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Tuesday, November 13, 2018

Fractured Sesamoid with long first metatarsal: 2 Year Need Minimum of Dancer's Padding

Dr. Blake,

Thank you for your very informative blog. It has more information about sesamoid fractures than most other sources combined. 

I'm 56 years old and have always been very active outdoors hiking and biking, although I've never been a runner. 12 months ago I felt a pop while squatting during some home repairs. The immediate discomfort was not great and I quickly forgot about it and learned to favor that foot slightly and not squat, thinking it would work itself out. As the weeks and months progressed, so did the discomfort. I never had any discoloration, obvious swelling or point tenderness. The range of motion is good.
Dr. Blake's comment: That is the history of the big toe joint sprain, not fracture. The sprain is the ligaments in that area and can be the ligaments around the sesamoids or between a bipartite sesamoid. 

6 months after the injury I finally got an x-ray with a diagnosis of the fractured lateral sesamoid. The podiatrist said the pieces had moved too far apart to knit back together and gave me a steroid injection to help calm down the tendon. We also put a cut-out dancer's pad under my insoles to relieve pressure around the sesamoids. I started an ice massage 3-5 times/day. The plan has been to let things calm down, then make custom orthotics to replace the dancer's pad. Surgical removal was mentioned as a possibility if things didn't improve.
Dr. Blake's comment: Remember, steroid injections give some relief up to 9 months, but they also mask pain which may not be good. 

By 9 months it was feeling much better and I was able to routinely hike 4-8 miles again, with pain levels in the 0-2 range. I stopped icing. Then I got a new pair of cycling shoes and did ONE RIDE without the relief pad. The next day I noticed slight discomfort had come back and it continued to get worse over the next two weeks. I resumed icing. A new x-ray at 10 months showed the sesamoid remains non-union and I got another steroid injection. As the first injection, it took about 2 weeks before I sensed improvement. 

It's now been 12 months since the injury and I'm again feeling like there's hope of a good long-term outcome. But information here has me wondering. My questions are:

1) Is the steroid injection simply masking symptoms? Dr. Blake' comment: Yes, stop doing those, you can hurt other things by masking the pain. These long-acting cortisone shots, I am assuming this is what you got, work for 9 months. With 2 in your system, you have 7 more months of the shots doing something so it will be May 2019 before they are out of your system. If your symptoms are still good in May, then you will probably be fine. 

2) At this point, is there any hope that the sesamoid pieces will heal back together? If not, can I have an active lifestyle (backpacking, mountain biking) with a fractured sesamoid? Dr. Blake's comment: The last 2 xray views show very round edges to the junction which means it was probably a bipartite sesamoid that broke. This means it will never go back, you just want the injury to stabilize and stop hurting. Your injury made sense for a bipartite sesamoid sprain where the two pieces separated more than a fracture. 

3) How concerned should I be about the degradation of cartilage on the metatarsal head caused by the rough, fractured edges of the sesamoid? Dr. Blake's comment: I am not sure. We don't remove the sesamoid for fear of this being a problem. When sesamoids are removed, it is due to the disability the whole problem produces. It can be hard to know exactly what is the trigger of pain in some patients. Sesamoid removals are in so few patients who break their sesamoids, and some heal with a lot of irregularity. Yearly checks on the condition by the treating doc is advised if only to refurbish orthotics and occasionally take x-rays. 

4) What symptoms should I be alert for that would indicate avascular necrosis? Is AVN still a risk 1 year after injury? Dr. Blake's comment: Not much of a risk here. Full examination with MRI and CT scan would be required. Bone stimulation for 9 months if any signs.  I sure hope this information helps you. 

I'm emailing x-rays, in case they help if you have a chance to answer. 

Irregularities noted on the bottom of both sesamoids, especially lateral



Smooth borders of separated sesamoid fragments appearing to show bi-partite condition

The lateral or fibular sesamoid has definitely been remodeling. The irregularities within the bone show this process. I love the Exogen 5000 bone stim if insurance covers. I also love contrast bathes each evening as a deep flush to the bone to remove swelling that can slow bone healing. I also want you in sesamoid protection nonstop until you are back doing everything for several months. 

