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Please consider a donation if you feel the blog has helped you. A $5 donation will help me pay for the blog artwork, guest writers, etc. Dr Rich Blake

As of 7/27/16 $85 has been donated. Thank you.


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About Me

San Francisco, CA, United States
I have been a podiatrist for 34 years now and I am excited about sharing what I have learned on this blog. I love to exercise, especially basketball and hiking. I love to travel. I am very happily married to Patty, and have 2 wonderful sons Steve and Chris, a great daughter in law Clare, my new grandson Henry, and a grand dog Felix.

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Monday, July 25, 2016

Sesamoid Fracture: Email Advice

Hi dr Blake 

I am a physician in early 50s with dx of medial sesamoid fracture since April 2016 after initial misdiagnosis of gout. Been reading your blog on sesamoid injuries and I am impressed with your advice to so many fellow sufferers. 

Here is my story with my main question now at the end

1.  April 15 X-ray showed R medial sesamoid fracture. Likely from hard sprinting and then 3 days later stepping off a curb with sharp pain in ball of foot. DPM saw me on April 15 with x ray and made dx. Tx was low dose cortisone injection and J pad w sesamoid cutout and activity modification. 

2. Only mild improve 2 weeks later so start. cam walker with metatarsal padding.  Then signif slow improvement for about 3 weeks but then signif relapse with swelling of MTP joint and pain similar to initial presentation of April when I drove in stop and go traffic While in cam walker  
Dr Blake's comment: Definitely against the law in California to drive with one of those boots, even on the left foot. 

3.  End of May- now in relapse I get a second low dose cortisone injection and MRI scan. Go to crutches and non weight bearing. MRI shows medial sesamoid fracture with AVN, stress reaction in big toe and maybe some signal in fibular sesamoid.  DPM recommends more time non weight bearing and orthofix EMF stim. If no improvement by end of July. Then consider medial sesamoidectomy. I used EMF stim 3 hrs daily for 2 weeks and it seemed to cause more swelling and pain so I discontinue it at end of June. 
Dr Blake's comment: These bone stimulators do increase circulation, so the 20 minute daily of Exogen is preferable. Non weight bearing I hate, because it always causes more swelling, which causes more pain. The MRI results suggesting AVN really forces the docs hand, since the AVN protocol is non weight bearing. 

4.  I get second opinion from orthopedist foot specialist in notable academic center early July who reviews history and exams and radiology. Says stay with cam walker and non weight bearing for another 8 weeks, start PT to help with reconditioning and strengthening foot muscles, and exogen stim which he feels is more effective than EMF. Wants to avoid surgery because of risk to the fibular sesamoid. While waiting for insurance approval of stim, I get 2 acupuncture treatments with low electrical stim which seems to help.  I just started exogen 20 min treatment for 3 days and now notice possible increase in swelling and pain. Call exogen and they say swelling not common but possible. Tell me to stop 1 to 2 days and restart 5 min a day and build up to 20 again. Thoughts?  Does bone stim cause more swelling again? Maybe this is sign of increasing vascularity and bone healing?  Just ice and do your contrast bath technique?
Dr Blake's comment: Yes, bone stims increase circulation. Stay with the 20 minutes daily since the bone strength is crucial. Twice daily ice pack, and once daily contrast bathes with one minute heat one minute cold reps for 20 minutes for deep bone flush. 

Also crutching around is breaking down my body. Now possible big toe tendonitis in my other foot and R elbow tendinitis. So using I walk 2.0 no hands crutch to give arms a break although I am worried about developing sesamoiditis in my other foot.  More padding now in my other shoe to avoid further strain on my good foot. 
Dr Blake's comment: I love the concept of the iWalk but have no experience. I am happy to review your images. Just take a photo of the T2 images for 3 planes of the sesamoids to start, and several xray views you have. Have they done a plantar axial view. Rich

Thanks so much

Sunday, July 24, 2016

Ankylosing Spondylitis: Video Presentation

I have had several of these patients in my practice over the years with this rare condition. It is tested with a blood test called HLA-B27. It can be associated with chronic heel pain. My current patient Keith, no need to change his name, only comes in for me to cut his toenails since he can not bend over himself. Secretly, he only really comes in to work on his stand up comedy routine, but I benefit for the occasional good one!!


Q: What did the blonde say when she saw the sign for the YMCA?
A: "Look, they spelled Macy's wrong!"

