Sesamoid Injury Healing and Some Prolonged Sensitivity: Email Correspondance

Dear Dr. Blake,

I hope you have enjoyed the summer! I believe I am writing to you for the fourth time now in about three years. I know you must be very busy and getting a lot of emails so I would be extremely grateful for even a very short reply from you. I am writing again because I still have some issues with my left foot after injuring both my feet in July 2015, and I have not been able to find anyone in my country with your knowledge on difficult foot injuries.

I do have some very good news also! My right foot, which had injured sesamoids, some cartilage breakdown and lots of edema in the metatarsal head is now free of pain for walking in my daily life. It took about 2 1/2 years to get there, but it is a major relief.

Now my only problem is the left foot. It has never felt quite right since the injury, although up and down pain-wise. The last time I wrote to you, maybe a year ago, the pain was worst in my outside ankle (lateral?). Some tendonitis and tenosynovitis of a few tendons were confirmed on MRI, as well as a small split in the brevis tendon. This pain has gotten a lot better, and I think the tendon split probably is from an old injury and completely unrelated, as you suggested. But I suspect this ankle pain is only secondary to the sesamoid injury I got initially in 2015. As my right foot initially was so painful, I had to choose to put the weight on my "least bad foot" when on my feet. I suspect that the pain in my left foot at times also was masked by the stronger pain from the other. Therefore I, unfortunately, may have been walking with more than the 0-2 pain level that you recommend for a long period.

Anyway, I now had a flare-up of stronger pain after our national day in Norway, the 17th of May. I was walking quite a lot and even dancing that day in nice (but not so well cushioned) shoes and also had drinks. At one point I felt a sharp sting in the ball of my foot, then it did seem to go away again quickly. But I later woke up during the night with achy pain, and it didn't really seem to go away the next few days. But no real swelling of any kind. My fear is that the sesamoids didn't heal completely, and I maybe re-injured them now. So I have been trying to offload for most of the summer, hoping to make it better. Generally, the pain in my left foot has been more aching, widespread, coming and going, and difficult to pinpoint. Often worse after activity, not so much during (but sometimes). 

I had an MRI done in 2015, maybe 2 months after injury. I have now recently done both an MRI and a CT. Back In 2015, it read "sesamoiditis", and the edema is pretty clear in the pictures. But the radiologist seems to think everything looks normal again now in 2018 and found no issues. I am attaching a few screenshots from 2015 and a few recent. It would be wonderful if you could have a look and say if you agree with him. Personally, I seem to think at least the MRI of the medial sesamoid looks a bit strange now, but probably there is a good explanation for this. If you also feel that everything looks as it should, I will try to gradually get walking more again. Maybe the pain is more from hypersensitive nerves, sore tendons, not so great orthotics for a long time and so on.

I have named the pictures with the year which they were taken. The recent MRI is from early July, and CT now early August. 

Hope for a reply from you.

The reader must be aware these images are on the left foot, but since MRIs are mirror images, they look like the right. On my computer, I can flip the images horizontally when looking at them with the patient. 

Tibial Sesamoid Injury 2015 (the dark area is where the ligaments and tendons attach and is commonly mis-read as bone death (aka avascular necrosis)

Tibial Sesamoid 2015 noting some inflammation in both sesamoids

Tibial Sesamoid 2018 Slightly Irregular (the most important thing is that it is solid)

Tibial Sesamoid 2018 not Inflamed (no sign it is actively trying to heal something) with some inflammation between sesamoid and metatarsal. Another important point is not bone swelling on the under surface of the metatarsal

Tibial Sesamoid 2018 Normal Appearance (good bone marrow is seen, although the tibial and fibular sesamoids have a different look since the tibial sesamoid underwent some bone healing) The sensitivity that he is experiencing is that maybe the tibial sesamoid is more dense or harder and that irritates the first metatarsal although no sign is noted. 

Dr. Blake's response: thanks for the email and photos. The MRI and CT scans look fine. That does not mean you do not have some irregularity in the sesamoid that makes it sensitive and subject to flares. You should work hard over the next months trying to perfect the mechanical help from an orthotic device, and some of my patients are even using the 1/8 or 1/4 inch Dr. Jill's gel dancer's pads with the orthotic and permanently with any shoe or sandal they wear. They can even be worn on your foot if you are barefoot. Definitely buy a nerve cream that you massage in 3 times a day for the next month, and watch my video on neural flossing that helps relax the nerves. Thank you for sharing your story. You have a built-in hyper protection nervous system for these sesamoids, and flares can be more sensitive than for others. The 3 sources of pain management for these are mechanical changes, anti-inflammatory changes, and nerve hypersensity changes. Keep me in the loop. Rich

Foam Rolling can Improve Flexibility: Article sent to me after a Hard Work out by my Personal Trainor

https://www.ncbi.nlm.nih.gov/pubmed/22580977

Beginning Fitness as we Age along with Yoga helping Bone Health: Email Exchange with my patient

Hi Dr. Blake,

Thanks for all your help!  I think the Neuro EZE really helps alleviate my nerve pain in my toes!  I’ll switch now, as I am anxious to try out the Neuro One!  I’ll let you know what happens.  And, when I get back to my dance class, I’ll “buddy tape” my toes!

This is the TV show that I mentioned.  It has been on public television for 30 years!  I only have known about it for about 10!  I think my mother told me about it…  not sure….

It is a good well-rounded, well-thought-out exercise program for all levels of ability, and I liked it when I was post surgery last year.  https://www.sitandbefit.org/ 

Here’s a few more that I know:

I also like the Classical Stretch show with the Canadian ballet dancer, Miranda Esmonde White. On KQED, this is being aired regularly, I get it on Channel 17 and there are youtube videos, too: https://www.kqed.org/tv/programs/index.jsp?pgmid=15089

And then, there is a gentle Yoga by Peggy Cappy.  She calls it “Yoga for the Rest of Us”.  I saw her introductory presentation on PBS a few years ago.  It’s a good introduction for people who may be hesitant to start Yoga or have some limitations, or older adults.  https://www.youtube.com/watch?v=0Ce_UERHzuU

I love my Yoga teacher, who does the Iyengar style.  It is “alignment” based and a pretty intense class.  My teacher, Tony Eason is a long-distance bicyclist and Marathon runner.  My DEXA scan results have improved over the last 9 years with Yoga.    I had read the research of Dr. Loren Fishman about Yoga and improving Osteoporosis after I was diagnosed with Osteoporosis.  I am now in the “safe” zone with my numbers!  I have a couple of his books on healing Yoga, and I’ve used his Yoga technique to help my rotator cuff as well.  http://www.manhattanphysicalmedicine.com/

Posterior Tibial Tendon Dysfunction: Email Advice

Dr.  Blake:

I'd be glad to pay you for some advice on my recently diagnosed posterior tibial dysfunction or contribute to your blog as you see appropriate.

