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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. I am very honored and grateful. Dr Rich Blake


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Monday, September 25, 2017

Posterior Tibial Tendon Injury: Email Advice

Good afternoon Dr Blake. I am writing you from New York City. First I want to say THANK YOU for the wonderful blog that you have created. I will be as short and concise with my situation. Like you I have a long history of playing basketball and also running wind sprints. I have sprained my ankle numerous times from basketball. This current injury is different as its the inside side of my left ankle that has PTT (posterior tibial tendon). 

In January I was running wind sprints up a hill in the park on concrete. After my workout, I felt some pain and swelling. I thought it odd that it was the inside side and I don't recall twisting my ankle.  I went to the doctor and he prescribed physical therapy. I went to 5 sessions over 3 weeks and all the pain went away. I did NO home exercises. Fast forward to July and I did the hill workout again. I felt tightness in my calves and some slight swelling but not pain. 2 weeks later I did a sprint workout at a soccer field. After my 4th sprint, my foot locked up on me. I thought it was the dreaded Achilles tendon tear and it hurt and I could barely walk. I elevated a few days, not too much ice. Went back to the doctor. Got a script for physical therapy. I STOPPED all jogging, skipping rope, doing wind sprints.  I went to one clinic 4 times over 2 weeks. I wore no brace. The therapist didn't believe in braces. I took Aleve for 10 days. I switched to another physical therapy clinic. Went there 5 times over 2 weeks. I wasn't getting better. I then went to an orthopaedic surgeon. I believed I needed an MRI. He took Xray and said no stress fracture. He did some manual tests and concluded I had an Unstable Ankle and Posterior Tibialis Tendonitis. He suggested one of the more expensive over the counter Orthotics(hard plastic type). He said I had flat feet but only when standing. He said I might only need the Orthotic for 3-4 weeks. He did not think I needed surgery at all anytime soon. He said 3-4 sessions of physical therapy would be beneficial. 

After 2 weeks of the swelling/inflammation not going down, I went to a new physical therapist. He concluded I didn't have swelling/inflammation and needed heat and home exercises. Things like calf raise (2 sets of 12 twice per day). Theraband for inversion (2 sets x 12 twice per day). The one legged balance for 30" (2 sets x 30" twice per day). Stretch the calves and soleous twice per day for 30". After 2 weeks of still the swelling not going down I went to a podiatrist. He ordered MRI and after the MRI he got me a knee high walking boot. He said to use the boot for 3 weeks (follow-up visit after the 3 weeks

Highlights of MRI:

Chronic postraumatic deformities of the tips of the medial and lateral malleolar are noted 
There is a chronic full-thickness tear of the anterior talofibular ligament 
There is marrow edema within the talar head and neck. Different considerations include a bone contusion or stress reaction. 
There is increased fluid in the posterior tibialis sheath consistent moderate tenosynoviitis with intermediate signal in inframalleolar component of the tendon consistent with mild tendinosis. 
A type 2 accessory navicular is noted with marrow edema within. 
A ganglion is noted with Kager's fat pad measuring 1.9 x 1.1 x 1.4cm 

I have yet to find a physical therapist who actually knows what to do for PTT. Also as nice as the podiatrist was I dont think he fully understands/emphasizes with my frustration as to what to do at home to best heal, strengthen, stretch.

The last physical therapist session was with a new person who suggested to STOP doing calve raises and to stop doing the soleous stretch. To do the theraband in the 2 directions that dont put any strain on the Posterior Tibialis Tendon. I am to return to that therapist in 2-3 weeks. They also said do NOT use heat but to ice 1-2/day. 

I dont know how long to wear the boot. I also dont know what is safe to do strengthening wise. My frustration is not getting the inflammation/swelling completely gone

Have you heard of Tendex Fast surgery?

Oh yeah

What specialist would be able to tell if I have muscle weakness or tightness in my hips, thighs, hamstrings, or calves? I think the PTT is the result of some other problem in the chain.

I have placed the Orthotic in my walking boot. I will be watching all of your youtube clips regarding PTT. I wonder if even walking in a boot puts some stress/pressure on the PTT. Currently its is around a portion of the ankle bone where I still feel inflammation/swelling and some pain. The pain flares up when I walk too long. I am wondering if staying at home just reading and watching movies for say a week or two would be truly resting the PTT.

