercise.
As far as a timetable, I had my PT cut off again but in Dec. last they thought that I would be ready by June. My acupuncturist thinks I’ll be ready by April-most optimistic of all.
I’ll update you when I get rest of info you asked for about strength tests hopefully at next appt.
BTW do you have any NYC recommendations for doctors who treat this issue?
Dr. Blake's comment: You can see Dr. Joseph D'Amico at the New York College of Podiatry.
Thanks so much for your help. The videos are great for reference.
I have a way of ignoring issues if they threaten to get in the way of running…..
At least this is on my right foot. Somehow that makes me feel better, though that is the side where I seem to be developing a hammertoe. You noted that on my last visit.
I’d been having some pain in the three smaller toes. Metatarsal area, but bending them up. Not totally one thing, but my foot hurt in that general area for a few days. I was trying to tell myself it was just my neuroma, my non-Morton’s neuroma. But I also kept thinking — it doesn’t feel quite like that.
See the callus under the 2nd through 4th metatarsals and not the first. There is more pressure in the middle of her metatarsals where she is complaining.
Anyway, it finally dawned on me to take a look and I could see that the right side was inflamed compared to the left — the metatarsal pad area, the ball of the foot — but basically that sort of fatty pad just below the toes — not as far over as the big toe.
Looking on the Internet, I wondered if this wouldn’t be called Metatarsalgia. And I suppose with my high arch and longer second toe — I am at more risk for this just as I am for neuromas?
Dr. Blake's comment: The high arch (called pes cavus) places a lot of force on the metatarsals over a flatter foot. Other conditions that place force on the front, so you could be in an overload situation, are forefoot running, shoes with a high heel pitch forward, hill running up or down in general, and sprinting. You may have several of these common causes stacking up against you.
I am guessing it’s from running, but, possibly, more specifically, a fair bit of hill running that I’ve been doing. Now, the smart move would have been to NOT RUN today, I imagine. i rationalized going, however, because
1) It seemed improved this morning, and not worse than yesterday night.
2) I am trying new shoes this week — Altras. So they offer more room in the toe box and are neutral, flat, so that should reduce the impact on the forefoot.
3) I plan to ice the area.
4) I thought I would take Ibuprofen for a period.
5) It didn’t hurt while I ran, though I tried to alter my landing somewhat at the few times when I did notice the pain.
Let me know what you think. Do I need to stop running? Should I come in to be seen? Last night I realized I couldn’t stand on my toes. But today, it’s much better.
I attached photos, though I’m not sure they are helpful.
Best,
Dr. Blake's comment: When a toe runner begins to get ball of the foot pain, you are thinking the right thought process. Temporarily, avoiding hills, icing for 10 minutes twice daily, trying to run more midfoot (Chi running), lowering the heel drop (Altra shoes are all zero drop), and cutting your mileage in half to see if that can give you 0-2 pain levels. Stay at that mileage for a short period, and then gradually increase 10% or 1/2 mile every 4th day. Hope this helps. Toe running with pes cavus with hills is deadly at times, so shoe changes, gait changes, avoidance of hills are all helpful. Rich
I am a runner who partially tore the medial band of his plantar fascia in March 2017. Started a run/walk comeback in Nov 2017 and developed some sesamoid pain around Thanksgiving.
Traditional X-rays were ok about 20 days after onset of pain, but the improvement has plateaued after using dancer’s pad for last four weeks or so. Had an MRI on Jan 2, which showed sesamoiditis. Report is attached. However, everything I read in the literature suggests that MRI is not great at showing how far along the continuum of bone injury one is and there can be different treatment paths that are best for different degrees of the catch all “sesamoiditis”. Dr. Blake's comment: First of all, the MRI report showed healing of the tear!!! Hooray!! It showed some wear and tear of the cartilage of the big toe joint (mild arthritis) and showed swelling, no sign of a break, in the fibular sesamoid. In my mind, you have to put sesamoid swelling in the category of a stress fracture to treat the worst case scenario. That sesamoid swelling, without a sign of any fracture lines, could be a stress fracture or bone bruise. Sesamoiditis just means there is inflammation at the sesamoid from any cause. The injury to the sesamoid area has gone deep enough to affect the bone. Therefore, the bone must be mechanically protected with off weight-bearing padding, and there must be enough decrease of big toe joint bend to create a healing environment: normally 0-2 pain levels. This is how you know how much or little to treat, what does it take to get to 0-2 pain? This does not change if you do not know if it is a stress fracture. Without evidence of a fracture line, an Exogen bone stimulator is usually not utilized or approved by insurance. I love that to strengthen the bone, even if just bruised. You may be able to get via the bone changes in the first metatarsal which you do not know if new or old. If it is a new cartilage injury, a bone stim would be wonderful, as you could be looking at microfracture surgery. It was injured because it is one of your personal weak spots, so why wouldn't you want it stronger. Contrast baths daily are crucial with bone edema to remove the swelling on a consistent basis. Helps prevent avascular necrosis, bone death from too much swelling cutting off normal circulation, along with a bone stimulator. Acupuncture would also be great if the practitioner knew how to get the blood flow greater in a small bone like this.