Saturday, October 27, 2018

Nerve pain in Ankle Area: Email Advice

Dear Dr. Richard,

I live in London, U.K. My job is in I.T. - so desk based all day.

I came across your blog today, looks very informative. I actually saw the video where you talked about pain around the heel possibly due to back issues.



https://youtu.be/E0E60NpOSHg

Please, could you provide some advice to me? 

I have had foot pain since last 4.5 years that started one morning after some leg exercises in the gym (possibly causing back issue?). I felt heaviness in the left footbed when I sat cross-legged in the office after gym. Now the issue is with both feet - which are very flat, but show arch if I am dangling my feet in the air, rather than standing on them. 
Dr. Blake's comment: This is called a flexible flatfoot. The heaviness is a symptom of nerve dyskinesias, also called abnormal sensations like buzzing, burning, things crawling on your skin, or a rolled up towel under your arch or toes. 

Pain first thing in the morning has always been 3/10 level, never to the level of having to scream. The pain is worse if I walk a lot or stand at one place for more than a couple of minutes. 
Dr. Blake's comment: Yes, standing can be the worst time, since nerves like motion most of the time (like neural flossing exercises). 
The pain is around the heel area and travels up on the calves. Areas of soleus, behind the knee are always sore be it first thing in the morning or last thing in the day. The metatarsals and Achilles also have random tenderness.
Dr. Blake's comment: I always think nerve pain if there is tenderness but not swelling in the tissues. Do you have any swelling when it hurts?

Different types of insoles haven't helped. Recently I got expensive custom-made orthotics done, but I doubt them. Funny enough, I feel more comfortable wearing "Teva jetter lux slide sandals" than ASICS Kayano 25 that I am wearing with insoles. 
Dr. Blake's comment: Nerve Pain around the ankles, called tarsal tunnel syndrome or some version of it, can make patients wear the least supportive shoe or sandal so the sides of the shoe do not press against a sore spot. 

Recently I got MRI of feet done, which showed some bursa, inflammation liquid, little spur under left foot - which doctor said could be present in a healthy person's feet too.
The doctor also said that the plantar F hasn't got enough thickening to say that is an issue. He thinks I might have fat pad syndrome or something coming down from my back. I am currently waiting for my back MRI results.
Dr. Blake's comment: Yes, sounds typically double crush syndrome where the nerve is being irritated from above (even at the neck) and at the foot. The back MRI is a static exam, so will not pick up some back problems, but is a good place to start. You want to find a conservative peripheral nerve specialist, in the states they tend to be osteopaths, who will look at all the possible causes of sciatic nerve involvement. 

I have recently got some tape which my partner wound around my heels and that felt good after walking in that. I will try that for a few days.

Any guidance from you will be greatly received and I will make a donation too at some point as gratitude. 

Regards and many thanks in advance.
Dr. Blake's comment: I think you are going in the right direction. Make sure you are massaging the area three times a day with a gel or lotion for nerve pain, not anti-inflammatory (I have my patients buy Neuro-Eze online). Learn how to neural floss from a physio (my one video is below, but there are various techniques). 



See if Lidoderm patches can be prescribed for a month trial. Begin 3 weeks experiments of the supplements that help nerve pain. 
1.      Lipoic Acid 300mg 2x/day
2.      Acetyl-L-Carnitine 2000 mg/day
3.      Inositol 500-1000mg/day
4.      Vit B6 50mg/day
5.      Vit B12 1000mcg/day
6.      Vit E (up to 1,600units/day)
7.      Thyroid Natural Supplements

Diet for Nerve Pain

Here was the advice I gave to another patient:

 Nerve Pain is helped by some combination of the following (many of these topics are in the blog already):
  • Neural Flossing three times daily (find out if sitting or laying techniques more productive)
  • Nerve Pain supplements like B12, Vit C, (gradually you add one per month to check effectiveness so you would wait on this right now) etc 
  • Some topical nerve cream applied 4 times daily (NeuroEze or Rx)
  • Heat over ice
  • No sciatic nerve/calf stretching (find out everything postural wise that is tasking your sciatic nerve from beds, sitting chairs, standing habits, workout techniques). 
  • Oral meds (start with evening doses only of Lyrica, Neurontin, or Cymbalta). 
  • Epidural injections into the L5 nerve root
  • Soft based orthotic devices like Hannafords
  • See if there is a Calmare Pain Therapy center near you 
  • Sometimes TENS and Capsaicin is helpful (but you have to go through 14-20 days of more pain first)
Hope this points you in the right direction. Rich


Toenail Fungus is Among us!!!

