First, to my request before you stop reading. If you like or feel there is value in the content on the Angry Orthopod please spread the word on social media or any way you feel you can. This is particularly true when you have personally benefited as a result. This is a groundswell process and thus requires your support. Thank you.
please spread the word on social media or any way you feel you can
I know, you have been losing sleep at night wondering, “Where did he go?” As arrogant as I am, even I don’t believe that. OK, I was not actually on a sabbatical. I electively retired from active clinical practice to change careers. I am still in the medical field with just a different angle on things. This change has made me busier than a rooster in a henhouse. Things have finally settled and I am back, angrier and sassier than ever.
Even though clinical practice for me is over after 3 decades, my desire to help you all here has only strengthened. Make no mistake, the experience that has allowed me to question and challenge mainstream establishment medicine is alive and well.
As a reminder, I am not angry at you unless you give me a reason. I am angry (code: trying to make a change and promoting preventative and non-operative health) at my medical colleagues who, in my humble hubris opinion, are all too often not giving needed time and/or non-operative treatment enough of a chance and opting too quickly for surgical solutions. How convenient.
my desire to help you all here has only strengthened
Recently I read a transformative book that confirmed my long-held conscious realization that surgery wasn’t all that. Professor (Dr.) Ian Harris, the author of Surgery, The Ultimate Placebo: A Surgeon Cuts through the Evidence, is a seasoned Australian orthopaedic surgeon, traumatologist and serial researcher. Amazon sums it up perfectly, “For many complaints and conditions, the benefits from surgery are lower, and the risks higher, than you or your surgeon think.” Dr. Harris focuses more on the ineffectiveness of many common mainstream surgeries accurately covering the evidence that they are all too often no better than doing nothing and can clearly cause harm. I would vehemently add that there are many curative non-operative treatments out there that are either unknown by your doc or are suppressed.
When it comes to the risks and surgical complications, we surgeons have a saying you need to know: “The risk of complications for [insert your surgery here] is about 1%, until it happens to you, then it is 100%.” And every surgery brings the risk of harm into play. Period. Harris covers this point to perfection.
Don’t get me wrong, surgery definitely has its place and can be life-changing, but only after an informed, careful consideration and a collaborative decision process between surgeon and patient. You are in control and you have the right and power, and you should make these critical decisions for yourself. I highly recommend this book whether surgery is a consideration or not.
surgery…a collaborative decision process between surgeon and patient
Last request, which concerns requests. I welcome your requests for blogs on subjects that might be of interest to you and others. Please keep focused on basically foot and ankle issues. I will be selective on which are chosen especially if there are numerous requests.
Finally, I am in the process of answering many of your regretfully neglected comments/questions you all have posted over the past 18 months. Even if your problem has resolved or the question is “off the table” for you, I will still answer because the questions are excellent and the answers are good for all to see.
Stay healthy my friends,
I’m so happy you are back, AO! Please consider writing about 1) the misalignment that is often referred to as a bunion but which is really (I think) the result of wearing narrow toe shoes; and 2) ball of the foot pain. I thought I’d seen articles on your site about the second topic, but now I can’t find them.
I am happy I am back and I am back for people just like you. Even though all of you make me angry I love each and every one of you and I want you to not be well! Just think of my comments as tough love.
I think your suggestion for a “bunion blog” is good and bad. It is good for all the AO peeps, but it is bad for me and of course, it is all about me. Here is my challenge and Mark Twain said it so well, “I didn’t have time to write a short letter, so I wrote a long one instead.” I will have to work to keep it simple and on point.
As for the “ball of the foot pain,” I can honestly say I have written on that one indeed. See links below. Here is the thing about second MTP synovitis, it is associated with bunions, but maybe not in a way you might be told. I will address in the bunion blog.
Thanks for making a suggestion. WHAT ABOUT THE REST OF YOU?