THANK YOU for your time. I appreciate any and all feedback

Dr Blake's comment: Thank you so very much for emailing. I will try to give you my impressions with the info you provided. The MRI was very helpful, and you need another one 6 months from now to check on the edema. I see no place now to consider a surgery. Surgery typically would be a year from now if you are not able to get back. I know it sounds long, but you have to get rid of the underlining talar head and neck bone edema due to impact stresses. It probably is the cause of all your pain with secondary posterior tibial tendon issues. If you rush a talar injury, the stress fracture or stress reaction which is there now could become a full-blown fracture. I have seen fast recoveries from these, but I can not predict. You have to go one month at a time. You want a 9-month course of Exogen bone stim, and a current bone density and Vit D test. You should avoid all impact for 9 months and work on your ankle strength. The ankle sprains could be coming back to haunt you with instability and abnormal stresses. As long as you can avoid painful exercises, do the posterior tibial strengthening program, also Single Leg Balancing, and the peroneus longus and brevis therabands. Do contrasts each evening as a good flush to the superficial and deep bone swelling. 
     The basic routine is to avoid deep ankle flexion as with landing from a jump or deep plie in ballet. Avoid stretching your Achilles for the next month, then one month only with the knee straight, and no negative heel stretching where you drop the heel off the stair. Contrasts each evening, and evaluate bone density for issues. Bone stim for 9 months, and repeat MRI in 6 months. Start a super strengthening program. Stay in the boot 3 months, and then transition to shoes. Monthly evaluations should be done to check progress. I hope this helps. Rich. 

Tuesday, September 19, 2017

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I am a 24-year-old, healthy female. Last month I was on vacation with my sister for 3 days and we walked about 5 miles each day. On the last day of vacation, the ball of my foot started hurting gradually, no big deal. The next morning, the pain woke me up and it was extremely swollen. It did not improve so I made an appointment with a podiatrist for 3 days later.

The podiatrist did an X-Ray and explained some foot anatomy to me. She said it looked like I had a bipartite sesamoid bone because though it was in two pieces, the pieces looked smooth rather than jagged. She then said that on the very edge of one of the pieces, she saw some shading in the X-Ray. "I'm not sure it's a true fracture, but we're going to treat it as one so you can get feeling better."
Dr. Blake's comment: This is the right idea. You are forced to treat the worst case possibility since under treating sesamoid injuries can be harmful to you. 

She wrapped my foot in a compression wrap and gave me a walking boot. She said to stay off it as much as possible (crutches or knee scooter) and to come back in 4 weeks.

My 4-week appointment was on Thursday, and I guess I was expecting that I would be done with all this. She did another X-Ray, poked around my foot to see where it was still painful. It does still hurt a bit, but only when I walk and maybe only 25% as much as it did at first. She told me I could begin walking regularly with the boot and ease into tennis shoes.
Dr. Blake's comment: Sounds wonderful so far. The off-weighting can make swelling collect in the tissues, not be pushed out by weight bearing, and the pain worse even though the injury is healing. This did not happen to you, so I feel blessed. Need to get into some dancer's pad arrangement in your shoes to wean out of the boot, but still be protected. It can take several more months to wean out of the boot, so bring it with you wherever you go. 

I did some walking around the city this past weekend in my tennis shoes. It did hurt a bit - also on the outside of my foot where I think I was putting more pressure. I decided to go back to the boot. I have another follow-up in 4 more weeks.
Dr. Blake's comment: Smart, see if you can get an earlier appt to start the design of off-weighting it. Remember that there are 3 types of pain at play in these situations: mechanical (so off-weighting helps), inflammatory (so icing twice daily for 10 minutes, and a 20 minute evening contrast bath for deep flushing), and neuropathic (so non-painful massage to the tissue and gentle range of motion of the big toe twice daily for 2 minutes is great). 

Long story short, I started reading about sesamoid injuries today and I guess I didn't realize how serious they could be. I'm reading horror stories of how it never heals for some people, and I'm panicked thinking about the fact that I could go the rest of my long life without being able to run, or jump, or even walk comfortably!! I have a history of anxiety and this is a lot to bear. I just want to get back to normal.

If you have any words of advice or comfort, I would be glad to hear them!
Dr. Blake's comment: You sound you are in good hands, and you are responding wonderfully. Create that 0-2 pain level, gradually wean off the boot, work on the 3 levels of pain daily, and read the general rules of sesamoid fracture treatment. Get an MRI if possible because that can be followed better than x-rays. If you get an MRI it will be clearer what you have, and another MRI can be done if needed 6 months down the line to check progress. Good luck. You are doing good right now!!