Hello,

We have been faithfully 100% following your protocol you sent me back in FEB!!!!! Vinegar soaks 3x per week, sanding once a week and nightly application of TT oil on the toenails. The first pic is what they look like today and the other is back in Feb. when I first contacted you! They are looking better, but still not GREAT! I am curious to know what I should do next?? Do I continue or switch it up at this point? OR LEAVE THEM ALONE?! It has been quite a process😊

Thank you for your kindness in helping me!


Before Treatment


After 8 months, a lot of Vinegar (70% better to my eye)

Dr. Blake's comment: My comment to the mom was to keep going. She is doing this for her son. I told her for her reward of doing so well, 6 more months of the same thing. The nails seem to be clearing, the part at the end of the toenails is the last to go. 

Maximalist vs. Minimalistic Shoes: Dr. Blake debates Dr. McClanahan

https://www.podiatrytoday.com/point-counterpoint-are-maximalist-running-shoes-better-minimalist-running-shoes

And yes, another picture from my son's wedding in Maui last Saturday 10-20-18!!


Meet Mr. and Mrs. Chris and Courtney Blake!!

Does B12 Injections help with Nerve Pain like Mortons Neuroma? Some feel it does and should be Considered.

A question was just asked my blog about the use of B12 injections for nerve pain like Morton's neuromas. This seems to be a technique not commonly in use, but why? I found many articles discussing its use and I would use the guidelines from the first article for the 2 injections. I do not see why it could not be added to cortisone or alcohol injections (although you would have to calculate the alcohol percentage with this in mind). The B12 comes 1000 micrograms per ml, so you would use 1/2 ml. See the interactions discussed in the last article below from the Mayo Clinic.





https://www.sciencedirect.com/science/article/pii/S0929644115000053

This article proposes 500 mcg (micrograms) of methylcobalamin injected around the nerve twice (after the first one wait 2 weeks for the second shot).

https://www.webmd.com/drugs/2/drug-6550/vitamin-b-12-injection/details

http://www.vitality101.com/health-a-z/Neuropathy-b12_shots_for_nerve_pain

https://www.mayoclinic.org/drugs-supplements-vitamin-b12/art-20363663

Cheilectomy: Exercise Program Post Surgery


My wife Patty's Wish came true: Sunset, Champagne, and Santorini on 60th Birthday!!! 
(4 Years Ago)



Hello Dr. Blake,

I am writing to you from Santorini,… Eventually, I have not avoided the operation and I had cheilectomy in my right big toe. Stitches were taken out 2 weeks ago and it seems everything is fine. I have started wearing mainly my training shoes and also I walk every day, for about half an hour.

My doctor said I do not need any physiotherapy, he only told me to do one simple exercise 2-3 times a day, for 3-4 minutes, it would be sufficient. I am attaching a photo of my foot doing the prescribed exercise.
Please, would you be kind enough to propose me any kind of additional exercises you deem necessary so that to perfect my toe mobilization, apart from the one I am sending you?
Best Regards,

PS I was glad, that you had attended the conference in Santiago de Compostela, which is one of our favorite places in Northwest Spain. Think about revisiting Greece, so that you visit the island of Santorini.

Dr. Blake's comment: The image below shows good motion, but it is only a stretch on the bottom structures of the foot and you need to get the weight on the lower part of the toe (you are bending the joint closest to the toenail more than the one you need to be stretching. 
And yes, if we get back to Greece, for sure we want to go the Crete and Rhodes, we will want to spend several days again on Santorini!! Unbelievable place!! You can not take your eyes away from the vistas!! We stayed at Canavas Suites in Oia Village. 

We definitely want to do self-mobilization as shown in this video. No exercise should evoke pain, however. 



You should also strengthen both the Extensor Hallucis Longus and Flexor Hallucis Longus.

If you want to learn how to do theraband progression, see my video on posterior tibial exercises. It will be the same principle for any muscle. 