2nd Metatarsal Pain: Email Advice

Hi Dr Blake

I am a 37 yr old female of average size and weight - on the thin side actually- presented with foot pain predominately to the first and second digit as well as the metatarsal-phalangeal region.
Dr Blake's comment: What type of pain are we talking about? How does it affect your function, day to day and athletics?

Tried the walking boot for one month without relief. Second opinion doctor ordered mri which showed 2cm bursitis in that region as well as inflammation of the second toe joint.

 I am an active mother but not a runner or extensive athlete. Possibly ill fitting shoes at times. Had a cortisone injection 4 days ago. Have had some nerve pain in the first and second toe but not terrible post injection, but I am not having total relief from the foot pain. 
Dr Blake's comment: It can take 2-3 weeks, if long acting cortisone was used, to see the overall effect. 

Still it is there as before but slightly reduced. The initial injury pain began 4 months ago. Took oral steroid first and antibiotic - now injection. 
Dr Blake's comment: Do you have the option of physical therapy? Have they tried met pads, Budin splints, accommodative padding, toe crests, etc to check its effect on the pain syndrome? 

Mother recently diagnosed RA however negative bloodwork but positive on clinical presentation. Should I be concerned of an impending RA diagnosis for myself ? Should I be having full relief from the injection and if so why am I not ?
Dr Blake's comment: If you see my post on cortisone shots, it can take 2 to 3 shots to check the effectiveness. It is easy to get several arthritis lab screens done, which I would do in your case. 

Strength Training: Correcting The Weaker Side

This concept of strengthening is truly a big deal. We need to strengthen the weaker side by doing either twice as many repetitions as the strong side, or by breaking down the sets into smaller reps to keep proper technique. This applies to any strengthening program you are doing on both sides, even if you do not know the current reason. Correcting these imbalances will always help you in the future.


Sesamoid Fracture: Email Advice

Hi Dr. Blake, 

Thank you so much for all the information you share on your blog and YouTube channel. I have learned so much over the last week or so while trying to get some relief from my foot pain. I was wondering, is it ever possible to heal a sesamoid fracture without wearing the boot? 

A little over a week ago, I started experiencing intense pain in my foot (I know now that this was from a fibular sesamoid fracture that happened gradually). I couldn't walk on it, could barely stand to touch it, and it woke me up two nights in a row with an aching/throbbing/burning/sharp pain. During the day, the pain was slightly less intense, but my foot was swollen, purplish, and hot. Prior to this, I would sometimes get pain and minor swelling in that area and the side of my foot just below the base of the big toe after running, plyometrics, wearing flip-flops a lot, even some yoga, etc, but rest would take care of it. This cycle went on for about a year. 

After trying to treat the new, more intense pain myself with rest, ice (which made it feel worse), and elevation for a couple of days, I made an appointment with a podiatrist, but the earliest they could see me was several days away (my fault for calling on a Thursday). Since I had to wait so long to see the doctor and none of my shoes were comfortable anymore, I researched a bit on what type might take the pressure off of the painful area and offer good support. I ended up purchasing a pair of Birkenstock Gizehs with a normal, not soft, footbed. My heel sinks low into the shoe, the sole is extremely stiff, and it has support for my high arches like I've never had before. I stopped going barefoot at all and kept those on my feet Friday-Monday. The swelling was almost non-existent and the pain was completely gone by Saturday morning, but I kept my appointment with the podiatrist. He found the fracture in the x-ray, put me in a rocker-bottom boot, and said to come back in six weeks. I've been in the boot for about a day now but I feel like it's slightly increasing the pain (dull throbbing in that area and my big toe joint) and the feeling of inflammation on the side of my toe, and maybe even putting more pressure in that area at times. 
Dr Blake's comment: I am sorry for your dilemma. Even though I prefer the removable walking boots, you can heal a stress fracture to the sesamoid without one. My office handout reflects that as well. You basically have to listen to your body, and create a 0-2 pain level consistently for a 3 month period. The Gizeh is not listed as a stiff sole, but I will take your word from it. Removable boots have to be modified in probably 50% of the situations with dancer's padding, etc, to make comfortable. Plus you need an EvenUp for the other side. Several of the problems not wearing the boot are 1) John Q Public does not know you are injured, and 2) you forget you are in the 3 month period of no pushing off, or it can rebreak.