Sunday, September 17, 2017

Electronic Medical Records are not my Friend

    Hi, this is Dr. Blake and I need to express my thoughts on the electronic medical records that I was forced to adapt in February of this year. I do not want your sympathy, but it has added an extra day to my practice per week just trying to keep up. I spend the same amount of time with my patients which I know many doctors are forced to see patients faster. But, my tradeoff is longer and longer time doing my records, and I feel I am very dedicated to doing them right. This article at least shows that I am not alone. I see patients for 40 hours per week (around 40 or so) and spend 13-14 hours doing their chart work on the electronic medical records. Since all medical practices have 2 hours a day or normal paperwork also (insurance, DMV, disability, etc), this now puts me at 65 hours per week of normal routine stuff. I like to do my own orthotic work, work on my blog, read to learn, etc, and how I am at 75-80 hours without blinking an eye. 
     Why am I telling you this? Just be kind to all the docs in the country that this has been forced on. The 3 hours a day additional work brought on by the computer is handled differently by all: less patient time with less satisfaction, fewer patients overall with less satisfaction, working longer hours with less satisfaction with less time with your loved ones, total burnout, leaving the medical career, or a combination of strategies. I tend to work harder and longer because that is what I have always done, but it is not healthy, and I am not getting younger. I think the younger docs, that do not know any different, may not be as grumpy as I feel. If you pray, I accept all donations in this sphere. Thanks for listening.

Wednesday, September 6, 2017

Podiatry Blogs Listed in Order of Greatest to Least

Guess who is #1, alright a guy can brag once in awhile!

I figure that many of the blogs would also have good information for my readers!!

Tuesday, September 5, 2017

Can I wean off my full time use of Orthotics?

Hi, Dr. Blake!

I've been reading your book and need your advice. 

Long story short, I have been wearing orthotics pretty much all the time (even stay In my shoes at home) for about a year and a half.  I went to see a PT for bilateral knee pain and he told me my feet were causing a dysfunctional gate cycle leading to overall tightness and knee pain.  He took a mold of my foot and sent them to a sports podiatrist he works within Iowa that made me some orthotics.  He also said that there was really no workaround for me with regard to improving foot function on my own and I pretty much-needed orthotics 24/7 for me to move correctly.  They do make a drastic difference with regard to the knee pain and tightness but I still have some issues and am questioning some things, specifically that my foot is structurally so messed up like he said it was.

I have attached the sheet rationale for the PRI orthotics that I received if you have interested in reading it.  The PT said the human foot was not made to function on flat ground like concrete and functions better on undulating terrain which the orthotics provide and also keep me from overpronating by stabilizing my left heel when I walk which allows me to push off my toe instead of pronating.  He said when my foot over-pronates when I walk (mainly the left one) it anteriorly tips my pelvis and basically throws me out of alignment and puts me in a bad position for when I start lifting or try to work out or lift weights. 

I've been active my whole life and never had knee pain until I started dental school where I was sitting the majority of the day and was forced to wear dress shoes.  This is in contrast to my previous 7 years as a personal trainer walking around all day in athletic shoes. I always had insoles that my podiatrist made because I would get pressure calcifications I would have to go have picked out but I never had any biomechanical issues like what started a few years ago.  Obviously, I don’t want to have to keep wearing my shoes all the time for the rest of my life, as that doesn't seem like a fix IMO.  I’m not sure if my left foot overpronating is due to a handedness pattern type thing or if I really have developed an alignment issue, maybe an x-ray would help this or show if I had an alignment issue?

What direction should I take from here to fix my feet?

Dr. Blake's comment: I have found that moderation with the use of anything is normally best. Some use of orthotics when you need them for activities, some walking without orthotics, and some barefoot is normally a great recipe. You could take some photos of your feet standing, especially looking from the front, looking towards the back of the heel, and then the arch from the side. Best to have another take these so you can normal with your feet firmly on the ground.
     One of the keys to great feet is strong feet. My blog is filled with information on strengthening the intrinsics with met doming, the Achilles with 2 positional heel raises, and the arch with single leg balancing and theraband work for the posterior tibial tendon and the peroneus longus. You will find as your feet get stronger there is less need for orthotics and the most stable shoes. I said less need, not no need!
     Various types of orthotics give different support. Various types of shoes give different support. Various types of activities need different support. So, this is a lifelong challenge of all of us wanted to stay upright and exercise. What do I need to protect my feet and still participate at a high level? Many use pain as their guide, many have such a high pain threshold that they have to use educated guesses.
     Besides strengthening, the tightness you mentioned may play a major role in symptoms. Almost everyone should be on a daily regimen of Achilles, quadriceps, hamstring, iliopsoas, and low back stretches. These should take 5-10 minutes to do before and after your workout, never with pain, and done at least once on your rest days. If you find tightness, stretch 3 times a day until it resolves. If you find you are tight on one side of your body more than another, stretch that tight side 50% more than the looser side. 
     I hope this gives you my general philosophy. Next time you see the physical therapist ask for a lower extremity tightness and weakness evaluation so you can know the pattern in your body and can work to fix it. Good luck. Rich

Lis Franc Injury: Email Advice

Dear Dr. Blake, 

I (myself) have what I think is an interesting Lis franc injury and if you have a moment I would greatly appreciate your opinion. 