ME: 63-year-old white male, 220 lbs, HLAB27 positive with possible ankylosing spondylitis (not disabling).  Rt. hip osteoarthritis but able to walk 1-4 miles daily with dogs until about one month ago.   The pain started after doing some low weight leg presses but not acute and has gotten progressively worse.  Initially behind my medial ankle but now very tender in front of ankle towards the top of the foot.  It is possibly coming from the insertion of the tendon into the navicular.  I'd call it a 6.  Intermittent swelling treated with ice and piroxicam.  I did try a short course of oral prednisone.  I have been wearing lace-up figure 8 brace on old orthotics.   I bought a cam walker a few days ago but this was not suggested as needed by the local podiatrist.  He did say stop walking trails on uneven surfaces.  Was hoping to continue some 1/2 mile road walking with the cam boot but that is not going to happen at this point.   Let's just say that the alarm bell is ringing.

 Podiatrist took x-rays and gave laser treatment and has ordered new orthotics with a 7-degree inversion and a skive.  He says x-ray shows moderate pronation and some drop now coming from the navicular I think.     He said a Richie brace might be helpful and have an appt. for casting on Monday.  Just a few questions:

Is the Richie appropriate for trying to calm this down to a pain level 2 and should I be attempting any exercise for the tendon at all until then, including an unweighted range of motion?

Dr. Blake's comment: This is wonderful that you are writing at the same time your injury is relatively new and you are seeing a podiatrist who is talking about inversion and skives. Sounds like everything is good. First, he must confirm the diagnosis of posterior tibial tendon dysfunction and stage you at I, II, III, or IV. This knowledge will help us a lot. Then, you must be good at finding whatever treatment now gets you into 0-2 pain level consistently. Typically these are walking cam boot, or boot and PTTD braces, etc, even crutches if needed at times. I find that patients need various things at different times. So it may be appropriate to tape and orthotic for some activities, other activities with a Richie, and others with a below knee cam walker. Unless they are telling you that you have severe stage 3 or early stage 4 and surgery is being suggested, then most patients are walking and talking whiles they take care of their dogs and get very strong. I will attach the 2 videos on taping and exercises. The exercise will show you how to find the right level for now, and give you advice on how to get very strong. BTW, a 7-degree inversion with skive is very good and protective. 

https://youtu.be/AcSSyBfFocE




https://youtu.be/w3FXx4OFqec

Do you consider the cam walker imperative for all steps now or can I walk around the house in the figure 8 on the orthotics, perhaps assisted by forearm crutches?

Dr. Blake's comment: The 5 common criteria we use to see the severity to know how to advise you are:

1. What does it take to maintain a 0-2 pain level
2. What is the strength found and the pain experienced of the tendon when testing it against resistance (manual muscle test in office)
3. Has there been any increase in pronation (arch flattening) subjectively by the patient and objectively by the doctor's evaluation and xrays?
4. What does the MRI tell us of the state of the tendon? 
5. Can the patient raise their heel off the ground in single leg support positioning, and how much, and does it hurt? 

But, without alot of information, you can still use common sense about maintaining low pain levels, finding your strength difference (comparing right to left), icing 3 times a day for 10 minutes to decrease the local inflammation that hurts. 

Would you recommend a different brace, even an Arizona AFO that stops the dorsi and plantar flection? 

Dr. Blake's comment: The most common brace is the Aircast PTTD Airlift brace, and the taping I linked above with leukotape (strongest tape made). If you can do less then the Richie or Arizona, then the shorty brace from MSI Orthotic Lab looks interesting. I typically use the same type of inversion with a foot orthotic and add the taping even during the first visit. Do not do any resistance bands for strengthening, which can make you worse, if you are not ready for them. Richie is introducing, although I have not tried it yet, and smaller AFO that most labs know about. 

 How about a UCBL or hard shell type brace that controls that motion.  The motion on that plane is indeed painful, but I can manage what I think is a normal gait if taken slowly.   A hard brace around the front top side of the ankle might produce significant pain I would think.

Dr. Blake's comment: I, of course, invented the Inverted Technique for severe pronation which is just the control of the plantar surface of the foot. You can combine the heel inversion with a deep heel cup of 25 mm or so and have a wonderful hybrid orthotic between the inverted technique, the Kirby skive, and the UCBL. 

  I'll mention that I do have intermittent heel pain that I believe is caused by the plantar fascia or perhaps loss of the fat pad so an unpadded orthotic might be an issue. The fascia was surgically released about thirty years ago with good results and I had one cortisone injection there for a flare up about 5 years ago.  I'm not a wealthy man but throwing a couple thousand dollars at this really is something I would like to do to try to keep this from progressing.  I'll hopefully be getting an order for an MRI next week as well.

Dr. Blake's comment: Any orthotic or brace can be padded. Great, I hope you can get an MRI so that they can stage you. 

Do you ever ship out your custom orthotics made from one of the impression kits?   I realize I'd have to get any adjustments made here locally.  Any help or advice on this would be greatly appreciated.