I found you researching some very sudden onset and alarming toe pain I was having last week. I had been hitting golf balls and then was walking down the driveway when I suddenly felt like I had some thing sharp inside my shoe. I took my shoe off and looked for what I thought would be a small short stick. I found nothing in my shoe or sock so I put it back on and began walking again. First step on my right foot and it did it again. Pain was on the medial side of my second toe on my right foot. My amateur diagnosis, which was founded on the most cursory internet research, was that it was an MN. Perhaps it will require professional medical attention in the future, but in the meantime I have been doing your recommended calf stretches (I also tore my left Achilles last year, no surgery, apparently I’m a starfish, but it is forcing my to stretch that as well) as it has not reoccurred and I have been doing the same things I was doing when it happened. Im occasionally in an office with a stand up desk so it is quite easy for me to stretch while working using a stack of books or pamphlets. I also have terrible feet, have had bunion-like feet since I was born, so I may be the foot problems “perfect storm.” I do wish you luck in your new field, just thought I’d drop an appreciative note of thanks for your blog. Of course any extra suggestions you might have as far as caring for my bony feet would be most welcome as well, I side with Paula and would enjoy a “bunion blog.”
You sound very insightful and maybe less of an amateur than many of my blinded professional colleagues. All I can say is that the odds are enormous that simple calf stretching has you covered. Especially since you have a history of an Achilles rupture. The bunion does not help as it contributes by throwing forefoot load onto the 2nd MT head, but you have had that, right? The change was not a sudden appearance of a bunion, it was silent equinus that crept up on you. While the bunion presents its own set of problems, the second MTP synovitis will still resolve in most cases with just calf stretching. Unfortunately, calf stretching will not fix the bunion. I am working on that bunion blog as well. Best of luck. Stretch.
Stay healthy my friends,
Hi AO, I have just discovered you in the nick of time me thinks. I fractured (avulsion) my left ankle last year and about 6 months later developed forefoot pain in my right foot after trotting down some stairs in the wrong shoes (then aged 55 – bingo!) I went to a Pod about the R. forefoot pain and he sent me off for an ultrasound revealing a mass in the 1/2 and 2/3 headspace in keeping with a MN (apparently). I was also forthcoming with a painless Mulder’s Click in both feet. My L. ankle rehab was going slowly so they decided to do a MRI (now 12 mths post injury) revealing chronically ruptured ATFL and CFL as well as a chondral defect. I have had 3 Ortho. surgeon opinions (2 said to go for reconstruction and one said it may not make my situation any better). I am about to get my final surgeon’s opinion tomorrow. Following this reconstruction, I have been mentally preparing to have surgery again for MN. But after reading your blog, I think my symptoms in my R. forefoot (which have developed in L. forefoot as well now) mirror 2nd MTP synovitis rather than MR. I have the beginnings of hammer toes on number 2 toes and these are beginning to drift to the great toe. I also have a bit of puffiness at the base of the second toe. I think I read somewhere that you said it is imperative to get an injection in the joint to slow down the inflammation. Is this correct? Yesterday I began the stretching in earnest. I hope my Pod can come around to your way of thinking. I can’t begin to tell you the relief I feel in finding an alternative to MN surgery. I have a long road ahead as it is with reconstruction. Thank you so much for being so generous in sharing your expertise.
First of all, you know something about medicine and ortho based on your comments. So I might take this discussion a bit more scientific. I am going to separate ankle and foot as well.
As far as your ankle is concerned, be careful of ligament reconstruction. Without delving into the ankle too deep, there is a good chance the calf stretching will make a significant change there. MRI findings don’t necessarily correlate with the source of symptoms, so beware, and your ankle does not seem to be urgent a year out. Who knows, you stretch for your foot and you might kill two birds with one stone. I have seen it play out hundreds of times.
The foot I agree sounds like classic second MTP synovitis. Morton’s neuroma is a clinical diagnosis and ultrasound, and MRI has shown no evidence to have any utility. And as you have read on the AO, second MTP synovitis is far more common. Yes, an intra-articular cortisone injection will work quickly for the debilitating symptoms and arrest the joint destabilizing effects of the joint swelling. It is the treatment today. Then the root cause, equinus, must be addressed with the calf stretching. That is the treatment for tomorrow. Be patient and don’t stop.