Athletic history, 10 years of ultra-endurance running (trail 100 miles) and Ironman triathlons. 

MOI: Outstretched leg on the boat dock with the boat moving towards the dock. Arch placed on edge of dock, the force of boat bent foot at arch (plantar surface towards the heel). immediate “pop” swelling over medial cuneiform, tender to palpation.  

Date of injury ~June 1st. Initial X-ray negative, circumferential swelling/bruising (medial and plantar, mainly) and the majority of pain subsided by day 3-4. Walked but with slight limb but continued to improve slowly over next 4-weeks but still had difficulty running (pain around 1st/2nd metatarsals and medial arch with push-off. No pain with stairs. At 4-weeks had MRI 

MRI: tiny non-displaced fx at the medial aspect of navicular, small cortical avulsion fx from the second metatarsal base. interosseous Lis franc “compatible with high-grade disruption, A torn stump of fibers remain attached to the medial second metatarsal base and distal lateral aspect of the medial cuneiform. It is difficult to appreciate intact interosseous Lis Franc ligament fibers at this time. Complete disruption of the dorsal Lis Franc ligament. The plantar ligament is at least partially detached from the second metatarsal base, in the setting of the tiny cortical avulsion fx.”

presentation at 4-weeks - near normal ambulation, minimal pain (except attempting to run) and very little instability
Due to lack of instability Ortho Rx: non-weight bearing in boot x 4 weeks, ambulating in boot x 2 weeks, then 2weeks in stiff soled shoes, then follow up. 

Currently, I’m in my 1st week of walking in stiff shoes. Very little pain around Lis franc/dorsal part of the foot, other than the feel of stretching. Occasional pain in 3rd/4th phalanges. Occasional pain around the anterior portion of ankle/malleolus, (navicular/cuboid area). There is a firm “nodule” about the mid portion of the foot in-between the plantar fascia and medial portion of the arch. A majority of the pain (nearly constant) is in the area of the medial side of foot near the top of the arch. Occasionally it occurs distally, and other times it's more proximal (in/around the fleshy area between the medial malleolus and calcaneus). Pain is reproducible by full dorsiflexion and eversion. Pain is felt along the medial arch and pulls (causes pain on top of medial cuneiform. Little to no instability, but will occasionally “lock-up” and feel a "knuckle crack" (no pain). 

when performing single leg toe raises slight pain from arch/nodule area and “stretching” around medial cuneiform. I can run, but the pain from arch and ankle area increase post-run. My follow-up is next week and although considering the severity of the MRI, I feel my presentation is not remarkable. With the ultimate goal of returning to running,  I’m curious on your thoughts if surgery sounds like it might still be necessary? Or other options you might suggest at this point. 

I appreciate any advice you might have!

Thank you, 

Dr. Blake's comment: Thank you so very much for emailing this problem. Typically, we will have a surgeon have the first crack at deciding if the foot should be repaired. With your wonderful athletic life, if the wrong decision is made, the arch could collapse the next time or even the thousandth time you put a tremendous load on it. So, 2-3 independent surgical opinions to protect you from yourself and your goals are in order. This is different from a fracture we can follow pain wise as we rehabilitate someone. And, you have to treat the worse case scenario possibility. If you do have it repaired, even though there is a time for rehabilitation, there should be no reason you can not get back into full activity. 
     Please have a stress test x-ray put on the Lisfranc's to check its integrity. This is particularly important if they decide to let you go back to athletics. Athletics should be with KT arch taping to stabilise the joint, along with the highest arched orthotic that can be made to stabilise without throwing you to the outside. I hope this helps somewhat.

Here is the section from my book on Lisfranc's Joint Injuries which emphasizes the conservative.

2. Lisfranc’s Sprain

    Across the instep, where the metatarsals meet the arch, is a series of joints called the Lisfrancs joint. It involves all the metatarsals, with the most severe injury under the first and second metatarsal bases. Here lies the Lisfranc Ligament, and when torn, can cause the entire arch to collapse.
     A complete tear of the Lisfranc’s ligament, a diagnosis made by MRI, is a surgical injury. It is one of the most serious sprains in the whole body and must be over treated. This is not the topic of our discussion here. For the many Lisfranc injuries, not involving a complete tear of the ligament, conservative treatment works well. Remember a sprain occurs with some twisting motion or sudden acute jarring force. Without a history of this, most likely pain in this area is some other diagnosis as we will discuss later.

The Lisfranc Ligament runs between the base of the 2nd metatarsal and the first cuneiform.