Dr. Blake's comment: I would only work with a local podiatrist if there was trouble getting something accomplished. Start with where you are, get the treatment moving, see what happens. Remember there are 3 Phases of Rehabilitation: Immobilization (where you are, and where braces, AFO, taping, orthotics are working like casts to help rest the injured tissue), Re-Strengthening (which you should be starting now with at least active range of motion exercises, but will be in full force 3 months from now with resistance bands and functional exercises), and finally Return to Activity. Doctors and therapists try to blend all 3 phases all the time, but techniquely for awhile you will be in and out and back into the Immobilization Phase until you get it all calmed down. There is a logic to this rehab, and setting time frames for them is dangerous. For right now, find out by MRI what you have, begin some form of strengthening, find out how to stay in 0-2 with the help of the doctor and other physical therapist. I wish you good luck. Rich

Sesamoid Blog: Follow Julie's Progress Post Partial Sesamoid Removal

Hi Dr. Blake. I have been following your blog quite a bit ever since I fractured my medial sesamoid bone. I remember you saying there was not very much info on partial sesamoidectomies. I ended up having one yesterday July 27th and have set up a blog about my experience with great pictures. If you have the time to review it I would appreciate it as I think it could help many others out there. Below is the URL...thank you!

https://juliessesamoidstory.blogspot.com

Dr. Blake's comment: Thank you Julie. I am sure many readers will follow and I will send them to it also in my podiatry practice. Here's to speedy and complete healing. Rich

Sesamoid Injury: Email Advice

Hi Dr. Blake,

     I woke up to a swollen and painful foot in the big toe junction area at the end of February this year. Got misdiagnosed at an ortho as gout, then a strain, then a sprain as my blood work was clear of autoimmune signs and PT for the strain/sprain was helping, but slowly and then progress would recede. 

     Second opinion sought after an MRI I demanded revealed sesamoiditis and it was recommended I try to take it easy. An experienced podiatrist took X-rays and found a fractured lateral sesamoid, and indications of tendon tears in the area. Proceeded with red laser therapy weekly, non-weight-bearing and a dancers pad. Pain level kept lowering. 

     5 weeks ago 2nd ultrasound showed no change in the amount of swelling. Was placed in a cam walker boot. I feel this helps walking, but can be painful when sitting or laying. This boot was an attempt to stabilize my forefoot (high arches, flexible forefoot). Swelling is an issue bc I seem to have the family Raynaud's Syndrome. Every time I try to ice, even for just a few moments I  experience incredible pain. Even tried going 10 seconds and then into warm water for 30. 

     I just want to make sure we aren’t missing something in our diagnosis/treatment. And the swelling greatly concerns me. I’ve been doing self-massage to try to get the swelling down daily and taking a load of turmeric as the prescription anti-inflammatory was having adverse effects on my digestive tract after 1.5 months. Also had tried a steroid pack at week three with the ortho doctor. Had no effect but I was still on my feet. 

     Your input would be GREATLY appreciated!!!

Dr. Blake's comment: Sorry for the long road, but it sounds like you are finally in the Immobilization phase of rehabilitation (Phase 1) to allow this to heal. Typically strains do not cause swelling, so I am going to discount that diagnosis. A sprain would be related to a fall, trip, stumble, so what brought this on? If you did not have an acute incident that could have sprained the tissue, I am assuming that is also incorrect. Sesamoiditis vs stress reaction vs stress fracture of one of the sesamoids is the highest possibility and they all look essentially the same on MRI, and you have to treat them the same. A fractured sesamoid looks a lot different. These injuries are caused by walking too much, dancing too much, etc, especially if the winter brought some silent Vitamin D deficiency. With this type of injury, you go into a removable boot/cam walker and get the pain to 0-2 as quickly as you can. You can walk for bone mineralization with these injuries. Sometimes you have to stay in the boot 3-4 months, but other times you can wean into a Hoka One One shoe or Chrome Bike shoe (or something similar) with the embedded cleat even after one month. All based on achieving the 0-2 pain level consistently. 
     If you go to YouTube and type drblakeshealingsole sesamoid in the search area, you should come to all my videos on sesamoid injuries. The typical treatment has to include: contrast bathing (important for the painful swelling trapped in the sesamoid), dancer's padding and cluffy wedges (important to off weight the sesamoid slightly), an Exogen bone stimulator if it is actually broken (fractured), and non-painful massage and range of motion for nerve hypersensitivity. You can use lukewarm water with Epsom salts for 30 minutes with toe range of motion for the circulation because of the Raynaud's instead of the contrast bathing. Look at google for foods that produce inflammation, like peppers. Consider physical therapy to strengthen your foot and as an anti-inflammatory measure with all their wonderful equipment. See my post on making a sesamoid well for doing protected weight-bearing exercises like single leg balancing or achilles stretching without putting too much pressure on the sesamoids themselves. I hope this helps. Rich

Alcohol Shots for Morton's Neuroma: Email Advice

Dear Dr. Blake,

I found your blog several days ago and have found it very helpful and informative. I have been experiencing pain in my left foot since September 2017. This past Wednesday my podiatrist administered an alcohol sclerosing injection in my foot for a Morton's Neuroma. I have a follow-up appointment with my podiatrist next week; in the meantime, I have two main questions about the shot that I was hoping that you could answer.

1. Prior to receiving the shot on Wednesday, I experienced mild to moderate pain on the top of my foot and the ball of my foot. Since receiving the shot, I have experienced intense pain in the arch of my left foot. My podiatrist told me that a sclerosing shot can cause an initial increase in pain; however, is it normal/to be expected that I would feel increased pain in a new area of my foot (the arch?)

Dr. Blake's comment: Yes, unfortunately, I have had patients feel the entire bottom of the foot was hit by a board, and very sore for up to 2 weeks. Unusual, and typically the first one in the series, but definitely a temporary problem. The symptoms can last for 4 days to 2 weeks. All of my patients that had that experience did continue to have the complete series of 5 without other flare-ups. 

2. The pain that I have been experiencing after the sclerosing shot is very intense, and I am not sure that I want to proceed with the series of shots. The original pain from my neuroma was more tolerable, and was also intermittent--this new pain is intolerable and constant. If I were to stop the sclerosing treatments, how long would it take for this new pain in my foot to subside? Also, are there different courses of treatment that I could discuss with my podiatrist?

Dr. Blake's comment: I can sympathize with you. The alcohol works on the nerves and nerve pain, of all the types of pain we deal with, is the most intense. Once this calms down, it is still considered safe to continue, and less likely you will hurt as much. Alcohol is safer overall then cortisone shots. What I do not know is how much volume or what percentage was used, or even if the right technique was utilized to advise you further? I can comment more if you get me at least the information on percentage. 
     When you treat nerve pain, you should be doing the basic treatments of Neuro-Eze topical, neural flossing techniques, shoe selection (what feels better less padding or more, stiff or flexible, rocker or not, etc), icing or other forms of anti-inflammatory measures,  inserts with metatarsal padding and accommodative padding, etc. Let me know what else you are doing. Also, let me know how long it takes to feel better. Good luck. 