For the extensor, put your back against the wall and assume a sitting position with the knees at a 45-degree angle. Then do 2 sets of 10 of pulling your big toes up into the air slowly, leaving the rest of the foot on the ground. When 2 sets of 10 get easy, try 2 sets of 15, gradually getting to 2 sets of 25.

I also think building up to 2 minutes of single leg balancing helps tremendously. And gradually increase the height of 2 sided heel raises to get the achilles working well. Like with sesamoid injuries, you sometimes have to protect the big toe joint by building a well to offload. Good luck Rich


Friday, October 26, 2018

Maui Wedding for My son Chris and his new Bride Courtney!!

Rich, Courtney, Chris, Pat (my wife), Henry (grandson), Steve (other son), Clare (daughter in law)

Hallux Rigidus Post Toe Fusion Running!!! Amazing!!

And here is John Trautmann running a 4:14 mile in his mid-40s with a fused left toe:


He wins the race beating a bunch of college kids.  Look at his form in the very last straight away, he is sprinting with a fused toe.  I've tried very hard to detect an obvious bio-mechanical abnormality that would indicate a toe fusion but I can't see anything.  Amazing.


Friday, October 12, 2018

Snapping Peroneal Tendons and Nerve Hypersensitivity: Email Advice

Hi Dr. Blake,

I am not sure if you remember my previous emails, but I started experiencing bilateral sesamoid pain after an ankle sprain and I wanted to update you on my condition and ask a few questions if you have time.


I did physical therapy for a month - my hips are strong now, but I still have the same pain level. I decided to get a second opinion from an osteopathic doctor/foot and ankle surgeon. He found that the outer sesamoid bone is tender on my right foot, and both are tender on my left foot. My peroneal tendons are snapping over the bone slightly on the left side (this began at the end of August when I tried Hokas and the previous doctor said not to worry) and while the intensity of the snapping motion has decreased slightly over time, I am having a lot of pain in the area of the tendons and all the way up through the muscles of the leg. He decided to put me in a CAM boot on the left side for a month. He did say that often this can't be fixed without surgery. He also talked about surgery for the sesamoids. That was scary!
Dr. Blake's comment: Nothing points to surgery for these unless MRIs show a permanent condition. Patients who irritate the peroneal tendons somehow, sometimes abnormally supinating away from their sore sesamoids, begin to feel snapping as the tendons get tight from overuse and the motion of two abnormally tight tendons causes snapping sound. You have to make sure you are not abnormally supinating, and make sure you are icing the area twice daily do remove some of the inflammation.


I asked about using sesamoid protection in the boot, but he said it wasn't necessary. However, I think I will follow your advice and make a pad out of felt.
Dr. Blake's comment: Thanks for the common sense.


I'm also having custom orthotics made (finally) that will be able to be adjusted as many times as needed.


My first question is, what can I do to maintain strength while in the boot? I'm allowed to take it off while at rest on the couch and for sleeping. Obviously, I will avoid any motions that cause the tendons to snap, but I'm worried. I will continue to do my hip exercises from PT.
Dr. Blake's comment: You are trying to relax the tendons, not strengthen them at this point. Standing flat for balance should be okay for 2-3 minutes twice daily. The tendons are irritated in different ways when the ankle is pointed or flexed too much. The most important is cross training with stationary bike riding if available. You usually can lower the seat enough to feel the less strain on the tendons.


Next, I'm still having constant tingling in both of my feet and legs (worse on the left side). My spinal MRIs are clean (very slight bulge at L4-L5 but the neurologist said it was so small they weren't sure it was there). I also had a nerve conduction test and an EEG and both were normal. The neurologist decided to start me on Effexor/venfaxaline as we both think my nervous system is just on overdrive due to anxiety. I've been on it for five days. Last night, I awoke in the middle of the night and there was no tingling for the first time in months! It did come back, but I think that is progress.
Dr. Blake's comment: I think this is a good approach. Unfortunately, those tests only show big issues, so fortunately, you have some nerve hypersensitivity but it should resolve. The medication helps the nervous system relax. You keep whatever dose needed to achieve pain/symptom relief for 2 months straight, and then you try to wean with less dose per week not per day.