    The top 10 conservative treatments for Lisfranc’s sprain/injuries (without complete rupture of the Lisfranc Ligament):
  1. Arch supports (typically custom) with as high of a medial arch as possible/comfortable.
  2. MRI for ligament testing. Also, make sure patient can do a one sided toe raise. This can be impossible with a complete ligament tear.
  3.  Kinesio taping in a circumferential wrap around the entire foot for 2 months longer than you think you need to.
  4. Avoid activities that lift the heel off the ground initially.
  5. Ice Pack 2 times daily for 20 minutes to reduce the inflammation.
  6. Create a pain-free environment with crutches, removable boots, other assistive aids.
  7. Pain over 5 in the area of the Lisfranc’s Joint should be over protected until you are certain it is not a ligament rupture.
  8. Begin metatarsal doming, 2 positional inversion/eversion therabands, and Single Leg Balancing. Go to YouTube and type drblakeshealingsole foot strengthening exercise playlist. Remember no exercise should hurt.
  9. There is really no stretching for this injury that helps directly. However, massaging the arch to move the swelling that collects there can be very helpful.
  10.     Stretching the Achilles tendon indirectly takes the tension off the arch. When done, do both gastrocnemius and soleus stretches but only with the heel firmly on the ground. Go to YouTube and type drblakeshealingsole Achilles stretches.
Lisfrancs and Sesamoid Injury: Email Advice

Hi Dr. Blake,
First, let me say what an incredible resource your blog has been for me - and how grateful I am that you take the time to advise and treat patients simply because you believe everyone has the right to heal. So thank you.  As for me, I've seen far too many doctors - who all have very different opinions (and seemingly different levels of commitment to my healing). I'm desperately seeking a treatment plan - and some patience with the many questions that I have.
Now here's my story… I'm 30 years old and live in New York City. Back in late MARCH, I tripped up (yes UP) the stairs -- and injured my toe/foot. I seemed to only have pain in my big toe (top of my foot) - in the phalange and metatarsal. The first podiatrist I saw didn't catch anything in the x-ray and believed it was a stress fracture. After 3 weeks of it not seeming to get any better, he still gave me his blessing to go on my 2 week Europe trip. I should have listened to instinct...but alas. I went, wrapped my foot, threw it in a hiking boot, grabbed a cane, and went on my way. The trip was great - but by the last day, I couldn't stand. And my foot was purple.
Came home beginning of May - switched doctors. Got an MRI (and another x ray) - and it was confirmed that I have a fractured tibial sesamoid, as well as a Lis franc ligament sprain. The doctor seemed to pay little regard to the Lis franc injury - saying that a sprain isn't serious.
Dr. Blake' s comment: A Lisfranc injury is one of the most severe foot injuries I treat, with one of the highest percentages for sprains needing surgery.  
Now here's where things get even more complicated. I was heading to Los Angeles for a gig a few days later. The doctor advised me to non-weight bear for 3 weeks (in a removable walking boot), use a dancers pad, then see another doctor (doctor #3).  I continued to have swelling - but iced and did contrast baths daily. Saw an ortho in Los Angeles - who perhaps due to my desire to be as conservative as possible - decided to keep me non-weight bearing for 8 weeks. The last thing I wanted was to look back and wish I would have committed to more time. He also thought that the bone might be dying, and thought that when I'm back in NYC I should have a CT scan (or bone scan?)
So now...I'm back in NYC. Saw a new Ortho (doc #4). He said that I should start putting weight on it and to stay in the boot until my next appointment -- in 4 weeks. And he said no CT scan.  Unfortunately, I had no advice on how to wean off the crutches - it was implied that it would easy to just start walking. Not really the case for me. So...I started weight bearing while still using the crutches for a few days, then went down to one crutch, and now to a cane. I seem to be doing pretty well -- except that I keep getting a shooting pain in my ankle every time I step a certain way (which isn't that often - but when it happens it HURTS). Been happening now for the last 4 days. The sesamoid, however, seems to be ok. Still a little swollen - but doesn't seem to have very much pain at the fracture site.
Also, my whole body seems pretty out of whack (my hips have a very strange turn out right now).
Dr. Blake's comment: Typically this out of whack feeling is part of any cast regimen.  It is helped greatly by using an EvenUp on the side without the cast and never going to one crutch.  It should be 2 crutches or no crutches since one crutch and sometimes canes throw your back and pelvis into strange tilts.

So now that you know my story, I have so many questions...

1. My big toe still feels so strange. Like it weighs 5 pounds. Which is how it felt when I first injured it (why I assumed I broke my toe). I can barely bend it down - and can't bend it up at all. Is this normal? The pain/stiffness/heaviness goes from the joint of my big toe down to the middle of my foot. Often times I have strange twitching there as well...
Dr. Blake's comment: For what I know, this is all normal for your injury and being in a cast and non-weight bearing for a while. You are gradually progressing from the Immobilization Phase of Rehab to the Re-Strengthening Phase. During this phase, you need a lot of physical therapy guidance to work on the remaining swelling and increase the range of motion, strength, flexibility, and balance. There is a lot of hard work ahead.  