I hope these questions are clear. Thank you for writing such a thorough and helpful blog. 

Sincerely,

Clinical Biomechanics for Podiatry (Post #5): Think about Pain Syndromes and Mechanical Causes

     Certain mechanics produce certain pain patterns or syndromes. The 4 common types of mechanical faults which can produce predictable pain patterns are:

1. Over Pronation
2. Over Supination
3. Poor Shock Absorption
4. Limb Length Discrepancies

     Every bio mechanical oriented practitioner looks at these 4 areas when initially evaluating an injury for cause. Could it be from Over Pronation? Could it be from Over Supination (also called Under Pronation)? Could it be Poor Shock Absorption? Could it be tied into one leg being longer than the other?

     It is important to note here that there can be more than one issue going on at once causing symptoms, or confusing the treatment plan? Since 80% of patients have one leg longer (either structurally, functionally, or both), and 99% of patients are have dominant right or left sides (right handed vs left handed), and 10% or so of patients I see have a past injury which affects mechanics (ie. old knee injury), the complexity can be intense, but treatment can logically work through the issues.

     The treatment of these 4 common areas can also be complete or partial for many reasons. Some injuries need 100% correction of the mechanical fault to get better, another injury requiring 20% or so. I tend to personally shoot to correct a problem close to 100% if I think it is the cause or major contributor to the pain syndrome. I can give you hundreds of examples when treatment  near the 100% level was extremely important, but also hundreds of examples when 20 to 30% correction of the mechanics was all that was needed. An easy example of this is low back pain and short legs. If a patient has an 1 inch short right leg with lower back pain, they normally present to my office with 1/4 inch heel lifts. Patients tend to say it was helpful, but they still have back pain. Why are they left with this 25% correction? Because it is much more difficult going to the next level of lift therapy when some or all is placed in the mid sole or on to the outer sole of the shoe.  This same problem is seen in the treatment of over pronation, over supination, and poor shock absorption.

With the onset of very unprotected shoes, we may see a new category arise of Poor Foot Protection, or over protected shoes that weaken our feet!! . I have 3 patients now injured in these less protective shoes that I am unsure if the cause was poor protection, over pronation, or poor shock absorption. Perhaps each factor played a role in the injuries and they all had to be present for the injury to occur. And perhaps it was poor training techniques, the jury is out at this time.

Plantar Plate Tear 2nd MTJ: Email Advice

Dear Dr. Blake,

I was wondering if you could help me with answering some of my questions.  Firstly, I'll describe my situation.  Right before Christmas last year I stopped running due to extreme pain I endured in my last two runs. I struggled even to walk so I altered my gait to take pressure off the top part of my right foot. I can say that after 5 months I can now walk without pain but that is because I walk without using the front part of my foot and no longer using winter boots as it's warmer.  Now I am using Merrell vibram normal shoes which I find comfortable and I can detect which part of my foot that I can use. My second toe on both feet are longer than my big toe.

I have had an xray of my foot and an MRI.  The results of my MRI are as follows:

Irregularities seen in 2. Mtp-joint with a few very small subchondrale cysts with basis of prime phalanx. Implied hydrops and small periarticulare deposits dorsally. Suspected a small avulsion cortical fragment from basis of phalanx. Also markedly edema lateroplantar along course of lateral part of the plantar fascia and lateral collateralligaments so could be the state after avulsion of the plantar fascia with a small cortical fragment from the base of prime phalanx. No enhanced intermetarsal bursa, no Morton's nevrom. Normal flexor and extended tendons. Unremarkable sesame bone complex plantate for caput of 1.metatars. 

In 2. MTP-joint suspected sequelae after avulsion of the plantar fascia with a small torn cortical fragment from basolateral part of prime phalanx, and some synovitt changes and beginning small degenerative deposits

Dr. Blake's Comment: Yes, from you image above, the lateral aspect of the plantar plate is torn causing the 2nd toe to drift medially (toward the 1st toe). 

I have attached a photo of my foot, where toe drifting of the 2nd toe is quite apparent (please excuse the look of my sticky taped toes).

I will be meeting with a surgeon in October in discuss options for surgery.

In the meantime i have been recommended to use Hoka arachi runners to avoid pain and the ability to walk normally. I have tried a pair on and when I try to walk as normally as I remember I do not appear to have pain.  I was wondering, if I should purchase these shoes? If I do, the main reason would be so that I could resume running until my surgery. I tape my toe regularly.  I do pronate and have used orthotics in the past but not since my injury. My main question here is, will I cause more damage to my toe if I start running in the hoka arcachi runners , more so than if I wait until the surgery and resume running again then? 

Dr. Blake's comment: As long as you maintain the 0-2 pain level, you are okay to run. The joint has arthritis starting (all the bone cysts and periarticular deposits), but hopefully the surgeon will clean that out at the time of surgery along with fixing the ligament. There are so many types of surgery for this, it is hard to know. 

     So many of my patients wait and wait on surgery, some preventing it, and some having it eventually. The pain is from the joint not lining up and the joint lining gets irritated. This is the same as the knee cap tracking slightly off line laterally, and the pain is unbearable to some (called "runner's knee"). Normally, we can get rid of the pain overtime with icing routinely, rocker bottom shoes to avoid toe bend (like Hoka), Budin splints (in your case a single loop is opened up and put over the 2nd and 3rd toes together, maybe even taping the 2nd and 3rd toes in buddy taping fashion, and using an insert like an orthotic to off weight the bottom of the 2nd joint with accommodative padding (I have many examples in my blog). I have so many patients that have the surgery after years of these treatments, not because they are in pain and disabled, but they just get tired of the daily process and they hope the surgery makes them better. Normally it does. Good luck. Rich

I really appreciate your advice on this matter.

