Morton’s Neuroma-Revised Rewound Rebuffed Revisited
Thank you all so much for your comments and support. I have received a lot of feedback and fantastic questions about Morton’s neuromas (MN) and your problems with diagnosis and treatment of such. This area of the foot can indeed be terrifically confusing and difficult to diagnose. I want to help you all as much as I can with this conundrum, and I would love to answer each and every one of you individually, but I just can’t and shouldn’t in this setting. As always refer to AOFAS for specific help.
If you have been labeled with the diagnosis of a Morton’s neuroma and various treatments are not working so well, maybe you don’t have a Morton’s neuroma.
The MN diagnosis is made way too often. Why? Here are some misconceptions that surround the dreaded Morton’s neuroma and lead us astray:
- MN’s are really common. Actually they are not common, especially a 2nd web space MN (15%). Even 3rd web space MN are not common. If your doc is indicating a 2nd web space MN, question it and consider the much more common 2nd MTP synovitis (inflammation of the central ball joint). If they are thinking 1st or 4th web space, RUN.
- MN diagnosis is SEXY. We docs just got to make that diagnosis. “You have a Morton’s neuroma”. It has teeth. It sounds so definitive and sure. It is like a golf ball set up on a tee just waiting to be shanked.
- MN’s are easy to diagnose. Actually, they are not easy to diagnose. I have done this for 27 years and now more than ever, I am now even more cautious and I respect making this diagnosis ore than ever. It is actually a diagnosis of exclusion. This means that I rule out the other possibilities to the best of my ability before making the call of a MN. Too many good docs jump right to this diagnosis. It has to be the last diagnosis, and even then I am often not as sure as I would like to be normally.
- “You have a Mulder’s click”. This is a physical finding that is rarely helpful, but boy, do we really like it.
- The MRI and more recently, ultrasound have not helped matters either. In fact, those who rely on these tests are trying to increasingly make a claim regarding their diagnostic prowess, which is not true. Stick to old fashion history and exam.
- MN may be all your doctor knows.
Basically, central forefoot (2nd, 3rd, 4th metatarsal head region, not 1st or 5th) pain that starts in an otherwise normal foot can be divvied up into four basic diagnoses the great majority of the time. There are several more diagnoses that are uncommon and frankly, outliers that are not discussed here such as Freiberg’s infraction, inflammatory arthritis (rheumatoid), etc. Here are the names and the diagnostic criteria, according to the AO. Keep in mind that the majority of these can be diagnosed by history alone and an MRI or an ultra sound is generally not needed in any of these. Waste of time and money. If your doc is quick to say they need an MRI to make the diagnosis consider another route. I’m not sayin’, I’m just sayin’.
Exam is important, but only to support and confirm the history. By the way, no matter what you think or hear, none of these ever have a history of actual causative acute trauma. If you have a history of trauma and you have one of these I would say True-True-Unrelated.
Finally I am not discussing treatment. The treatment of each of these is clearcut as long as one is confident in the diagnosis, which what this is about.
Intractable plantar keratosis (IPK) or plantar corn or callus
- Generally older, 50 yo plus, but can be any adult
- Pain is on the bottom
- Insidious slow onset, present for some time
- Visible seed, small tight callus that is exquisitely tender to touch.
- No swelling
- You would have to be brain dead to miss this one.
- Pain only with weight bearing
- Worse on barefoot, better in shoes
- When it comes to trauma, this one could be the exception. If there is bonafide past or remote trauma to your foot/metatarsal or previous surgery that leads you to have a residual unevenness to the weight bearing surface of your metatarsals, then you could develop an IPK form that.
- X-rays negative
- Can be confused with a plantar wart.
Metatarsal neck stress fracture
- Ages
- Military recruits, boot camp, “march fracture”
- Distance runners, any age, training error
- 50+ female>>male
- Recent rapid onset
- Recent rise in activity level, especially number of steps! Normal activity to many more steps per day, vacation, new exercise program, etc. Or lower activity as in being down from prolonged inactivity, i.e.illness, heading back to your normal activity level. Jumping out of the back of a pick up truck and breaking your metatarsal is an acute fracture, not a stress fracture, and is different.
- Pain on top of foot
- Swelling top of foot
- Usually 2nd metatarsal, next to big toe metatarsal
- Pain with weight bearing, with or with out shoes
- X-rays negative in first 21 days, then new reparative bone formation is seen and sometimes the fracture is seen.