2. At this point, should I be forcing my toe to bend? Or is it all still healing that it should still be immobilized most of the time?
Dr. Blake's comment: For these injuries, you never push the toe bending part of rehab. You let that come naturally. It is always fun to measure the range of motion at each stage if you have a therapist you will be working with. Typically you come out of the cast with almost no motion in the joint. Definitely, you can start doing some of the self-mobilization movements. Go to YouTube and type drblakeshealingsole Self Mobilization Hallux Limitus. You can gain 20-30 degrees as you begin to walk normally, and another 20 degrees as you begin to run.  Keep the joint pain free when you are working on it, you never know if more healing is still going on it there.

3. What about ankle exercises? Could that also interfere with the healing of the sesamoid/toe? Any physical therapy for the rest of my body? Or should I still wait?
Dr. Blake's comment: Core and other lower extremity strengthening that does not hurt the injury can normally be started right after the injury.  There is a benefit to riding a stationary bike with one foot even when there is no tension on the foot in the boot. There are so many core, hip, knee, and ankle movements that you should be doing right now, and that is why a PT or Personal Trainer can help. The stronger the core, the more normal you are lifted off the foot, and the faster the rehabilitation goes.
4. This Lis franc sprain - is this really something that should be so swept under the rug? I finally researched it and it sounds like it could be a big deal. How do I find out if the sprain has healed?
Dr. Blake's comment: Lisfranc Injuries are big deals. You need to wait 3 months for your first MRI  to get a repeat MRI to document healing.  I treat all Lisfranc Sprains very seriously with a 2-year commitment to orthotic devices, arch taping, and a gradual progressive re-strengthening program on all the important intrinsic and extrinsic muscles/tendons that support the arch. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist.

    The middle of my foot definitely hurts right now - but I assume a lot of it has to do with the fact that I'm putting weight on it for the first time in 8 weeks. I also have a bony bump in the middle of my foot - under the big toe. The doctor assumed it was from the boot. Does that sound right to you - or could it have something to do with this Lis franc thing?
Dr. Blake's comment: Lisfranc's Injuries hurt in the middle of the foot. If you are weight bearing, get an orthotic ASAP to stabilize that area and learn to tape your arch (Chapter 4).  I am not sure what the bony bump is. You could send me a photo of you pointing it out, and another of the same spot on MRI.  

5. Does walking in the walking boot for 4 weeks after being non-weight bearing for 8 (and in a hiking boot for 4 weeks before that) seem like the right treatment course?
Dr. Blake's comment: Yes, but 16 weeks of immobilization means 32 weeks minimum more to get your foot healthy again. Go slow, go gentle, but persist. You are still in the hands of the docs for direction, but PTs and Personal Trainers and Athletic Trainers should have the most prominent role in your recovery now.  

6. My left foot has also been hurting quite a bit - since it's been doing most of the work the last couple of months. Is there an insert/insole you can recommend helping this? Mostly the middle of my foot. What about Superfeet?
Dr. Blake's comment: When you get custom made functional foot orthotics from a sports podiatrist, they are always made in pairs. Consider seeing Dr. Karen Langone, Dr. Robert Conenello, and Dr. David Davidson in New York. You can also see the AAPSM website for all the New York members. I am typically safe recommending from that list.  

7. I've been using the bone stimulator twice a day on my sesamoid - which is why I haven't been taping. Should I be taping and just removing it daily?
Dr. Blake's comment: The bone stimulator has a 3-inch penetration. You can aim the beam from the top of your foot where you do not have tape, and it will still work. That way you can tape also. This is at least my understanding of the Exogen bone stimulator but check with the local rep.
8. I'm not 100% sold on this ortho I'm seeing in NYC. He's just so rushed - in and out in 5 minutes. Do you know a doc (ortho or DPM) here that you would recommend? I had been recommended someone at the hospital for special surgery - but unfortunately, they don't take my insurance (GHI/Emblem)
Dr. Blake's comment: See my recommendations above. Even if they are a distance, it is worth it. They can refer you to a local PT to do the lion's share of the work.  

9. Would it be possible for me to send you my MRI from the beginning of May? I would love to know your thoughts.
Dr. Blake's comment: Yes, Dr. Rich Blake, 900 Hyde Street, San Francisco,
         CA, 94109.  

    Thank you so much for taking the time. As I mentioned, I generally need to be on my feet all day (although this last one in LA was thankfully pretty low key). I'm so anxious for my foot to feel normal again, but I'm also committed to recovery and can be as patient as I need to be. However, I just need to feel like I'm doing what's "right". And with so many different doctors over the last few months (all with very different opinions) - I'm left fairly confused and rather discouraged.
Any thoughts/advice would be so greatly appreciated.