Thank you,

Clinical Biomechanics for Podiatry Series (Post #4):Taking a Good (Biomechanics) History

This is where it all begins in the doctor/patient or therapist/patient relationship. The time spent here discussing the historical facts of an injury or pain syndrome, and important contributing factors, can be vital in the success or failure of treatment. Why is it so vital? Followup visits work off the success or failure of the treatment plan set on that first visit. If the information collected is inadequate, the entire sequence of events following may be subpar. I refer the reader to a post I did earlier on giving a good history. Please review it now before we go further.

http://www.drblakeshealingsole.com/2010/06/giving-good-medical-history-for-pain.html

The biomechanics history related to injuries is looking for patterns or facts that can cause injuries to occur. Here are some of the many questions that normally get asked, or at least you should add to your thoughts prior to seeing a doctor or therapist. These include:

1. Do you know if you have a short leg?
2. Do you believe you have weak or tight muscles in general, or around the injured part?
3. Do you have loose ligaments in general?
4. Are you right or left-handed?
5. When you were a child did you have to wear braces or shoe inserts?
6. Have you ever been prescribed shoe inserts?
7. Have people told you that you walk or run funny?
8. What has your history been of overuse injuries (nontraumatic)?
9. How all or most of your injuries been to one side of your body?
10. Do you have high arches, flat feet, bow legs, knock knees, bunions, hammertoes, or other abnormalities?
11. Do you have any arthritis from your hips downward and wear?
12. Do you feel unstable in any joints?

A skilled practitioner knows the relevancy of the answers. The answers will help point the course of treatment in the right direction. 

Clinical Biomechanics for Podiatry (Post #3): Orthotic Devices: Adding More Stability

The 2 pairs of orthotic devices above are actually the same pair. The patient Luz presented to my office with the pair on the top of prescription orthotic devices. These orthotic devices were not controlling her pronation motion enough, and I felt that some of her symptoms could be caused by this motion. Instead of just making a new pair, I was able to get more stability by teaching her power lacing, and having the podiatry laboratory place extrinsic rearfoot posts (brown) and arch reinforcements (white). This simple solution can be the subtle difference in motion that eliminates pain. This is one example of the art of medicine combined with the KISS principle that I use on a routine basis with great results for patients. 

Bike Shoes for Walking to Limit Metatarsal Bend

These are Chrome Bike shoes with the embedded cleat for bikes. They are the best looking ones I have seen. I use them in almost every treatment plan for chronic plantar fasciitis, or plantar fascia tear. They are also used for many ball of the foot problems that you want to avoid toe bend. Of course, you should have your orthotics and padding, etc, in the shoes. 

    REI link

Foot Massage Balls: Patient Recommendation

This was highly recommended by one of my patients as a great way to stretch out the arch and loosen trigger points.

https://www.optp.com/Franklin-Textured-Ball-Set

Clinical Biomechanics for Podiatry (Post #2): Foot Orthotic Devices: General Principles

There are many types of foot orthotic devices for the consumer. They fall into 5 categories based on the needs of the patient. These 5 categories are:

1. Corrective (or Controlling)
2. Stabilizing (or Balancing)
3. Shock Absorbing (or Cushioning)
4. Accommodative (or Weight Transferring)
5. Combination (or Multi-Functional)

How is the correct orthotic device ordered or purchased? The orthotic device that you prescribe, or that you recommend purchasing in a store, may or may not help if it is not the correct type. At its best, the correct orthotic device will successfully make the necessary change in mechanics, but it may still be crucial to work on all the other aspects of rehabilitation (anti-inflammatory, flexibility, strengthening, etc.) in order to relieve all your symptoms. It is important when prescribing the orthotic device that you are familiar with the many different types of orthotic devices available. It is also important for the patient/customer to be somewhat clear on what type of orthotic device is needed. And, unfortunately, the type of orthotic device required today may change in the future with different sports, different symptoms, different shoe types, and different age. You need to be willing to change to a different type of orthotic device if the patient's symptoms are not improving with the present pair of orthotics, and if there is another type available that may help them. Sometimes, practitioners don’t like discussing this type of change due to the added cost to the patient, but it is important that they know there are options.

Corrective or Controlling Orthotic Devices do what they say---correct or control excessive pronation or supination (the inward collapse of the arch, or the outside roll of the ankle, respectively). This type of orthotic device produces the most dramatic change in function, and may take the most time to get used to wearing.

Stabilizing or Balancing Orthotic Devices normally do not change foot position much, but the patient/customer feels more centered, more balanced. The weight of any point can become so distributed that only a small fraction of the original weight bearing still exists. This can be vital for heel pain, some arch pain, fifth metatarsal base pain, and many metatarsal problems.

Shock Absorbing or Cushioning Orthotic Devices take the stress out of the pounding of heel impact. Runner’s versions need to have equal cushion at the heel and forefoot. These can dramatically reduce the stresses which cause or aggravate stress fractures, joint pains (knee and hip), and heel pain. One of the best shock absorbing orthotic devices is the Hannaford which will be discussed later.

Accommodative or Weight Transferring Orthotic Devices try to transfer weight from a painful area to a non-painful area. These orthotic devices have probably been around the longest of all orthotic devices prescribed by podiatrists. If you have heel pain, you need an orthotic device that transfers weight into the arch. If you have sesamoid pain, you need an orthotic to transfer weight back into the arch and onto the 2nd and 3rd metatarsal heads.

Combination or Multi-Functional Orthotic Devices are probably the most prescribed type of orthotic device. The prescribing practitioner attempts to accomplish multiple tasks with one type of orthotic device. This is why there are so many types of orthotic devices out there. When you really study them, most primarily do one of the 4 basic functions really well, and then 1 to 3 of the other functions somewhat or not at all. A good practitioner will try to get the most out of orthotic therapy. This means that the practitioner tries to combine different functions into each orthotic device on a routine basis. Sometimes, however, doing too much sacrificing the most important function.

Hopefully, this post helped you understand some of the basics of orthotic therapy. When discussing with a patient, try to understand what we want the orthotic device to do. Ask yourself these questions:

1. Do I need to order a corrective device to change foot positioning?
2. Does the patient primarily need to feel more centered and stable?
3. Do they need cushion/shock absorption as they walk or run?
4. Do they need to transfer weight from a painful area to a non-painful area?
5. Do they need a multi-purpose orthotic device with many functions to help the problems at hand?

Perhaps the patient will need several orthotic versions since their activities, shoe gear, etc. vary so much. The doctor and patient must be on the same relative page, and the patient must be aware that there may be a plan B. 