So, I guess my biggest question is what can I do to keep myself comfortable while dealing with the boot? I am worried about the stress on the nerves. Should I continue contrast baths/neuro-Eze/gentle massage?
Dr. Blake's comment: Yes, please continue the gentle help from neuro-eze, gentle massage, contrast bathing, and neuro-flossing. These will help the nerves. Take the boot on and off as much as possible, since you only want the boot on when you walk. If you are wearing a boot, you have to get an Even Up on the other side, so balance the hip height with adequate shoe height. That will protect your spine.
 Do you think these approaches sound adequate (boot for peroneals, orthotics for sesamoids)? See above, and good luck. Rich

Thank you so much for taking the time to read this.

Thursday, October 11, 2018

Recovering from Sesamoid Stress Fracture: It can be done!!

Hi - I’d like to thank you for the advice you gave me last year for a sesamoid stress fracture. It’s been a very slow recovery process, however, I was just able to run the Chicago marathon! I’m still trying to get back into racing shape and am dealing with overcompensation injuries, but it feels great to be running again and building confidence in my foot. I really appreciate your help with understanding the injury and recovery!

Wednesday, October 10, 2018

Conference in Santiago de Compostela Spain



I just spent a wonderful week in Spain at the 49th Congress of Podiatry in Santiago de Compostela. It was through this blog that I was invited and had a wonderful time. Thank you Eladio Martinez Garzon for arranging such an incredible adventure for my wife and I. I gave three presentations: 1) Runner Treatment Philosophies, 2) 35 Years with the Inverted Orthotic Technique, and 3) Treatment of Adult Acquired Flat Feet. I hope to get back to my normal schedule, although jet lag is a wonderful time at tiring you out. Rich

Wednesday, September 26, 2018

Orthotic Cast Correction on Cast Fill: Email Question

Good morning, Rich.  A quick question – regarding “cast fill” – do you generally prescribe the “normal” cast fill on the Root Lab form and find that leads to good patient outcomes?  My experience with other labs has been that their standard cast fill, seeking to make the device more “tolerable,” is so much that it significantly compromises the effectiveness of the device for people with excessive pronation issues.  That is far and away the most common problem I see with my PT patients who are referred to me because of other injuries, but for which excessive pronation is really the root cause -- e.g., runner’s knee.  I often prescribed “minimal” cast fill with other labs and I just wonder what your experience has been with Root lab with whom our practice is now working. 
Dr. Blake's comment: Yes, that is a big problem. Root Lab is truer to the arch than some labs for sure. You do want to have a grinder since some plantar fascial bowstringing requires a groove when the arch is true. If you are using vertical cast correction, how much change (transition modification at the first metatarsal head) will you ask them to do to a 5 degree vs 10-degree forefoot varus? I have found you have to go to a 25 degree inverted cast correction if the forefoot varus is over 5 degrees and you want great support (or at least modified forefoot correction for comfort but ask them to use a 2-3 mm Kirby skive and some extra medial column support (minimal fill proximally in the arch not distally). I will send this to Jeff Root to see if he responds. I hope this helps. Rich 

Any experience you can impart would be very much appreciated.

Thank you.

Sesamoid Injury: MRI report.


Hey Dr. Blake, 

I found an article you had written where the Drs said a girl had broken her sesamoid bone but it ended up being a cyst. I am still waiting to hear from my dr and I am no radiologist, but based on my MRI results, I think  I may have the same thing.  I am so glad I found your article.  Here are my MRI results, any insight?  This is my 2nd opinion.  The first dr taped me up and told me to go run and let him know how it felt, I quickly sought a 2nd opinion.  Both of my Drs did think I broke my bone though.

History: Sesamoid bone.  Abnormal ultrasound.  Cyst.

Technique: Right forefoot MRI with and without contrast.

Sequences: Axial T2 proton density fat sat, coronal STIR, sagittal T1, coronal T1, sagittal T2 proton density fat-sat and coronal T1 fat sat sequences were obtained.  The patient was intravenously injected with 6 ccs of Gadavist contrast and post contrast multiplanar T1 fat sat sequences were obtained and submitted for review.

Comparisons: None.

Findings:

The bone marrow signal: Heterogeneous T1 dark signal with a near serpentine appearance of the fibular sesamoid bone.  There is a corresponding increased T2 signal.  There is an enhancement with contrast.  There are no diastases.  There is an adjacent T2 bright signal with enhancement of the surrounding soft tissues.