As for your orthopod coming around, Julie from Australia, your chances are better in Australia because your docs are a lot more progressive and open-minded! However, when it comes to equinus and its causal relationship to foot and ankle pathology- well, don’t hold your breath.
Stay healthy my friends,
AO – I wanted to drop a note of appreciation. I’m a 41 year old recreational runner with recurring PF over the past 2 years. I’ve been calf stretching frequently after stumbling upon your blog and it’s really helped!!
I’ve coupled the stretching with some exercise band exercises to strength my tibialis anterior. Not sure if it’s contributing to my recovery, but certainly doesn’t seem to be hindering it!
Thanks so much for this treasure chest of a blog!!!!
Thanks for the boost. I like your addition of the anterior tibialis resistance exercises. For those of you who don’t know, the anterior tibialis muscle is the main opposing muscle to the calf that pulls ankle up and BTW keeps us from tripping on our feet. That is an exercise every runner should do in addition to calf stretching.
Isn’t it interesting that you qualify for chronic plantar fasciitis (> 6 months duration) and somehow stretching magically helped? Regardless of plantar fasciitis duration, I found no difference in efficacy of calf stretching. My colleagues would never even consider it after 6 months let alone before. All I can say is it works no matter when it is started. The problem is the perception is that it is a first line, weak treatment modality especially compared to others, so it does not get done. Thanks for doing it and getting back. Just in case you are on social media please let others know what works, and what does not.
Stay healthy my friends,
Hello, I’m eternally grateful I found your blog! I’m referring to the subject of plantar fasciitis. This I’ve had for too long with no relief, calf stretching is definitely the answer, I am already getting relief in just one week, but will continue doing. I’m sharing your print out. I did notice how tight my calves felt, but I was doing the stretching all wrong.
Thank you again!!
Isn’t just crazy how such an easy thing is so simple and effective. Here is what really does make me angry, why don’t my colleagues or other medical professionals see this? Maybe because there is no money in it? How long have you had plantar fasciitis and how many different types of treatments have you had? Please take a look at my response for Tony on Sabbatical.
Thanks for commenting and if you are on any social media please shout this out so others need not suffer. And yes, keep stretching indefinitely because calves can retighten.
Stay healthy my friends,
I am a practicing podiatrist. Only recently did I stumble upon your website/blog. I was quite intrigued reading many of your posts, as they really seem to articulate (certainly much better than I ever could) that many of the foot ailments that we see are actually driven by proximal musculoskeletal imbalances, namely gastrocnemius equinus/tight calf musculature. However, I do find that many of the patients I see do not truly exhibit “skin in the game“, meaning that I don’t believe that they are necessarily sold that calf stretching will solve their foot woes, despite the scientific evidence to the contrary and I don’t feel they do it diligently. In fact, I find that many of the patient populous that I am treating are looking for a ‘quick fix’ , specifically a “CORTISONE SHOT”. I certainly don’t blame them, but is it appropriate?
Perhaps I have missed it, but you are you able to provide commentary on the appropriateness of steroid injection therapy for the foot or ankle? I actually see that many of my peers/colleagues will provide these “shotgun injections“ for any foot malady that comes into their office. While in the right hands and the appropriate patient, a diagnostic and/or therapeutic injection should certainly be a part a podiatrist’s armament, but it should certainly NOT be utilized as a ‘panacea’ for every foot disorder.
Anyway, I have enjoyed reading many of your posts and just wanted to send you a shout-out! It would be great if you can provide commentary on the aforementioned.
Thanks so much for your kind words and it now is my favorite compliment ever. However this whole issue really angers me.