Clinical Biomechanics for Podiatry (Post # 1): Orthotic Designs: Positive Casts before Balancing

In designing orthotic devices, to achieve positive functional changes, and positive symptom outcomes, the prescribing health care provider needs to be fluent in orthotic casting, orthotic prescription variables, etc. I took 20 casts of my wife Pat's left foot to show common variables in orthotic prescription writing. The first cast I poured with plaster and left it uncorrected (the yellow positive cast below). The other 19 casts of her left foot I corrected various ways to achieve various functional results. I will try to show you that even though a good cast is taken (podiatry's Gold Standard in Root Biomechanics), your goals of what you are trying to achieve functionally and symptomatically may require a wide range of orthotic variables.

These 3 positive casts were made for 3 different patients: Orange for high degree of Forefoot Varus, Pink for high degree of Forefoot Valgus, and Yellow (my wife Pat) for a Neutral to Slight Varus forefoot to rearfoot relationship. 

Here are these 3 feet seen from the back of the heel. These represent the negative cast which were taken of three left feet. The Orange cast of a high Forefoot Varus deformity shows the heel collapsing into valgus to get the front of the foot to the ground. The Pink cast of a high Forefoot Valgus foot type shows the heel falls into varus to bring the forefoot to the ground. The Yellow cast (my wife) represents the more Neutral Forefoot to Rearfoot showing the heel position more near a vertical position. The orange and pink foot types are simple to analyze and correct and untreated can lead to devastating foot compensations and pain syndromes. 

Here is a blow up photo of two left feet positive casts. The one on the left shows FF Varus where the forefoot is inverted on the rearfoot. 20 to 50% of patients have this problem. After the foot lands on the ground, to get the big toe to the ground, the arch must collapse and the heel roll into valgus causing severe over pronation. The cast on the right (pink) shows a left foot of FF Valgus. This foot type must roll the heel out to get the metatarsal weight evenly spread and the foot stable. However, this outward roll of the heel, also called over supination, under pronation, or lateral instability, causes a very unstable foot. Try standing on the outside edge of your foot and see how stable you feel. The goal of orthotic devices with these 2 foot types is to get the feet balanced, centered, with the heel straight up and down. This is the goal for what is called Root Balance Technique. 

The Yellow cast of my wife's left foot shows a very Neutral foot. It is very stable. All the negative casts are poured with the heel vertical by propping up one side or the other to get the vertical heel position marked on the cast to be perpendicular to the top of the foot. This is the Gold Standard of Root Balanced Orthotic Devices, but can be your reference in other cast corrections such as the Inverted Orthotic Technique. 

This is a soft based orthotic device made directly off the uncorrected positive cast. By uncorrected, I mean no attempt was made to change the position of the foot. I will demonstrate in some of the upcoming posts, how simple changes to the positive cast correction can make powerful changes in the foot position. This soft based orthotic device is called an Accommodative Device and more correctly called a Hannaford Device (as first invented by Dr. David Hannaford).

External Hip Rotator Strengthening Videos

When performing external rotation exercises, which is a great core muscle group, and also very helpful if you excessively pronate, you typically want to avoid putting the resistance down at the ankles and bend the knee. As you get more and more resistance, the torque on a bent knee can be damaging. These 3 versions seem very safe.

https://youtu.be/gfHmUIuDmG0

https://youtu.be/SozJdHb10yM

https://youtu.be/wvJdiYHCg7k

Yoga for Beginners: Amazing for Strength and Flexibility

These videos were highly recommended by my patient. I think we all believe that there are benefits to be gained in yoga. These beginning yoga videos may just be the ticket for us to learn and have it enrich our lives. Start simple and go slow. Namaste (I bow to you)!!

https://www.bemoreyogic.com/videos/f/style-yoga-for-beginners

Sesamoid Injury: Controlling Inflammation while Transitioning from a boot

Dr. Blake,

Unfortunately, like many of the other readers of your blog, I have suffered a non-displaced medial sesamoid fracture in my right foot in November 2017. Since December 2017 I have been in a walking boot. A few months went by, and after making zero progress I started digging for more information and found this blog along with a bunch of other resources regarding bone health. Even though I knew I was getting more than adequate amounts of calcium each day, I started taking Vitamin D in March 2018 and my symptoms started radically changing, and the injury finally started to feel like it was 'healing'. To confirm my suspicion of low vitamin D, I ordered a blood test myself (via privatemdlabs.com, if any of your readers want to get one done without going to a Doctor) and found out my level was at 26 ng/ml. After finding this out, I increased my dosage, and I have been maintaining it around 50-60 ng/ml for about 3 months. 
Dr. Blake's comment: Thank you for the info on Vit D testing. 

Over these last 3 months, the pain has been primarily due to the inflammation and blood flow going to my forefoot, which I have been able to mitigate by keeping my foot elevated and icing it occasionally. I've done a decent job maintaining a 0-2 pain level as you suggest, and I feel like I am able to slowly transition out of the boot. At this point, I am able to (in the boot) put more weight through the ball of my foot simply because the inflammation is a lot milder than it was 3 months ago. My main question is, as I transition into a stiff-soled shoe with orthotics, what are the primary signs to go back into the boot temporarily?

Dr. Blake's comment: You have to maintain the 0-2 pain levels throughout. Look for patterns of what increases your pain and avoid for one month before retesting that benchmark again. As you transition from boot, you should ice twice daily whether or not you feel you need it, and contrast baths each evening. 

 During this transition period and after the transition period, is it common to have the area swell up still? I just want to get a good idea of how much inflammation I am supposed to expect as I transition into walking normally, and then transition into jogging and running months down the road.

Dr. Blake's comment: Swelling produced by an injury is a bell-shaped curve. Some people swell a lot and others don't. Swelling per say is not that important, but pain is. So, if it swells, but does not hurt, no big deal. But, the icing and contrasts and nonpainful massage are important on a daily basis. Good luck. Rich

Also, I want to say thanks for starting the blog, it looks like it has grown quite a bit and it is jam-packed with a ton of good information. I am making a donation for sure.

Thanks,

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I came across your blog while researching fractured sesamoids. Thanks for all the great information! I wanted to tell you about my experience and see if you had any additional insights int my condition or thoughts about my treatment thus far.   