There is a small first MTP joint effusion.

The plantar plates are unremarkable.

Tendons are unremarkable.

Impression: Nonspecific enhancing T2 bright fibular sesamoid bone signal with surrounding soft tissue enhancing T2 bright signal.  Question changes of sesamoiditis, AVN, or an intraosseous mass.

Dr. Blake's comment: The MRI report clearly shows the fibular sesamoid is hot and trying to heal. There is no indication of anything else. There is no definite diagnosis of sesamoid fracture, only that the bone is swollen for some reason. It could be a stress fracture, and you have to treat the worse case scenario with these. I would be happy to review the MRI scan if you want to mail to Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca 94109. Rich

Tuesday, September 25, 2018

Sesamoid Injury: Email Advice



First off I wanted to extend my appreciation for your amazing blog showing so much 
dedication to helping patients heal. The most frustrating thing for me on my
 sesamoid journey has been feeling like I don't have the right team of doctors/resources
 to begin 
healing from such a complex injury. I am willing to do anything but need to feel I am 
moving in the right direction to stop obsessing and focus on healing. 
Dr. Blake's comment: Thanks for the compliment. I am probably trying to pay off sins 
of the past. 

I am a 22-year-old, active, healthy female who rarely spent any time on the couch
 until recently. I am a Veterinary Nurse who works 8-10 hour shifts on my feet 4 days a week. 

I began having sesamoid pain in my left foot in early May 2018 likely caused by 
hiking at a quick pace, uphill, for long distances. I stayed active and ignored it for
 about a month as it wasn't bothering me until I came home from a two week trip to 
Colorado during which I was more active than ever. After coming home I realized I 
had a serious issue as I couldn't walk up my driveway without pain or otherwise dorsiflex
my big toe without pain. I went online and self-diagnosed myself with "turf toe" and
 taped it accordingly. I wore this tape for two weeks but didn't take more than a few days 
off hiking as it wasn't bothering me much with the help of the tape. While the taping helped 
I kept having the feeling that padding under the area I now know contains the sesamoids
 would have been helpful. After the two weeks in the tape, I was discouraged by not 
having more progress and made an appointment with a local orthopedic/sports medicine 
clinic. I saw the PA at this clinic on July 17th, 2018 and had xrays done on foot. The PA 
looked at my xrays, watched me stand, and felt my foot a bit. She said I likely injured the
 area (no specific diagnosis or fracture) and aggravated it by not resting and made the
 healing process take longer (2+ months at this point). She also said I had pronating feet 
with high arches and needed to do arch strengthening exercises and rest. If I didn't improve
 in 4 more weeks I was told to come back. 

I was encouraged by a lack of fracture and overall it definitely felt better than when
 I initially injured it (likely due to changing my gait and overcompensating) so I still did
not stop exercising and in fact began doing more. From the time of that appointment until
3 weeks ago I continued hiking and began more intense yoga (more planking/lunging/balance)
and started a new running hobby. I wore old, worn out running shoes and did not work up
 to running properly at all. I mostly ran on asphalt and the same trail I was hiking on (hilly)
and did not notice much pain except for when lunging/planking/dorsiflexing the toe, or
 running over a rock in the sesamoid area. In general, the foot was always irritated when
I would think about it but not so much so that I pursued further treatment. 

On Sunday, Sept 2nd, 2018 I went on a run at a park on concrete for the first time 
and then came home to do housework for a few hours in my bare feet. I sat down 
after all this and realized I had a throbbing pain in my sesamoid area that did not 
improve with anti-inflammatories and knew I needed to address this once and for all.
 I began researching and decided upon sesamoiditis as my new self-diagnosis. 
I called the same orthopedic/sports medicine clinic and scheduled a follow-up 
appointment with the surgeon himself but they couldn't get me in until October 5th. 
I attempted some home treatments with varying success that made walking bearable.
 During this time I also started developing issues with my other foot (right foot). 
 Eager to get some real answers and a real treatment plan going with the help 
of a doctor I tried calling another clinic. 