Jill (name changed)

Sorry, one last question!!  I've been using 1/4" adhesive felt applied directly to my foot for the dancer's pad. Is this correct for use in a boot?
Dr. Blake's comment: See if you can place as an insert in the boot. Somewhere in my blog “drblakeshealingsole” I have an example of this. Get working on your orthotics ASAP and then just place that in the boot. I sure hope this helps you.


Tuesday, August 29, 2017

Avascular Necrosis of the Tibial Sesamoid

Dear Dr. Blake:
I recently commented on one of your blogs posts on, before I came upon your blog. You seem to know much on the subject of sesamoids and their issues, more so than any doctor I’ve encountered.

I’m a 20-year-old college student with avascular necrosis of the right tibial sesamoid. I was diagnosed with stress fractures in my right foot 4 years ago, and when those failed to improve, I was eventually diagnosed with AVN 2 years ago by an orthopedist. He put me through conservative treatment (orthotics, carbon foot plate, Exogen bone stimulator) for a few months, but my symptoms persisted. He recommended surgery. I sought a second opinion from a podiatrist, and he recommended that I continue with whatever conservative treatment I was already doing. So here I am 2 years later still doing the Exogen bone stimulator every night and wearing orthotics in my sneakers (or dancer’s pad if I’m barefoot). I ice when there’s pain; sometimes I do a hot soak with Epson salts. I was an avid runner before I was diagnosed and have since quit because I still have pain when I run. I’ve found solace in swimming, rowing, and weight training but still sometimes get pain when rowing or going for long walks/hikes.

Long story short, my problem has steadily worsened over the past 2 years, and I was led to believe that it would continue to worsen until surgery was the only option. Reading your blog suggests otherwise though. In other emails from people with AVN of the sesamoids, you discuss treatment options that my doctors never mentioned, mainly spica taping, dry needling, contrast baths, foot mechanic evaluations, Neuro-Eze, bone density/Vitamin D screenings,  and CT scans to check for bone fragments. You also say that the chance of the injury re-occurring is very low in the case of the 14-year-old Irish step dancer, whereas my doctors told me that I would have this injury for the rest of my life with no hopes of improvement. 

But is there still hope for me, 2 years after the initial diagnosis? Is it common to have this injury for so long with gradual worsening over time? Is it still possible to reverse the effects this late in the game? I know you can’t answer specific medical questions over this forum, but do you have any words of wisdom for a frustrated young athlete? 
Thank you for your time.


Dr Blake's comment: Thank you so very much for reaching out. I would love to tell you some positive words, but there is so much we need you to do to find out what is really going on. I have to assume you have good bone density and overall healthy. Definitely if you want me to help you need a CT scan (your Primary can order) and a bone density screen. Also, this should be sent to me with your current MRI (within 6 months). They can be mailed to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. I do no charge for this. I hope I can help. Rich

Tuesday, August 22, 2017

Saturday, August 19, 2017

Another Motivational Video on Healing an Injury by Caroline Jordan

Caroline is such a delight to listen to as she herself is coping with trying to heal a foot injury. I have so many patients on both sides of the coin. Some stormed on through injury, and now are trying to control the quickest rehabilitation. Some get so frustrated that they give up, or try untested treatments, or even unnecessary surgeries. I think we have to surrender to the clock, and give up some goals possibly, and live in the present only as Caroline says. We however must not forget to listen to what our bodies are saying. If we have been told to ice, but it always increases pain, we should stop. If we got orthotics to shift the weight off a sesamoid, and we don't think it is enough, speak up. If we are told we have tight achilles, and we only stretched once a week in the past, we can control this. We can stretch more, 3 times a day can be needed to gain flexibility. So, control what you can, relax in the presence, learn some new things (cross training can be wonderful), and you may find you like something more that does not hurt than the activity that does hurt. Good luck. Thanks Caroline. You are motivating as always. 

Thursday, August 17, 2017

Sesamoid Pain: Email Advice

Hi Dr. Blake, 

Thank you for providing so much information on your blog. It really is so kind of you to selflessly help so many people. I was hoping you could provide some thoughts on my current sesamoid issue. 

I started feeling pain in the ball of my left foot around the beginning of 2016. I didn't go to a podiatrist until December 2016, as I ignorantly thought the pain would eventually go away. The pain was always a dull ache. I continued to run, do plyometrics, and perform lunges and push ups during this time. 

The podiatrist in December 2016 took xrays (attached both right and left to this email) and determined I had a fracture. As the injury had been there for a long time, he said it probably was already partially healed so directed me to stop running for 6-8 weeks and put padding in my sneakers. I follow his direction but did not see any improvement.