I’m a 45 year old male and fairly active. I woke up in March with some pain and discomfort in my big toe. I wasn’t paying very close attention to it but my impression at the time was that I thought I had slept on it funny, maybe did something like hyperextend it in my sleep or slept with it bent back for a length of time that caused me to wake up sore. It wasn’t incredibly painful though, so I didn’t think too much of it. In fact, I sort of figured the best thing to do was to work and stretch the toe as I normally would. That day I did the orbital machine at the gym as well as some shadow boxing and weightlifting, all of which put pressure on the toe.
Dr. Blake's comment: In some ways, this is a good sign. You did something in the presiding 3-4 days that the big toe did not like, but it took several awhile for the swelling to collect enough for it to hurt when you got up. The morning is the classic time to hurt since all night long when you are still, the swelling from an injury has time to settle into the tissues. The pain is for the inflammatory part of the pain. The injury happened without you noticing it a lot, so maybe a good sign!!?? Can you think back to these 3-4 days? Did anything stress the joint out of ordinary? 

I went to bed that night and maybe an hour or two after I fell asleep, I was awoken by excruciating pain. Throbbing, sensitivity etc.. I took some anti-inflammatories and iced it but could barely sleep. I hobbled to work the next day and taped my toe to restrict the movement of the joint for, what seemed to me, maybe some sort of turf toe but I did not see a doctor at that time. The taping helped and the pain subsided over the next few weeks. I was able to do yoga and box and was in a little discomfort but not bad pain.

Dr. Blake's comment: Again, good sign!! Most joint flares, if arthritic, occur over 4 days to 2 weeks if you are treating the flare-ups. They can last longer if you choose to ignore or to select inadequate treatments. We do not know what you did, but this pain is still inflammatory and not the injury itself. Inflammation is the response of the body to heal. You are trying to heal something? Perhaps it is gout or arthritis? Have you had recent uric acid levels? 

Maybe 5 or 6 weeks after that episode ( after 2 long intense bike rides which definitely put pressure on the toe and another intense workout) the toe pain came back and I was again having trouble walking. At this point, I found a podiatrist and went in for an appointment.

He took an X-ray which didn’t show anything and said his hunch was that it was gout, but that he would send me for both a blood test and an MRI. I also was given a 5 or 6-day pack of prednisone anti-inflammatory steroid.

Dr. Blake's comment: The thought was good. You do not want to take prednisone, even NSAIDs if you are suspicious for bone injury. Do not make this your way of handling bone/joint injuries in the future. 

The steroid cleared the pain up very quickly. I was hopping around barefoot and everything seemed good. The blood test came back before I could schedule an MRI and the uric acid read 8.1 which all seemed to point to a gout attack.

Dr. Blake's comment: First, do you know what the range is of normal for this lab. Please send. Gout attacks can occur with high uric acid when trauma occurs. So, just because there was a possible gout attack, you still could have a stress fracture that caused inflammation that sparked the gout attack. A twofer!!

When the course of prednisone was over, the pain came back with a little swelling. I was then able to get the MRI, which showed a comminuted fracture on the medial sesamoid. 

My podiatrist put me in a darco low top shoe with a few cutouts to isolate the sesamoid and told me I’d be in that shoe for 4 weeks. From everything I read that seemed optimistic and sure enough, I'm at the 5-week mark now and after an appointment yesterday, the doctor suggested 2 more weeks based on the fact that the area was sensitive to the touch yesterday. He says that progress is really just based on clinical diagnosis of comfort. The problem with that is, the more I try to give the area with attention, massaging and movement, the more sensitive it is after. 

Dr. Blake's comment: Here I will comment on the some of the images you sent me. First of all, when you use Prednisone, you should ice for 10 minutes three times a day after for the next 2 weeks. This helps to make the effects of the Prednisone last longer. 

Noting the inflammation in the first metatarsal above the sesamoid

When you push down, the sesamoid can push up against the first metatarsal causing injury. The arrow points to the darkened or inflamed first met head. This is a stress reaction, bone bruise, or stress fracture of the first metatarsal head. The stress fracture can actually heal much faster than the others!!

This image shows that the bone edema of the first metatarsal head is the most significant injury, not the sesamoid. 

This is not a fracture, but a bipartite sesamoid with a smaller piece nearest the toe. It looks a little inflamed in this view. What is also interesting to me is that the joint is not really inflamed. Gout usually shows intense inflammation, another reason to get the MRI when things are still inflamed (not being drugged up!!)

I wear the darco shoe whenever I’m outside but mainly I’m trying to stay off my feet and not walk a lot as the darco alters my gait enough that it’s uncomfortable for other parts of my feet, knees, etc...

Dr. Blake's comment: As long as you have something with a dancer's pad to off weight the sesamoid area, various the stresses with stiff soled mountain bike shoes, anklizer removable boots, Hoka One One shoes, stiff hiking boots. You must maintain the pain at 0-2. You should spica tape and cluffy wedge. You should get an Exogen bone stimulator for the next 9 months for the first metatarsal, not the sesamoid.

I still go to the gym but am doing the stationary bike in a way that puts no pressure on the upper foot or other exercises that do not involve the foot. When I'm home I’m barefoot but I walk on my heel and side of my foot and don't ever let the sesamoid hit the ground. 

I also got an exogen bone stim and am using that twice a day along with calcium supplements. 

Dr. Blake's comment: At home, try the Oofos sandals as house slippers. Hopefully, you can put down more normal weight. It is okay to put a dancer's pad in the oofos. Get your Vit D levels. Any osteoporosis run in the family? Bone health may be the issue in any bone injury. Consider a bone density screen if your diet is irregular, or chronically low Vitamin D, etc. 

I am trying to massage the area a bit and introduce a little motion to the joint but the times give done that, there is pain and more swelling the next day. My thought is that it should be ok to bend the big toe down but that I should not flex it up as that would pull the tendon tighter against the healing bone. Is that right? Yes

I’ve read about people in casts and much more restrictive boots for a fractured sesamoid. Is the darco shoe not conservative enough? I will say that I do not put pressure on the sesamoid nor do I flex the big toe when I’m walking. 

Dr. Blake's comment: You have to do whatever to create the most normal gait with a 0-2 pain level. I love also having three possibilities for shoe gear to alternate because you never really know if something is working if you are only trying one. See my comments above. The bike shoes and anklizer are both about $50 each (if you look around). 