Yesterday, Sept 24th, I went to see the podiatrist specialist. He took did more
 imaging (fluoroscopy) and examined my foot a bit. He diagnosed me with
sesamoiditis, saying that the tendon between the two sesamoids was stretched
 out and having trouble holding them in place. He also said there was a shaded
 area on the lateral sesamoid (the one I have issues with) and he wasn't sure if 
it was a stress fracture or not. He prescribed an air cam walking boot for the foot
 and told me to come back in 3 weeks. I was diagnosed with general metatarsalgia 
on the other foot from overcompensating (no imaging or palpation was done). I asked
 many questions regarding MRI, orthotics, physical therapy, why this happened/gait,
 etc. Basically, he was most concerned with getting me in the boot and addressing
 anything further after rechecking my progress in the boot. He said an MRI may be 
helpful but it wouldn't change his course of action so it is just an additional expense.
 After going home and taking this all in and reading further I had him order the MRI
anyway and will be having that on Friday, Sept 28th. I am still going to keep my 
appointment with the orthopedic surgeon on Oct 5th as well. 

I am willing to do anything but I am getting discouraged that I do not have the right
medical team or diagnosis to begin this healing journey properly. I am hoping after
hearing my story and hopefully reviewing my MRI very soon that you will be able
to help me develop a treatment plan that can aid my current doctors in treating me. 

My main questions are:
- Would you definitely suggest I have the MRI as the treatment plan should be
 different if I have sesamoiditis vs. a sesamoid fracture? 
Dr. Blake's comment: Yes, this injury is 4 months old now and the MRI is the most 
subtle at looking for bone injury. Plus, if it is a fracture, you may need a comparison 
MRI 6 months from now, so might as well get that first one. I love PAs, but they do 
not have the foot training of podiatrists and a lot of orthopedic surgeons. The podiatrist
 in my mind has made the right decision to put you in the cast. If there is a break,
 typically 3 months in the boot is needed, and a bone stimulator as soon as 
insurance allows. 

- If I will be in the boot what physical therapy/exercise would you suggest to
begin to regain the strength I have already lost and likely will lose? Do you have
 any tips for finding a physical therapist who is familiar with this condition? 
Dr. Blake's comment: Most physical therapy places have PTs that like feet. You start
 there by calling and find out who deals with the rehab of foot fractures the best.
 Don't accept "we all do." The restrengthening of the foot and leg will be directed 
by the therapist. You need to protect your sesamoid by not putting full weight on it 
with various exercises. The exercises include single leg balancing, heel raises,
achilles stretches, metatarsal doming, posterior tibial and peroneus longus theraband work. 





- How can I decide if the boot is properly placed to help the fracture (should it be one)?
I can definitely feel the area when wearing the boot and I would still say it is in the 0-2
range of pain but I can't tell if I should dancer pad the sesamoid or not? And if I do pad it,
how can I make sure the padding is right other than by feeling/trail and error? 
Dr. Blake's comment: You can place a shoe insert into the boot, then use lipstick to mark
 the sore area, put the foot in the boot and tighten and walk down the hallway a few times.
 When you take the insert out of the boot, it should be obvious what area to protect
 with the dancer's padding. 


- How should I address the developing issues in my other foot if I am not sure it is the
sesamoids? I'm not sure what to have the doctor evaluate if the pain is just general
tightness and soreness. Also, I'm not sure how/if I could have developed sesamoid issues
 in the other foot if I'm not doing any impact exercising?
Dr. Blake's comment: Most likely strain from placing too much pressure on the other side.
 Some sort of OTC arch support or arch wrap may help. You should be doing daily contrast 
baths for the sesamoid and you can do both feet together. Make sure they evaluate 
everything. Please have your Vit D blood level drawn, because having low Vit D 
can make you start breaking things. 
- I see you have lots of suggestions about healing a sesamoid fracture but if it is
just a tendonitis issue what do you suggest for treating this? 
Dr. Blake's comment: Thus the MRI, since you have to make sure it is not a 
broken sesamoid. The tendinitis is treating with spica taping, icing, some physical
 therapy, metatarsal doming, and FHL theraband strengthening. Some of this will not
 be good with a sesamoid fracture. 