How is it possible for my foot *not* to hurt if I have a fracture? I took my last Aleve on Friday night. And based on the relief I felt from wearing the Birkenstocks vs the discomfort of the boot, would it be possible to wear those instead of the boot and still heal?
Dr Blake's comment: Sesamoids initially hurt mechanically due to the injury, and then the inflammation comes in causing its own pain. When you were woken up for two nights, you probably had a combination of inflammatory pain and neuropathic pain (the pain produced by the pain itself and your body making the area hypersensitive to protect itself. So, you seem to have addressed the neuropathic pain, and stiff shoes helping with the mechanical pain. Keep icing 10-15 minutes twice per day, and contrast bathing in the evening for the inflammatory pain. 

What is your running shoe recommendation for someone with a very high arch, narrow feet, and a history of a sesamoid fracture? What about cross trainers?
Dr Blake's comment: The high arch feet seem to do better with Brooks Ghost or New Balance 928 with narrow width selections. The 928 has a rocker forefoot. For cross trainers, I like the New Balance 608. I sure hope this all helps. Good luck. Rich

Thank you so much for any advice you can offer.

Sesamoid Fractures:

By Richard L Blake, DPM

The top 10 initial treatments for sesamoid fractures are:

  1. Exogen bone stimulator for 6 to 9 months
  2. Removable boot or a stiff soled shoe like Hike and Bike for 3 months to create a consistent pain free (0-2 pain level) healing environment.
  3. Ice pack twice daily and contrast baths each evening for anti-inflammatory and deep bone flushing. Do the contrast baths twice on non-work days.
  4. During the initial 3 months of immobilization, have orthotic devices developed that off weight the sesamoids.
  5. Learn how to use 1/8th inch adhesive felt from Moore Medical to make dancer’s pads for the boot and for post-boot action.
  6. Learn how to spica tape for post boot action
  7. When you are not wearing the boot, avoid barefoot.
  8. Do cardio, core and foot and ankle strengthening the minute you hurt the bone, and on a daily basis. Keep Strong and Keep Fit!!
  9. Since we are dealing with bone metabolism, make sure your calcium and Vit D intake is good, and get counseling if you think that there might be a bone density issue.
  10. Use strict activity modification principles to keep the pain levels between 0-2 as you go from boot to regular shoes. The weaning out of the boot period can take anywhere from 2 to 6 weeks and no added soreness is allowed.

So, what do we know about sesamoid injuries that may help? Here are my top 20 plus pointers when teaching about sesamoid fractures.

  1. They rarely do not heal.
  2. Even with normal healing, they can take up to 2 years so patience is a virtue here (some fast and some slow, and all patients want the fast ones).
  3. Healing, and feeling better, is based on many factors that are unknown when the patient first presents.
  4. MRIs and CT Scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.
  5. Follow up MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI.

6.            The MRI can show initially that you are not dealing at all with a sesamoid fracture, but something else, and prevent treating the wrong diagnosis (self pay MRIs of this area are $500 in the San Francisco Bay Area).
7.            Since we are dealing with bone, we must look at diet, Vit D3 levels, calcium/zinc/magnesium, and bone density.

8.            Treatment of sesamoid injuries flows through 3 phases that are normally overlapping--Immobilization, Restrengthening, and Return to Activity.
9.            When the patient is in the Immobilization phase, the treatment visits should be thinking about (and acting on) the Return to Activity Phase with visits dedicated to shoes, orthotics, strengthening, cardio.
10.         Often times treatment mistakes involve having the patient in the wrong phase (like return to activity when they should be in the Immobilization phase).
11.         One of the crucial aspects of treatment, that can be hard to design, is protected weight bearing inserts and shoes.
12.         As treatment starts,the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc) that maintains 0-2 pain level.
13.         The initial goal is to create this pain free environment for 3 months by whatever means it takes.
14.         Non weight bearing (via crutches or RollaBouts) always increases swelling, so some protected weight bearing is crucial. Every step pushes fluid out of your foot.
15.         The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed.
16.         If you are basing treatment on x-rays alone, you may be way off base.
17.         Do not let the joint freeze up (frozen toe syndrome) with routine pain free range of motion or mobilization techniques. Go to YouTube and type drblakeshealingsole Self Mobilization.
18.         Start strengthening the minute you get injured, or at least after you read this, even if it takes some modification for pain. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist. Keep the joint/foot flexible and strong.
19.         Patients with sesamoid injuries are prone for setbacks so do not get discouraged.
20.         If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using. Some insurance companies require 3 months wait to document delayed healing, some not. Self pay for Exogen Bone Stimulator is around $500.