So, I am going to start a bit off track here. You, my friend, are part of the rapidly growing contingent of relevant, skilled podiatrist today. I feel that while the podiatric training and philosophic momentum moves in the right direction, the orthopaedic foot and ankle momentum is steered in the direction of the technical aspects of surgery, fancy devices and a “we can fix everything with a knife” mentality. Even some of my closest colleagues have taken this direction. They say they engage in non-operative treatment first, but do they really? I am not even sure what conservative means anymore. And patients (sorry, but you guys do unwittingly shoot yourselves in the foot all too often) are not much help either, ever seeking the “fast foodish” quick cure. If they only knew how much risk they are injecting into their own care. Speaking of injecting…
I have some very specific views based on ~30,000 injections over 30 years. In general, steroid injections are safe and very effective, but only when used appropriately. Based on what little you have said I think you follow this same logic, and it is not a panacea.
* Therapeutic orthopedic/podiatric musculoskeletal injections must be TACTICAL based on a solid diagnosis. In my opinion there is no place for the often utilized point tender, random soft tissue injection. In general it is nothing more than bad medicine. Of course there are a few exceptionsIt reeks of:
** “I don’t know what your diagnosis is, but I would like to help you, so I am going to inject the general area of your pain and see if it helps?”
** The subconscious thought is, ‘I can get you out of the office quicker using this method.’ That never seemed a fair way to treat my patients as I never felt I could effectively treat them unless i had a solid diagnosis. And point injections are usually done in absence of a diagnosis and serves the doc way better than the patient.
** And I have no stomach for post op or intra op incisional cortisone injections. They are dangerous and there are more direct and safe treatments for what ever one would do this for.
* My tactical injections were almost always aimed at one of just three areas each with a “space” to receive the injection:
** Joints: second MTPJ, ankle, talonavicular, midfoot, subtalar, etc.
** Bursal spaces: over first MT head medial eminence, retrocalcanel bursa, etc.
** Tendon sheaths: EDL at ankle, FHL for stenosing tenosynovitis, etc.
** There are a few notable excetions:
*** Morton’s neuroma space injection.
*** RA nodule injections. I found these actually very satisfactory for my patients and avoided OR visits most of the time
*** There may be a few I forgot
* Cortisone: Great drug for tactical injections, not so good for point injections. As you know, when injected near the skin the risks include focal depigmentation, lymphatic depigment, fat atrophy, etc. I don’t believe for a second that several well done interarticular joint injection of cortisone cause hyaline cartilage damage. Of note, when dealing with an arthritic joint the benefit risk ratio warrants use of cortisone. Of course there are others such as ligament or tendon rupture, but these are due to only two reasons:
** Misplaced injection into the tendon, but with correct method this should not happen. See below.
** Good injection where the pain relief removes the gait or muscle action compensation on an already weakened, compromised tendon. Asa result, the tensile forces increase and the weak, diseased tendon ruptures basically unprotected. This happened several times at my hands.
* My method I called the exchange method. Now I am going to brag. I mean really brag. In all these injections I could not hit the target maybe 10 times. And I never used ultrasound or any imaging, not once, and with the exception of a few, they were very quick. I am going to show my age and say ultrasound is fluff mostly for charge and unnecessary if one has an ounce of skill. And most were basically painless.
** First, I froze the skin with ridiculously cold Midi-First “Cold Spray” (not ethyl chloride, not cold enough) and injected subq with small gauge needle/lidocaine. BTW, no infections and evidence shows that the Cold Spray may be involved.
** Then I sounded the joint with a larger gauge needle (usually 20-22 gauge) using only local, carbocaine or lidocaine (no steroid yet), preloading local slowly in front of the advancing needle.
** The magic to find the joint, tendon sheath, or bursal space starts with knowing the anatomy and careful planning using palpation. As I approached the joint more by feel than by vision, I kept slight pressure on the syringe plunger and used the feel of the contrast of the resistance of the soft tissue compared to the free flow or release of the local once the joint was entered. I never relied on the “pop’ some talk of. Then confirmation came from injecting the joint with some of the local and aspirating it back.
** Then comes the EXCHANGE: the needle is carefully retained in place with a hemostat while the syringe is removed and another is screwed on. Of course this syringe has the cortisone and in my case a longer acting local such as carbocaine. Finally, inject and re-aspirate to confirm and re-inject. Done.