2 Views left tibial sesamoid December 2016
 I continued with this non-impact activity and padding method until mid-april when I came across your blog and started wearing a boot with a dancers pad for three months. I iced twice a day and contrast bathed at night. I also was weight training and cycled on a stationary bike in a surgical shoe during this time.  The pain level was definitely within 0-2 so I thought it could be healing. After three months, I decided to try to get an MRI so I visited a doctor recommended by you, Dr. Dan Altchuler in Santa Monica. He took xrays (attached), thought potentially I could be feeling pain because my sesamoid was slightly pointed and suggested potentially performing a sesamoid planing to shave off the point. He was surprised that it didn't hurt me more when he was putting pressure on my foot and moving my toes in certain ways so he directed me to stop wearing the boot and padding. to see how it felt without anything. 

Recent Xray showing left tibial sesamoid irregularity July 2017

My foot definitely felt weaker from non-use and I had to force myself to put weight through the full foot, as I previously had inadvertently been putting weight on my outer foot. I didn't feel any pain while walking unless I went up on my tippy toes but I did feel a dull ache at the end of the day. I starting wearing padding again which has helped. I told Dr. Altchuler that I wanted to get an MRI, especially before any surgery. I have the CD and have taken a few images (the program doesn't have set images but instead I use a slider to change the image so I don't know if I'm using it correctly but I tried to screenshot images that appear most clear). I also just got the report today. I will try to scan tomorrow and sent it to you. I have an appointment with Dr. Altchuler tomorrow and will update you on what he thinks. 

MRI showing intense inflammation/bone edema in tibial sesamoid

I completely understand if you don't have time to review the attached images or the report I will send tomorrow, but I would greatly appreciate if you could share any thoughts you may have!!

Thank you so much!!

Dr Blake's comment: Thanks for sending me the views. Since I am not a surgeon, I am not sure about the planing procedure. The pain right now from the August MRI is the intense inflammation still present in the tibial sesamoid. It is trying to heal!!As you put weight down, that sesamoid pushes against the first metatarsal and gives pain. You have been in a boot long enough, but no Exogen. That could be a wonderful new chapter. You have to commit to a year of activity modification to continue the 0-2 level, 9 months of Exogen twice daily, icing and contrast bathes, orthotics with dancer's padding or just dancer's padding if the 0-2 pain level can be attained, repeat MRI in one year. You could get a CT scan to get a clearer view of the sesamoid for avascular necrosis, which could speed up the decision making. We need you to weight bear for mineralization, but not to crank up the pain. Hard, but doable. You were doing a great job on creating the healing environment. The bones can desensitize so doing surgery in the next year makes sense only if you are frustrated too much. No one would blame you, but I would just recommend taking the whole sesamoid out, and not risk not doing enough surgery. Again, I am not a surgeon. I am assuming you can do alot, and continue in a 0-2 pain level now, while adding the Exogen bone stimulator. With the hot MRI, you do not know if the sesamoid hurts because it is still partially fractured, or it is just very sensitive due to bone inflammation. I hope this makes sense. What are your thoughts and I will put them below? 

Saturday, August 12, 2017

Neural Flossing or Gliding: Dr Blake's Video

Nerve pain in the foot goes right to the brain on a super highway called peripheral nerves and gives up the most significant pain a podiatrist will treat. Any time a patient says that they have level 6 pain or higher, I will always look for a nerve component to their pain. It is common for a podiatrist to treat nerve entrapments, Morton's or Joplin's neuromas, tarsal tunnel syndrome, but there are alot of chronic problems that develop a hypersensitivity from nerve overload that needs to be treated. Neural flossing is a wonderful part of any nerve treatment. Here my wife Pat demonstrates neural flossing, aka neural gliding, with several provocations. You are trying to get the nerve to break its pain cycle but gently stimulating it in some way. Warmth and painfree massage, acupuncture, transcutaneous nerve stimulation, Calmare, etc, and other ways to keep reset the nerves to generate less and hopefully no pain.

Nerve Innervation Foot: Great Review of Local Nerves and Low Back Innervation

Nerve pain, also called neuropathic, is one of three common causes of pain in the foot. This is a wonderful review of this innervation. Any pain can have one, two, or three causes: mechanical, inflammatory, and neuropathic. Each aspect can be simple or complex to treat or even recognize. So many of my patients start with mechanical pain (for example, the sesamoid hits the ground too hard in a work out), develop chronic inflammatory pain as the body unsuccessfully tries to heal it, and then nerve pain sets in making the pain intolerable as the body tries to protect itself. It does not take long for an injury to have all 3 types of pain going on, each needing its own treatment. For example, the same sore sesamoid bone may need mechanical off loading, a daily dose of ice and contrasts, and neural flossing, Neuro-Eze, gentle but deep massage to get at the nerve pain.

Wednesday, August 9, 2017