Morton’s neuroma
- Adults, peak age 40’s thru 50’s.
- Insidious onset, often years.
- Unlike all the others, at first and often even later, the location of the pain can be vague; can’t pinpoint. Can be frustrating for patient and doctor alike. However, knowing this can ultimately be helpful if used correctly.
- Pain mostly on bottom.
- Can take a while to get started with standing/walking.
- Worse in confining shoes, better in sandals or barefoot.
- NO SWELLING…………..EVER. Whoops, caps lock on again.
- Can feel swollen however. Numbness can feel like swelling. Remember the last time you got home from the dentist and you looked in the mirror because you were sure that your tongue was hanging out of your mouth only to find out all was well. I rest my case.
- There can be a sensation of actual, perceptible numbness between the two affected toe which border the neuroma. This sensation or finding by your doc is extremely variable and unreliable. It’s presence or absence really means nothing. I ignore it basically except to support my other findings.
- Mulder’s click is a useless finding. It’s absence means nothing. While I do dismiss it, a Mulder’s click may be supportive if when performed it exactly recreates your pain.
- 3rd web…85-90%, 2nd web 10-15%, 1st or 4th web…….not.
- These are two things that get my attention and often have meaning, but only supportive with other findings and history:
- feeling of folded sock bottom of foot
- urge to take off shoes and rub foot. Does not matter whether you actually ever do it, it is just the urge part.
Second MTP synovitis (AKA, capsulitis)
- Majority in specific demographic, 55 +/- yo female
- Not mentioned as differential diagnosis on Mayo or WebMD sites, but capsulitis is right there on Wikipedia.
- By and far the most common of these four diagnoses
- Primarily 2nd metatarsal. Infrequently the 3rd.
- Insidious onset, few days to weeks.
- Swelling top and bottom often, but not always.
- Painful “lump” or “rock” under ball of foot. Pain on bottom.
- Worse on hard floor barefoot, better on carpet or cushioned shoes.
- Sometimes there is the perception of some form of trauma, but any trauma is just the “straw that broke the camels back” phenomenon. For instance dancing at a wedding in heels to get it started. But here is something you MUST know; it was going to start eventually anyway because it is a result of:
- mostly these occur as a result of calves that are too tight which places more pressure on the forefoot/metatarsal heads. This represents a more recent change and why this is happening now and not before.
- in a very small part due to the anatomy because the 2nd metatarsal is the most prominent in almost all of us. This has been your anatomy forever and has not changed. Your doctor might refer to your 2nd metatarsal that is “too long”, but it has been that length all your life. Seriously, it isn’t as if your metatarsal magically grew longer recently. Now, refer back to calves.
- Transfer metatarsalgia secondary to a bunion. Often blamed, but the calves that are too tight are the larger reason this is going on at this point in your life.
- When this problem is left untreated, eventually a hammertoe will develop if the swelling is allowed to persist. Hey, here is a novel idea. The great majority of isolated 2nd and/or 3rd hammertoes result from MTP synovitis which comes from calves that are too tight, which is almost completely preventable as long as you stretch your calves.
- Often the inflammation from the 2nd MTP synovitis can irritate the adjacent 2nd web space nerve causing neuritis, which is a secondary thing and not a Morton’s neuroma.
If you are reading this, chances are you fit in one of these four groups. Certainly you’ve gotten loads of information from the stranger on the bus next to you, or your nosey neighbor (everybody is an expert), or from the internet, or even your doctor. Again, the mere fact that you are reading this means things probably aren’t going so well. No matter what you have heard from these sources statistically your problem is second MTP synovitis, and not a Morton’s neuroma.
IPK, seed callus under second metatarsal head
AP radiograph right foot 2nd metatarsal stress fracture, oldest with mature fracture callus; 4th metatarsal stress fracture, newer with early maturing fracture callus; 3rd metatarsal stress fracture, newest with minimal fracture callus
3rd web space Morton’s neuroma, plantar or bottom view
3rd web space Morton’s neuroma, dorsal or top view
Pedobarograph, 2nd metatarsal overload
2nd hammertoe
Hi Doctor:
I have been stretching as per your protocol for several months with no loosening up. My therapist recommended ACTIVE ISOLATED STRETCHING. There is tons of info on this technique.