This is certainly more than you asked for, but I saw it teed up and I decided to grip it, and rip it. So, in summary, cortisone safe as long as its use is selective and injected strategically. I am tired so I will quit.
Stay healthy my friends,
Your calf stretching cured my (alleged) gastroc equinus. Too bad I didn’t follow my own advice and have an ortho do my bunionectomy. Left with flexion contracture with big ol- scar bump of great toe. You’re the best! I hope you trained a clone to replace you in actual practice.
Thanks so much. There is no doubt there is a calf stretching hate fest out there. Puzzling considering the evidence. I think the feeling is that it is so simple it couldn’t possibly work, right!! At least you know.
I am not sure this will make you feel the least bit better, in fact I know it won’t, but bunions, especially when it comes to consistency, are difficult. Pity. For all of you AO followers, there are two basic things to consider when choosing a surgeon to perform your bunion surgery:
Bunion correction is likely the most experience-dependent surgery we foot and ankle surgeons perform. So, pick an older surgeon with more experience. There is an old saying, “When picking a surgeon, choose one old enough to have experience, but young enough to not be bored.” I can’t agree more.
Type of surgeon. Fellowship trained foot and ankle orthopaedic surgeons, as you allude, are currently the best bet. I am an orthopaedic surgeon, so of course, I am biased, or am I? No doubt that the younger podiatrists are coming on very strong with better training and increasing experience. I know this is a backhanded compliment, but true. Of course, there are exceptions to my assertions.
This one is for extra credit. As a patient, we need to comply! I know this sounds self-serving, but most often my failures came from those patients who are self-professed “quick healers” or “the rules are for others.” Noncompliance is reported at 27-88%[1,2]. Along the same lines considering experience, I believe our delivery of the post-op restrictions and expectations are remarkably improved and more convincing with time. This is called experience.
Stay healthy my friends,
 C. P. Chiodo, A. A. Macaulay, D. A. Palms, J. T. Smith, and E. M. Bluman. Patient compliance with postoperative lower-extremity non-weight-bearing restrictions. J Bone Joint Surg Am, 98(18):1563–1567, Sep 2016.
 B. J. Braun, N. T. Veith, M. Rollmann, M. Orth, T. Fritz, S. C. Herath, J. H. Holstein, and T. Pohlemann. Weight-bearing recommendations after operative fracture treatment-fact or fiction? Gait results with and feasibility of a dynamic, continuous pedobarography insole. Int Orthop, 41(8):1507–1512, Aug 2017.
Yikes! I am sorry I did not realize you were not here for a while. I have been counting on you being here for any new problems after the advice I sought and received once before. I am always praising you to my husband, a retired baseball player and new yoga advocate. He is firmly in your corner on stretching and your advice in general. I have a specific question about a foot injury that resulted in a toe becoming like a hammertoe. Specifically toe implants versus the traditional pin. If it is appropriate for me to ask that question here point me to the appropriate place. I want to stay active is my main goal. Many thanks!
I guess I was gone, mostly 2 parts too busy and 3 parts lazy. Maybe I was not angry enough. This is an excellent question BTW. Pins have always worked just fine and there is currently a slow trend back to pins from the PIP implants. The implants have become popular for three reasons and none because they are any better: 1) speaking of baseball, they are “Field of Dreams” meaning “If you build it they will come”. These fusion implants are like so many other new devices in that regard and sad. 2) Docs are always looking for an edge more than just being the best and letting their reputation and results speak for themselves. Too many docs are thus looking for cool gadgets to make them look better. 3) The pins work fine and are safe and effective, but too many patients frankly whine about having a pin. They heard aunt Janie had a bad experience with that damn pin. And they don’t want too look at it or have it pulled out. Painful, right? Not! I pulled maybe 5,000 during my career and maybe 4 said it hurt, the rest said they got all worked up for nothing. And then there is infection, which comes from too much external movement from walking and rolling off the toes. So, pins are fine and way less expensive.