The patient's response:

Thank you so much for all of this wonderful information and for taking the time to type out such a thorough response. I'm especially interested in the mobilization info and eager to watch the videos you mentioned because I was worried about a bit of stiffness in my big toe joint (it's not bad, but I'm glad to know there's something I can do for it). The Gizehs I bought have the classic footbed, so that may have contributed to the stiffness of the shoe. I'm not sure if that makes a difference since this was my first pair, but noticed there were two versions. They're a bit more flexible now than they were when I got them, but they still feel good.  

Thank you again. I really appreciate your advice. You have been such a huge help and I am so grateful!

Sesamoid Fracture: Email Advice

Hi Dr Blake

I discovered your blog/YouTube channel after conducting my own research on my fractured sesamoid bone. I was first diagnosed with this injury 1 month ago when I went to the ER for an X-ray. The ER doctors acted like it was no big deal and told me to follow up with a podiatrist.
Dr Blake's comment: Feet injuries are typically never life threatening, so if that ER doc had just saved someone's life suffering a cardiac arrest, your injury may have seems not that important at that time. 

 I saw a local podiatrist the next week and they put me a in cam walker and told me the fracture would heal it's self in a few weeks. 
Dr Blake's comment: I am sure my sesamoid patients would concur that typically 3 months in the boot is important, followed by 2-6 weeks of weaning out of the boot into shoes with orthotics and dancer's pads to off weight the area. 

They wanted to see me for a follow up after being in the cam walker for 14 days. At this appointment I got the bad news that my fracture had actually gotten worse. The doctor then told me that I was back to square 1, no weight bearing, crutches and to wear my flat walking shoe that the ER had given me. This new treatment plan really confused me and that is when I started to do my own research and discovered you.
Dr Blake's comment: Following these injuries by xray is very difficult. Xrays show the amount of calcium in a given area. When an injury is flooded with healing body fluid bringing in calcium, etc, to the wound site, the relative amount of calcium is less and the fracture looks worse. This would be usually the wrong interpretation of that xray. Yes, the fracture could be worse, but it is not typical unless you fell or had a high impact stumble while in the boot. By 2 months into the injury, the xrays are supposedly 2 months behind demonstrating the actual injury healing. What good are they after the initial diagnosis, unless there is a fall, etc? If I only had xrays to image, I would wait 4-5 months to get repeat xrays. 
I have 2 small children and we are extremely active. I jog, bike and weight train 5x a week so I need to heal this completely. I'm committed to doing whatever I have to and know that it is going to be a long road to recovery.
Dr Blake's comment: You have to listen to your body. As long as you can keep the pain level in the boot from 0-2, typically this is a weight bearing injury. I can not overstep the treating doc, of course, but I find non weight bearing causes more swelling, more pain, more bone demineralization, and slower healing typically. 

I'm currently on day 4 of zero weight bearing. I've been icing and elevating. I have
an appointment to see my podiatrist, but I think that I need to find a new Doctor in the meantime. It seems to me that he doesn't know how to treat this specific injury and is not giving me the correct information on how to heal it. I am going to start the heat/cold baths you recommended tonight. My other questions to you are do you think that I should continue to be non-weight bearing or do you think I am ready for the cam walker with the dancers insert? My doctor seemed to have no knowledge of the insert and seemed to treat it as any old fracture.
Dr Blake's comment: You have to feel comfortable with your treating doctor, and I am sure he means well, and because of the caution going to non weight bearing, you will heal fine. There is no research I have seen on non weight bearing vs weight bearing, but definitely get another opinion. One good place to start is the AAPSM website. Go to their member's list and see if one is near you. These are sports podiatrist who typically are conservative, and are very familiar with this injury. If she/he says the same thing, you can choose to go to whomever. Read all my posts on this subject. 

I'd greatly appreciate any input you could give me. I'm only 28 and as I've mentioned I have children so I'm just very worried about having to suffer from this for years to come. I will be donating to your cause and I look forward to hearing back from you.
Dr Blake's comment: Thank you so very much for that. I wish you well and you can comment on this post or through the email at any time. Rich

Thank you for your help.

Sadie Zeuner