Here is some: http://www.stretchingusa.com/active-isolated-stretching
They believe that prolonged stretching is not the optimal way to do it. Can you comment please?
Thanks very much
Carl
Hi Carl,
I am disappointed as you are that the stretching has not worked. I will say that there are many out there dead set on shooting down static stretching for some reason. If there are tons of info for AIS out there, there are megatons of evidence regarding passive static stretching as well as other methods*. I do believe there are several methods of stretching that might be effective, but the common denominator for success is stretch time in minutes (unlike AIS), isolating the target muscle, not a tendon, and finally doing it for months if needed. It sounds like you have been doing it for some time. Please keep with it at least to 8 months. Most respond in 1-3 months, however there are those at the right side of the bell curve who take longer. So maybe you are very close. I would continue with the static stretching and throw in the AIS if you want. My contention is that a stretch that is actually done is the one that works and passive, body weight loaded static stretching is the easiest to comply with everyday.
Thanks for your comments,
Stay healthy my friends,
AO
[1] A. Wilkinson. Stretching the truth. a review of the literature on muscle stretching. Australian Journal of Physiotherapy, 38(4):283–287, 1992.
Your CAPS LOCK on swelling leaves me shaken! I’m scheduled for a tendon release surgery following 3 years of pain, second metatarsal. I can manage the pain with a homemade insole that has a 1/2 in square cut out just under this spot, but I can’t walk barefoot on hard floors without pain.
Podiatrist zeroed in on MN by freezing the nerve between 2-3 metatarsal and having me walk barefoot on hard floor. No pain…. until the freezing wore off – then lots of pain and swelling all around the base of 2nd toe (compared to other foot, swelling subsided after 2 days).
In your opinion, humble or otherwise, does the swelling indicate no Morton’s Neuroma for sure?
Many thanks
Now you know any opinion I give has to be otherwise, never humble. The swelling comment only applies to before any injections. Everything you discuss here indicates second MTP synovitis especially if there was actual swelling before the injection. Swelling induced by the injection does not count and should resolve.
You do bring up a good point for me to cover. Morton’s neuroma can “feel” swollen on the bottom, but that is the numbness which can feel swollen. Think back to after a dentist visit and the numbing shot made your mouth or tongue feel huge, but it was not. That is the same thing.
So the punch line is if there has been actual palpable or visible swelling prior to the shot Morton’s neuroma is out.
Stay healthy my friends,
AO
Hi,
I was recently diagnosed with MN. I was given a pretty hard orthotic insert and a MT pad. However, neither have brought relief. In fact, wearing the pad seems to make things worse. The pain is very prominent when touched only between my 3rd and 4th toes. I also have shooting pain into my 3rd or 4th toe, depending on the day, after walking up and down stairs with or without shoes. Although, without shoes I will have pain 100% and immediate b/c any bending of the mostly 4th toe will send excruciating pain shooting into my toe and foot. I usually walk around in fit flops which help a great deal but they too can be of little help if I need to go up and down the stairs a lot. I do have very tight calves and have begun the stretching routine but only for 2 weeks since my dr visit. The toe hurts so much itself I am wondering if I need a stress fracture ruled out? My foot feels best when the toe is immobile and cannot bend. The shooting pain also can be set off just regular walking but always with stairs.
Any advice would be appreciated!
Thanks!
Hi,
I does sound like this might be a Morton’s neuroma. As clearcut as some might lead us to believe making this diagnosis is difficult even for me. I think it is the quick, default diagnosis too often. I will say start stretching you calves everyday because it is likely to work and what do you have to lose. All you need is a good old fashioned history and hands on exam to sort it out. It is very likely not a stress fracture. Having said that, this is one of the few times an MRI might help.
Stay healthy my friends,
AO
What I have seems pretty much like a left foot MN. 43yr old male, no swelling in forefoot but feels swollen, below 3rd webspace,and feels like a folded sock in the webspace if I wear shoes.Also, there is a kind of a click on the bit that feels swollen. I love your thoughts on calf stretching, and have started the regimen right away. Questions for you: Slightly to the left of my left shin area (below the calf), I can feel a nerve that runs down all the way to the top of the foot up to the third webspace. If I massage it there, I can feel a tingle that goes all the way down like an electric shock. It also seems to relieve the dull throbbing on the MN spot itself. Is massaging that area a good idea? Can shin splints cause a neuroma?