The one advantage of the implants is most have the option of a bend leaving the toe with a more natural bend of 10-20 degrees. I found a way to pin and create this natural bend. But all too often use of the pin can leave the toe “too” straight, which in my opinion is kind of ugly.
Hope this helps, don’t be afraid of the pin.
Stay healthy my friends,
So happy to have re-found you and see that you are back! Among other orthopedic complaints after 50 years of tennis, I have numbness in my toes. The podiatrist says I have Morton’s neuromas, but the number of toes involved doesn’t seem to fit the pattern. I can’t find any information that sounds like what I have. Is this something you’ve come across and is there anything I can do about it? (I’m not diabetic or anything like that.) Thanks and keep writing!
I can’t be sure what you have, but I like your logic. Maskill published in 2010 the reason you should address your calves. I don’t agree with the gastrocnemius recession because simple static calf stretching will do in most cases just as well. It is curious that my publishing colleagues love to lengthen the calf to solve all sorts of foot and ankle issues, yet they give little credence to calf stretching. The standard exclusion is “failure of non-operative measures” or “stretching failed to work”. Details please other than just random comments. So, according to Maskill and me, work on your calves no matter the diagnosis, just give the right stretch a chance before you consider calf lengthening by surgery.
Stay healthy my friends,
 J. D. Maskill, D. R. Bohay, and J. G. Anderson. Gastrocnemius recession to treat isolated foot pain. Foot & Ankle International, 31(1):19–23, 01 2010.
Re: Hyperextended Knees
PF & Hallux Rigidus
Hello and thank you-
You have renewed my hope.. a little.
I am a woman & I live in Manhattan, which means a lot of walking on cement.
I developed PF after a month of wearing a new pair of ‘comfort’ shoes- lace up oxfords with a thick foamy insole and a stabilized thick outer sole; A dirty trick i think since i wasnt wearing high heels.
I have very high arches but the arch of the insole on the new shoes felt too far back and i assume this was the culprit.
I have massaged, rested, iced, stretched (against the wall) & all to no avail. My PF worsens.
So i was excited to find your site and i have just begun your protocol.
1-) my knee joints ( and all my joints) are very hyper-extended, which i have learned to correct.
But, it makes the stretch a bit tricky.
I assume i should not allow my knees to hyperextend during the stretch & i find that doing one leg at a time is the only way i can control my knee placement at all. The hyperextension makes it hard to place the stretch in the calf muscle.
I would appreciate any feedback about this.
2- ) My Plantar Fasciitis is in my right foot. Years earlier, i developed a painful & limiting Hallux Rigidus in the same foot.
Now my big toe is leaning toward the others and a bunion has developed.
I have been wearing well made clogs ever since the HR began, they help diminish the pain in my big toe but i am not sure if they contributed to the PF.
Are there any specific exercises for Hallux Rigidus?
Two problems, same foot.
Without being Sherlock …. i cant help but wonder about the connection.
I searched your site for any previous input on hyperextension or hallux rigidus – but was not able to find it. I hope i didnt miss it.
So many thanks,
I am apologizing lots these days for late replies. Work, work, work. I have dip ing th answers to comment s addressed hall rigid (HR) and equinus, but I can’t remember more than that. Actually HR has been associated with HR and while I do believe stretching could help, it is not the level of consistent relief seen in other problems like plantar fasciitis. As far as you hyperextension, the first thing is to be careful calf stretching to not overdo that part. While I don’t thing there could be harm, you could certainly make your knee posterior capsule angry for a bit just like me. As far as the knee hyperextension, I am not aware of nor can I imagine how that might influence HR. You do know that hyperlaxity syndromes, much like you sound, is associated with osteoarthritis. So, maybe there is the association. As far as the bunion, there are only two things that can be done: move the shoe/pressure point or move the foot with surgery. Understand you can wear the best of shoes and those suckers can still kill, yet surgery is a last option and not fun. I hoe this helps.
Stay healthy my friends,