I live in the Chapel Hill, NC area and have been to multiple podiatrists, who all gave me bad advice on how to deal with chronic plantar fasciitis I had leading up to the tear. I realized this after reading all the research papers on a plantar fascial injury. This is why I am reaching out to you as someone who seems to be up to speed.
Dr. Blake's comment: I am getting older by the minute, so you do not realize how good that little compliment makes me feel. Thank you.
Would you be willing to look at my images and recommend how I treat this? The MRI data are 144 megabytes, but we may be able to figure out a way to get the data to you.
Dr. Blake's comment: Sending a CD always works. But patients do use Dropbox for my google drive. My address is 900 Hyde Street, San Francisco, Ca, 94109. Good luck Rich
Thanks very much for your time and Happy New Year!
I am wondering how to know if the pain in my foot/ankle/lower leg is coming from the FHL, FDL, or Tibialis Posterior? They all seem to have the same location and trigger points from the muscle are also close together. I would like to do self-massage to release whatever is trapped/tight if possible.
Some history:
Two and half years ago, I injured my FHL tendon where it meets my sesamoid (imaging showed inflammation and swelling of the 1st metatarsal, fracture of sesamoids ruled out) on my right foot. I developed nerve pain as a result (in right foot and leg, and mirror nerve pain in left foot and leg), as well as piriformis syndrome in my right glute from the gait changes. Tendon eventually healed, but different kinds of nerve pain/patterns and piriformis muscle pain remained, sometimes mild sometimes more severe. Additional imaging ruled out lower back/SIJ issues.
Two months ago, I developed an intense tension in my right foot, very close to my Achilles tendon, between my Achilles tendon and ankle bone on the inside of the leg, when walking. Tension would feel like somebody was pulling my heel back whenever I tried to take a step forward as if one of the tendons/ligaments was too short and bouncing back each time. Pain could not be reproduced by pressing the area of the pain, just when stepping forward. The pain only appeared when I put on my shoes and took a step when at home in flip-flops I could walk pain-free. The pain came and went for about 10 days, then disappeared. Dr. Blake's comment: This is classic neural tension from the piriformis or low back typically. Glad it resolved. Tendinitis would not of so quickly.
A week ago I started feeling pain in my right foot, starting from the bottom just in front of the heel (between heel and arch) and shooting upwards towards the back of my ankle bone on the inside of my leg. Not a nerve pain feeling, but a tension again, less severe than two months ago, different spot (but nearby), and sometimes starts tingling slightly when I press on it. Tried rolling foot on a tennis ball at the point of pain and felt tingling on the bottom of the foot towards big toe (similar to pain from FHL injury 2.5 years ago but much less intense). Did not continue rolling on the ball. Being familiar with trigger points, I press my lower leg up from the ankle (on inside of leg) to calf and get some referred pain into my foot between the heel and arch. Pain is felt when swimming, walking, and stretching body when waking up (tension/soreness) and when not moving (dull throbbing ache).
Dr. Blake's comment: Again, this is neural tension. The tingly, shooting sensation, does not like prolonged pressure, are classic for nerve generated symptoms.
Any ideas of which tendon this could be and suggestions of how to release whatever is pulling on the tendon would be much appreciated! I would rather not go to doctors and physiotherapists all over again, but would not want to leave this if it might get worse. I got used to the residual/chronic nerve pain and piriformis muscle pain but would not want to start shifting gait again.
Dr Blake's comment: Nerve generated pain can be numbness only, pain only, and a whole range of abnormal symptoms. These again seem more like nerve so neural flossing, Neuro-Eze, lidoderm patches, active range of motion (not resistance or pressure), perhaps a sciatic nerve program from a chiropractic to avoid irritating the nerve (you can do that seating, lying, lifting,etc. ) I would go in that direction.
My feet are holding up OK. Left ankle is still funky, as are some toes on the right. But nothing worse. And I did two marathons in four weeks at the end of this year (New York and CIM), so I can’t complain. For a while, I was feeling that no matter what shoes I tried, I couldn’t avoid neuroma pain and started to wonder if it was time for new orthotics. But things seem to be stable now.
I have a question about calf raises. I know you have cautioned against calf exercises that have one lowering past level. I know you didn’t want me doing that when my plantar fascia was healing from the tear. But, if I’m not mistaken, I think you aren’t a fan of that altogether (and would instead recommend, say, keeping one’s heel on the ground, or even doing downward dog). But I am checking.