Hi Ravi,
I would agree you likely have a 3rd web Morton’s neuroma. The connection between shin splints and Morton’s neuroma would be 2 degrees of Kevin Bacon. In other words one does not cause the other, but the common denominator is the calf contracture. Please stretch your calves.
Stay healthy my friends,
AO
This has been so valuable. Thank you. I was diagnosed with MN 7 years ago by a physiotherapist and followed advice about footwear and use of insoles. Over time the pain in the ball of my foot (sometimes so bad I had to take my shoe off in the street), plus some numbness in toes 2 and 3 became worse, and two years ago I was referred to a podiatrist. I pointed out to them that my 2nd toe was creeping towards my big toe which I thought odd. They confirmed the diagnosis as MN and I went through new orthotics, then two rounds of cortisone injections – which helped for a few weeks – and finally they recommended surgery. The ‘smell’ was strong – I was determined to avoid it, especially having read about poor outcomes and complications. It sounds like a ‘slippery slope’ to me. I did, however, have up do something, so I read a lot and found a specialist podiatrist who does cryosurgery (I’m in the UK). When I explained over the phone in advance that the top of my foot seemed swollen he asked me to see my GP first, get some antibiotics, and then go to him (300 miles away) after that. My foot was still swollen – the antibiotics didn’t make any difference – and I also pointed out that my 2nd toe was moving further over. I assumed this was a response to the neuroma. Anyway, he did the procedure, it felt better for a while (I think this was a result of the cortisone shot he also put in), but then reverted back and is now really chronic. When I read your information I realised that this seems to have been misdiagnosed three times and that it must actually surely be MTP Synovitis. 2nd toe moving across, knuckle starting to point up and rub, very tight calf, tight tendon through arch of foot, sometimes swollen on top of foot and also lower calf (one boot fits tighter than the other), painful on hard floor in bare feet, better in wide fitting trainers, folded over sock under foot. Do you agree? Is it possible that this has been developing over such a long time? The podiatrist said he could see the neuroma on the scan. Your advice means everything to me – I feel like this is a breakthrough moment for me. Thank you so much.
Hi Hannah,
First things first. I am American, yet I am a Bart’s man having spent six months of my training in the mid 80’s at St. Bartholomews in London. What a fantastic experience!
Your history is accurate and concise for typical second MTP synovitis. The answer I give here is not just for you, but for everyone. Your situation is so typical and is exactly what I am trying to help others with. The misdiagnosis of Morton’s neuroma in favor of second MTP synovitis is basically epidemic and frankly stupid. I could make a career on this problem alone because second MTP synovitis is so prevalent compared to Morton’s neuroma. Of course the majority of my colleagues would disagree. Forgive them for they know not what they do not know.
In fact I just saw The Big Short (Fabulous movie) last night and I would liken my battle with that of Dr. Michael Burry and subprime mortgage backed securities. While I don’t really have a way to short this system, I will keep on talking until someone listens.
To be clear and fair, Morton’s neuromas do occur and contrary to popular belief surgery is very successful in most cases. However a successful outcome in any surgery, particularly this one, requires that the surgery is done skillfully and correctly and the diagnosis is correct. It also requires the patient doing their part complying with the post op regimen. Could it be that I am correct in that Morton’s neuroma is way over diagnosed, actually misdiagnosed, and the failures of Morton’s neuroma surgery in most cases result from this misdiagnosis? I am certain this is true just like Dr Michael Blurry was certain.
My dedication to this issue is pretty obvious:
ALBERT PUJOLS, LOOKING IN ALL THE WRONG PLACES
HAMMER TOE AND YOUR PAIN
PLANTAR PLATE REPAIRS & THE PRE-DISLOCATION SYNDROME: WHAT THE F$@% (PART 1)
PLANTAR PLATE REPAIRS AND THE PRE-DISLOCATION SYNDROME: WHAT THE F$@% (PART 2)
56 YEAR OLD FEMALE
MORTON’S NEUROMA REVISITED
MORTON’S NEUROMA: CONTROVERSIAL TO SAY THE LEAST
So let’s examine your story and answer some questions of this typical scenario. This divided approach just tells the same story a different way.
-“some numbness in toes 2 and 3 became worse”. This is a license for the doc to put on the blinders, focus on Morton’s neuroma and forget any other possibility. Need I say more?