- Do you have any suggestions for doctors in North Carolina who you know have had experience/success with this issue?
Dr. Blake's comment: I am only acquaintance with Dr. Milch in Asheville, and Dr. 
J Barry Johnson in Winston Salem

I'd be happy to wait to get full answers to the questions after having my MRI and 
hopefully having you evaluate it. I am just looking for some encouragement that I
 am moving in the right direction and some advice from someone who is experienced 
with this condition. Dr. Blake's comment: Happy to review. Good luck. It can be a 
long road, but usually successful. The long part of it can drive people crazy, but not
 crazier than me I promise. Create your 0-2 pain level, and do not do anything that
 threatens that as you work through the rehab process. Rich

Thank you so much for your time and dedication to this issue.









Sunday, September 23, 2018

Stage ll Posterior Tibial Tendon Dysfunction: Give Conservative Care a Try


Dr. Blake, 
 This is the original post back in March 2018 when the patient contacted me. I referred her eventually to Dr. Matt Werd in Florida. 
I wanted to share with you a follow up on my progress with physical therapy. 

I am seeing Dr. Werd and he was very helpful in prescribing PT. Not only that but of all the doctors I have seen for this condition (4 so far), he has by far spent the most time with me analyzing my symptoms and going over the diagnostics and various alternatives. 

I had 5 months of PT. I was very blessed in finding an experienced therapist. I can tell you that it was not easy. It was sometimes painful and discouraging. However, I stuck with it daily, sometimes an hour or more of exercises every day. I had a couple of setbacks but am so thrilled with the results now. I am walking without pain, have full range of motion and full strength. I can easily do 50 single foot heel rises! Although it wasn't easy, I can also say that it was much easier for me to do PT than the alternative of surgery (with the post-op of being non-weight bearing, on painkillers all while trying to take care of my children.) I would have done surgery if absolutely needed but was so glad to have an alternative. 

I'm so thankful to God to lead me to this path. Thank you so much for your help along the way!

Sincerely,

P.S. Do you have any advice for me how to keep my foot healthy (exercises to do? any to avoid?) Dr. Blake's comment: This is your weak spot, but over the next year you will get it stronger and stronger. I pray that you are doing the posterior tibial theraband work level 6 2 sets of 25. Did you go through them? If you did, you need to do twice weekly to maintain the strength and make sure the tendon stays strong. Focus on activities until April that you can do with orthotics like hiking. I would wait another year before starting a walk-run program. Modified Yoga with orthotics on would be wonderful. I hope this gives some direction. You want to keep it strong forever so it will have minimal effects on your overall life. 
https://youtu.be/w3FXx4OFqec

Big Toe Bone Spur: Email Advice

Hello Dr. Blake,

I am very glad to say that searching on the Internet trying to find information about the problem I have I came across your blog. Thank God you have opened my eyes and gave me a better understanding of what I'm about to do.

I am about to have cheilectomy in my right big toe because I have developed a spur, which annoys me a lot when jogging. This is what my doctor here in Athens, Greece has suggested to me.
I am wondering if the simple movements on self-mobilization you are proposing for the big toe joint in your videos, might help and alleviate me from the burden of having the surgery.
Best Regards,

Dr. Blake's comment: 
     Yes, the conservative treatment can prevent or delay the course of surgery on the big toe joint. It is at least valuable information in the postoperative setting to see what helps take the pressure off the healing joint. Give yourself 3 months to see if it works. Self-mobilization is only one thing to try. My blog has been treatments for Hallux limitus which these spurs fall under. Try to skip the eyelet above the spur to help in any shoe you get pain. Try to place padding just to the bump, not over it. This is called proximal padding. I use 1/4 inch adhesive felt, but any soft material can be used in an inch square shape to tape down. Try spica taping to restrict the motion of the big toe joint. Try dancer's padding to off weight the whole joint from the bottom. Ice the area for 5 minutes twice daily for the next month to see if some of your pain is inflammatory, and not just mechanical. You can also experiment with shoes with bigger toe boxes depth-wise, or shoes with rocker to decrease toe bend like Hoka One One. Hope this experimentation helps you. Rich
PS. My wife and I have been to Athens, Mykonos, Delos, Paros, Naxos, and Santorini. Can not wait to go back in a couple of years. We want to see Crete and Rhodes for sure. Beautiful area.