Any insight or suggestions you have would be really appreciated! I'm a little unsure of my podiatrist's ability to provide nuanced advice based on what I’ve experienced thus far and if I don't get this healed properly I won't be able to work. I’m also unsure of his approach in taking additional x rays to monitor progress when an x-ray did not find the fracture in the first place.

Dr. Blake's comment: Definitely, you can go on symptoms, and then repeat the MRI if needed in 6 months. Hopefully, you do not need to. Follow up xrays could be taken once, and if it shows no change, it verifies that it is not the sesamoid. Also, if your symptoms keep flaring, consider the CT Scan which just looks at the bone to see if the bone injury is subtle or more involved. However, if it shows a change, then the sesamoid is more involved. Good luck. Rich

thanks a lot

I'm attaching some frames form the MRI as well as the report form that MRI:

"There is nondisplaced probably comminuted fracture involving the medial sesamoid with associated diffuse bone marrow edema within the and focal edema within the articulating plantar metatarsal head. There is trace focal edema within the plantar aspect of the lateral/!fibular sesamoid. The intersesamoid ligament and bilateral sesamoid phalangeal ligaments are intact. There are thickening and heterogeneity with a linear increased T2 signal at the origin of the medial collateral ligament (series 6, image 11). The joint spaces and alignment are maintained. The articular surfaces are intact. There is no aggressive osseous destruction. There is no joint effusion or synovitis. 

Tendons: The visualized extensor/#exor tendons and ligaments are intact. 

Miscellaneous: Ill-de!ned soft tissue like signal intensity within the second intermetatarsal web space possibly represent small neuroma. Plantar plates are intact. There is no abnormal signal in the musculature to suggest atrophy or denervation. The subcutaneous tissues are unremarkable. "

Dr. Blake's initial response:

     Thanks for reaching out. I will work on my comments over the next several days. I would definitely get a CT scan since the bottom of the first metatarsal looks injured above the sesamoid. Rich

The Patient's Response: 

Hi Dr Blake,

Thanks for the response on your blog. Here are my responses to your questions :

I can't recall anything specific that I did to the toe in the days immediately before the first symptoms but I suspect that I sometimes exert a lot of pressure on that toe area when I ride a bike so perhaps that is related. I had definitely ridden that week. I will be mindful of my technique in the future and perhaps get different shoes for riding.  

I do have a history of low vitamin D and had taken extra vitamin D in the past but not faithfully. in 2016 my vitamin D was 22.6 when normal range was described as 30-100. Clearly, a possible culprit here and I wish my primary physician had described the risks of low vitamin D. There is no history of osteoporosis that I know of. 

Dr. Blake's comment: This is such an epidemic, and at your age of 45, I would get the Vitamin D level, and a bone density test. These can change the course of treatment if abnormal. 

I think my podiatrist gave me prednisone because his initial thought was that it was gout. It seems like it was either was not gout or it was a secondary ( first time) gout attack brought on by the bone injury. The lab says that uric acid levels up to 8.5 falls in the normal range but elsewhere I've read that one should really keep them below 8.0. Mine was 8.1 at that time. The MRI was done about 11 days after my initial visit and 6  days after the prednisone schedule was over ( also about 7 weeks after the initial pain) and I was walking with some, but not major pain at that point. 

Dr. Blake's comment: In gout attacks, which can be brought on by trauma like breaking a bone, the uric acid levels in your bloodstream drop over 1 point. So, if you were 8.1 in a gout attack, you were really running at 9.1 to 9.6. The key now is to retake the uric acid one month later and see what is happening. If you are still 8.1 then you just run high, but if you are 8.7 or higher another gout attack is in the making. 

http://www.drblakeshealingsole.com/search/label/Gout%3A%20General%20Treatment%20Thoughts

I realized I probably have a bipartite sesamoid but are you saying you don't see any fracture in the sesamoid?

Dr. Blake's comment: From the views I see, there is evidence of bipartite, not fracture, although the bone is bruised. The main bone problem is in the first metatarsal head, and it treated the same as a broken sesamoid. It is the sesamoid pushing on the metatarsal that causes pain. This will take a while to heal. 

Here the tibial sesamoid lights up on T2 imaging meaning it is bruised. This is not the intensity of bone inflammation you typically see in a stress fracture. The uniqueness of this situation is the bone edema in the first metatarsal head signifying arthritis or stress fracture. The sesamoid pushes up right on the inflamed first metatarsal.

I've been slightly altering where I line up the Exogen bone stimulator. Sometimes under the sesamoid pointing up and sometimes more on the side pointing toward the joint. Is there a specific place you’d recommend to address the metatarsal?

Dr. Blake's comment: Since it has a 3 inch penetration, you can place on top of the metatarsal head and then walk around and multi-task. But, where you are putting it (bottom or side) is closer and either are fine. 

How do I know when I can start flexing the toe and pronating again? I dont want to inhibit the healing process or cause any further damage but am anxious to get everything working again in a way that wont make it worse. How will I know when I can put normal weight on the sesamoid without a pad? 

Dr. Blake's comment: This is the typical rehab question for any injury as we increase activity. It is important to make one change at a time, and probably one month apart is safe. Most athletes with this stay with the mechanical supports well into their athletes, and when they have leveled out the activity, start lessening the things that helped them get there. With sesamoid injuries, you can have cluffy wedges, spica taping, rocker shoes, orthotic devices, dancer's pads, etc. You have to stop one at a time in a logical order when you are doing all your activities and feel you are healed. 

I think/hope I am almost ready to segue out of the darco boot but how will I know for sure? I had bought some hoka one one bondis last week so I will start with them with a dancers pad. 

Dr. Blake's comment: This is how us rehab people find out what people need to move forward. What does it take to achieve a 0-2 pain level while we move the patient back towards a normal existence? If I had 100 patients at one time with the same injury, they would all be slightly different in their needs. There are general rules, but each individual has to be individualized. 

I went to the gym a few days ago and made a sesamoid relief platform so that I could work on my balance and address atrophy in other areas of my foot. It felt great and contrast baths helped with the swelling afterwards.

Below are the pics of the ( very simple) workout platform and some additional MRI images just in case they show anything additional.

Thanks again!