-“my 2nd toe was creeping towards my big toe”. This could be true for the 3rd web space Morton’s neuromas, but not 2nd, which are rare. This creeping deformity is a dead give away for 2nd MT overload and second MTP synovitis.
-“I feel like this is a breakthrough moment for me”. Correct.
-“I realized that this seems to have been misdiagnosed three times”. You got it! You hit the nail on the head.
Why is it there are so many FB pages and other forums dedicated to how poorly people are doing treating their foot and ankle problems? Why do these treatments fail? Why are these chronic foot and ankle problems, such as plantar fasciitis, second MTP synovitis, Morton’s neuroma, insertional Achilles tendinosis, and the list goes on, so……well……CHRONIC?
I’m turning blue in the face right now! In almost every case, whether misdiagnosed as in your case, or correctly diagnosed, the culprit is the calf is too short: equinus or isolated gastrocnemius contracture.
Not to mince words, but you need to stretch your calves everyday and for now forget your crooked toe. If you have swelling you need to have the 2nd MTP joint injected with cortisone to reduce the swelling which leads to and further contributes to the hammertoe formation. God luck convincing someone to not inject the web space and inject the joint.
Here is my personal problem Hannah. If you do stretch and ultimately realize the stunning transformation, you will tell no one. CRICKETS. Why? Because it takes time and when it works, well who cares at that point. Your problem is over after all.
Please don’t forget, shout it out to help others.
Stay healthy my friends,
AO
The new podiatrist I saw yesterday didn’t tell me whether it was MN or MTV, and I didn’t ask. I just assumed MN. He’s conservative about where to start. He said he’s a wimp and never would want an injection right away. I’ve had pain between my 2nd and 3rd toe for a few years. Painful shocks mostly at night. Feels better barefoot. It came and went. Now it’s coming and staying, and the balls of my feet burn a lot. I can’t walk more than a few blocks before the pain and burning stop me in my tracks, so to speak. Doc put u-shaped pad on bottom of super feet insert. I don’t really like the feel of the inserts, but I think I’m “supposed to.” He didn’t seem to care what shoes or inserts I had. Just go by what feels good, he said. What does it sound like to you, and what would you do about it. Yes I will try stretching.
p.s. I also saw an orthopedist foot doctor last week, and he thought neuroma (I don’t care which one so I didn’t ask) too. Just suggested pad and wide toe box. Injection with ultrasound if I want one. Nice man, but I think I was a garden variety complaint and not terribly interesting. I decided to get 2nd opinion with podiatrist experience above.
p.p.s. And by 2nd and 3rd toe, I’m starting with little toe. Is that the right, or do you start with big toe? We should be giving these toes names, so we’re all on the same page here!
Hi Susan,
You are describing a third webspace Morton’s neuroma. The counting is from the big toe, so you are describing the 3rd and 4th toes and third webspace. As far as orthotics with or without a cutout or met pad or what kind of shoes you wear I completely agree with your podiatrist: basically wear what feels the best to you at this point. If the inserts hurt don’t suffer, take them out. A lot of this stuff like orthotics is sort of trial and error anyway. While not specially studied, my experience has been that calf stretching indeed significantly helps, if not irradiates, Morton’s neuromas, but it takes time. Finally a cortisone shot will not solve your problem, but it might make the journey better. It just depends on how much it hurts. But of luck.
Stay healthy my friends,
AO
I was diagnosed with MN 16 months ago after a slip and fall that took ages to heal- something about it wasn’t quite right though, mainly that I felt the pain on the MTP joint head and not really in the web space. After reading this post I got a second opinion and i’m told I have a non united avulsion fracture from a trauma that occurred 16 months ago.
Is it possible that the bone shard can still just be there after so much time? Shoudln’t the body have dissolved it? If it hasn’t gone after 16 months is there any reason to think it will dissolve in time? What options do i have?
Hi Adrian,
Glad to help. I think you are on the right path, but beware. I can not really shed too much light, but there are three points I can make here to help you and for all to learn from.