I noticed my online running coach had these two videos linked on his site as part of his foot/ ankle/strength routine. I wonder whether you would recommend these exercises or caution against them?
Why did the calf muscle pull? Typically fatigue and some element of the soft sand allowing the heel to drop too low or the knee extending too much.
Dr. Blake's comment: Thanks for the nice email. I will use it on my blog today because it reminds us of many points. When you are strengthening a muscle and its tendon, you have to think not only about concentric strengthening (where the muscle shortens doing its typical job) but also eccentric strengthening (where the muscle is in a controlled lengthening). Ask your therapist how to do each. I do not believe in pushing through pain when doing exercises, but some tendons have so much nerve innervation like the posterior tibial tendon with the posterior tibial nerve that we have to allow some pain as long as it does not affect the next day.
When you do calf eccentrics, which are wonderful exercises, you do not have to lower the heel past the level of the forefoot. So, in the two videos above that you sent me, I would have the patient just come back to ground level. You can get very very strong this way, and it is safer. Here is my original video after the article on eccentric strengthening.
So, when you put the heel lower than the forefoot, with all your body weight coming down, the Achilles and plantar fascia are getting abnormal stresses. Do everyone need to avoid negative heel positioning? No!! But we all have weak spots (Achilles issues, scar tissue from an old injury, knock-knees, unstable ankles,etc.) that come and go during our lives, and that we have to be diligent of and work towards making less vulnerable. If you have old Achilles or plantar fascia injuries, or perhaps an MRI for some other reason showed some degenerative changes in these areas, then it is prudent not to intentionally place your weak spot under high stresses. People do not injure their Achilles running uphill on their toes, they hurt the Achilles when they are tired or untrained for the activity and their heel keeps dropping below the forefoot.
I am sorry if this is hard to explain so I am trying various explanations. The body can be worked for the positive (hooray!!) and overworked for the negative. What can make an exercise have a negative impact on you? The common components are a poor technique in general, stressing the tendon/tissues in abnormal positions, the stresses overload the tissue by jerking too much, too much weight, holding too long, starting out too tight, etc. The list goes on. The stress may be to the tissue being exercised directly or a byproduct of the exercise (like the plantar fascia being torn while doing eccentric negative heel Achilles strengthening).
I think your plantar fascia, from your previous injury, is a weak link, therefore, overstressing, when you can avoid it, is preferable. I think the downward dog pose is probably fine now since your injury has healed, and your weight is so forward (versus the vertical column of weight crashing down on the plantar fascia in the 2 videos above.
I have to finish the conversation by emphasizing the normal ways to strengthen the Achilles in my practice to see if you are doing all of these:
2 positional Achilles stretching and other warming up exercises (like bike riding)
Straight leg two-sided heel raises 20 rep warm up, slow going up as high as possible concentrically and slow bringing the heel down to the ground eccentrically
Bent knee two-sided heel raises 10 rep warm up, slow going up as high as possible concentrically and slow bringing the heel down to the ground eccentrically
Straight leg two-sided up 20 reps, then with right off weighted, and lowering the left side slowly bringing the heel to the ground
Straight leg two-sided up 20 reps, then with left off weighted, and lowering the right side slowly bringing the heel to the ground
Bent knee two-sided up 10 reps, then with right off weighted, and lowering the left side bringing the heel to the ground
Bent knee two-sided up 10 reps, then with left off weighted, and lowering the right side bringing the heel to the ground
Straight leg right off weighted, maximal left one-sided heel raises (until pain or burning or just can not do it more)
Straight leg left off weighted, maximal right one-sided heel raises (until pain or burning or just can not do it more)
2 positional Achilles stretching
You can then slowly build up to 50 one-sided straight knee and 25 one-sided bent knee over time. It is fun to chart the numbers. These exercises are done in the evening at best to allow the most rest after (in the 2 hours before you go to bed). With the one-sided Achilles, the numbers will vary from day to day, but you should see improvement each week with the total done. For example, I also mark the calendar Right Straight Right Bent Left Straight Left Bent so it would be an entry 10/4, 13/6. Anyone looking at the calendar would not know what they are looking at. Build up to every other day 50/25, 50/25. This can take a year, and longer if there are setbacks. Remember, never through pain, and rest day in between.
There is more, but I can not remember anyone going through this program having too much strength issues. The slowest part, and sometimes the part that takes the most time, is when you can do 2 sided, but not one-sided (at least on one of the sides). Then you have to do many other things like toe walking, pool walking, first build to 100 two-sided, etc. I can get in more depth if someone is interested and emails me at drblakeshealingsole@gmail.com.