1. Even though there is an “avulsion/bone shard” on your X-ray it is still possible it is not the source of your pain. That is the beware part. When something is seen on x-ray or MRI, etc., docs and patients both put on the blinders. Case solved, there it is! It is sort of like the guy standing over the dead body with the gun in hand. He obviously did it! Maybe not. In medicine we call it clinical correlation and it is done far too little today. It is connect the dots based on the evidence. But what evidence are we using? Today it is the test and way to little history and exam are relied upon. For God’s sake, we have a test, a smoking gun.The more tests available the more we rely on them and turn our brains off and make the obvious assumption. For me the fun is the old fashioned history to solve the “crime”. Otherwise what fun is there in it. Is your doc having fun or just reading tests?
2. In your case, if your chronic pain is a result of an ununited avulsion fracture, the source of the pain is likely not the “shard” just being there (unless it creates a pressure point plantarly). The source of the pain is the fibrous nonunion and the mechanical torque/strain between the main bone part and the small adjacent avulsion fracture. It acts kind of like a hang nail. Sight unseen if it is what I imagine it to be and it is causing the pain then you have to ask yourself, “how much pain is there and loss of quality of life?” If it just an annoyance, then live with it. If it is more then act, but it may be surgery.
3. I can’t tell you how many patients I have seen who had this or that already booked by another doc for surgery on the smoking gun, you know, the blinders thing, when all along they had the most common problem of all, second MTP synovitis. I know you had an injury, but is it the source of your problem now? Was it really a traumatic injury or did you start having pain and attributed the pain to an injury. This is all too common and leads us all astray. The story, the history holds this secret and you don’t need a doctor to figure that out for you. Not to be nosy, but would be interesting to know if you are a female close to 56 years old. Adrian after all could be male or female.
Hope this helps.
Stay healthy my friends,
AO
I first felt a numbness or tingling on the bottom of my left foot two years ago. The tingling was concentrated at the base of my toes. The tingling has gardually increased over the past two years. There is no pain, just a feeling that my socks need to be pulled tighter. It is most noticable when wearing tighter shoes. I hardly notice any sensation when wearing wide crocs. Once my shoes have been removed , most of the numb feeling dissipates.
In the last month I have begun to get a similar tingling in my right foot. At my annual physical last month, my GP referred my to a neurologist for neuropathy diagnosis. Do you think this is the correct first diagnostic step?
Hi Fran,
It is hard for me to say here, but it sounds more like a Morton’s neuroma. Peripheral neuropathy really does not act like that. It should sensed more at bedtime and less in the day in shoe and is usually equal right and left. Also a neurologist is unlikely to head light and definitely can’t help you. If it was, and I don’t think it is, the largest cause of peripheral neuropathy far and away is diabetes mellitus, so you might have that checked. In the mean time start calf stretching because it is good for both problems. Stay active Fran.
Stay healthy my friends,
AO
I’m a 55-year-old female, diagnosed with MN. Professional orthotics and multiple visits to a podiatrist were no help. Because I have systemic lupus with neurological complications and chronic kidney disease, my neurologist strongly advised against any foot surgery. I began to think there was no hope for me to walk without pain, until I found the Angry Orthopod blog. Having been educated by the AO, I now believe I have second MTP synovitis. I’ve been stretching my calf muscles for about two weeks, and I’m already feeling quite a bit better. I walked two miles today with only mild discomfort. Thank you, AO. I believe you’ve changed my life!
Sylvia, You know I love ya. How can we get the word out the value of calf stretching. Certainly the utter disregard for this free, definitive treatment is undeniable. Then someone life you comes along and “gives it a try” and voilà, it works. As I have been saying and meaning every word to the OA Nation, daily calf stretching works because i addresses the root cause. The more we speak up like you Sylvia, the less people suffer and the more money we save.
Stay healthy my friends,
AO
I have terrible Morton’s neuroma (I was told this by 2 podiatrists) in both feet. The worst is my right and I am now limping. I had 2 shots a couple of years ago and they did nothing. I put a piece of padding on the bottom of my foot to take the pressure off the nerve but there is no relief anymore. I’d like to schedule an appt. with you but cant’ find your info anywhere. Can you send it to me. Thanks.
Hi Karen and everyone else,
While this request is very flattering I have left clinical practice and changed careers. So I can’t see you even if I wanted. This change has kept me very busy and thus my absence from the AO gig. I would like to say I am back because this site is a huge priority for me. So please spread to word so I can help as many as possible. As a note, my colleagues still are not on board and as much as I have worked, and published to get them to see the light, they just don’t get it.
As for you Karen, even if I saw you you know what I would say, “Stretch your calves every day”.
Stay healthy my friends,
AO