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Wednesday, September 10, 2014

Sesamoid Injury with Complex Regional Pain Syndrome: Email Advice

Good morning Dr. blake hope you are doing fine .
Thank you a lot for your help ,
Just wanted to update you regarding my algodystrophy (aka complex regional pain syndrome).
Sorry for the long mail .

I did a new X-ray which shows some areas of bone demineralization in my foot “ including some small stripes on the sesamoids”  unfortunately they didn’t give me a CD so I cannot send them to you.
The MRi didn’t show demineralization “ doctor said it’s normal in algodystrophy”
I have the synovial fluid of 4 mm under second metatarsal but doesn’t seems to cause any pain , and doctor suggested it will disappear on it’s own.

I did very good progress after 2,5 month , so now I feel my pain is mainly mechanical ‘ from bone loss” no more nerve issue I guess.
And I did a lot of efforts to relax , since there’s a real relation between pain and stress or anxiety.

Acupuncture helped me a lot , it also removed the inflammation from the sesamoid area like magic from the 2nd session.
and swimming was also beneficial.
I have reduced now my smoking habit. And trying to quit , I know this is bad for blood flow.

I can spend now an “ almost “ normal life with the help of orthotics and 2-3 Advil per day
My pain level vary between 2-3- and maximum of 5-6 – but I keep walking sometimes even with pain , since the doctor told me it’s better for bones to heal faster.

I started to feel now that I might be , from the lucky guys who will finish algodystrohy  within 6 month time frame. Still have 3.5 month So I cross my fingers.

I am mostly worried about the sesamoids areas , it is the place where all this hell started for me , and it’s the most painful site in my algo as well.
 the original tendonitis injury seem to be gone as you predicted ,
but I was wondering how long it would take for these sesamoids bones to be normal again and make mineralization.

I am afraid to live all my life in orthotics as sesamoid are very stubborn , and I read all those “ horror stories online about people stuck with this hell”
 Since my original tendonitis 10 month ago , I have tried several brands and went to professional people for custom made.. bought a lot of shoes..ect
Orthotics always coz discomfort in other areas of the foot as you know , the stress from this issue made me so anxious for 9 month and  This is what launched my regional pain syndrome I guess.
and I work in outdoor sales , so life is not fun at all with orthotics.

You told me to wear orthotics full time , and I am doing that now , even  at home
Only take them out for the shower or for the pool,

I now wear Reebok easy tone  with custom made orthotics , that what I found most comfortable.
but I hope if you can give me the name of a brand that makes  classic and formal shoes for men ideal for sesamoids.
Since at work I am supposed to wear a suit with tie and now obliged to wear jeans , I tried MBT but couldn’t balance in it and felt like wearing ladders.
this would help a lot to have something similar to easy tone but formal or classic.
Any other advise for shoes is great.

If I need a bone stimulator and I am abroad and cannot have a doctor prescription here , how we can arrange to buy it ?
And If I do buy them ,  how this would affect my healing ?

I appreciate your help

Dr Blake's comment: Thank you so very much for your email. Ebay does sell bone stimulators, but I would call Bioventus company and explain your situation. Patients do get them without an Rx online, but someone typically has to help you with an RX. I am glad the neurological part is calming down, but be careful of producing pain over level 2. I wish I could convince all my, and other, success stories that heal their sesamoid injuries. It not only happens, healing occurs in the vast majority of cases. Orthotics also are part art part science. Forces on the foot are very hard to predict and the orthotic prescriber has to be very good at the art part of it. There are so many dress shoes that have removable inserts that fit a version of the orthotic that you have. But, that is the direction, dress shoe with removable/replaceable insert that you should evaluate. I hope this helps. Rich

Tuesday, September 9, 2014

Tight Achilles Tendons (aka Equinus) and its Consequences

Tight Achilles Tendons and their treatment is a common part of a podiatry practice. This extensive article highlights it's problems, although perhaps too much for my blog. If you know you have tight calves, or have been told that in the past, begin 2-3 times daily stretching as my video below reviews. For Equinus (yes, horses run on their toes), is a sometimes silent cause of many many lower extremity, even back, conditions.

Achilles Tendon Ruptures: Conservative Treatment with Casting

When I treat Achilles Tendon Complete Ruptures without surgery, prolonged casting is necessary. This article implies that weight bearing casting is probably actually better than the dreaded 6 weeks of non-weight bearing casting I presently use. See the link to my blog below the article.

Sunday, September 7, 2014

The Aging Process: A Good Laugh at the Inevitable

We all have our stories about aging, seemingly no matter what age we are over 18. As I slog through the early 60's, and wonder why I am not being picked for the basketball team, I need to get perspective. A little humor goes a long way and this video sure helps let me know that I am not alone. Thank you Joan for sharing this. Rich

Plantar Fasciitis: Email Advice

Hi Dr. Blake,

You were referred to me by a physical therapist here in SF I was seeing for a while for what I think I have is Plantar Fasciitis.  

I do quite a bit of walking and used to jog periodically until this pain developed in my left heel approx. 1 year ago. Over that time, I've seen two different physical therapists including a podiatrist in San Luis Obispo and all pretty much concluded the same diagnosis.  However my new PT seems to feel since I did suffer a severe sprain in the same foot a few years prior that I have scar tissue remaining from injury and possibly even a torn ligament that might be the root of problem.  She recommend I get x-rayed and that's how you came in to the picture.  

I'd be happy to get further evaluated by another person, however my issue is I've already spent well over a thousand dollars in doctor visits and I'm pretty much at the same discomfort as when the problem first arose.  I have insurance, but a 5k deductible, so any expenses for this I'm paying for out of pocket.  

Therefore before I schedule appointment, wanted to ask if you think an x-ray would even be able to determine if I have a torn ligament or do I need something more in dept like an MRI?  Also, because I'd be paying cash not going through insurance is there any break I could get, and if so what would be the cost for exam/x-ray?

Lastly, I did some research and found a company online  There were two particular products that when I called in the rep said they've had very high success rate with especially if used in combination: Plantar/spur Inferno wrap and Ultrasound therapy system.  The combined price for both these products with tax is just over $200 which is fine, IF IT WORKS, but hate to spend additional money on something that is a novelty with little or no results.  Are you familiar with this company/products or any products in particular that could aid in healing my foot if in fact I do have just the plantar fasciitis and not additional issues?  Also, do you think either of these products would help with healing scar tissue or a torn ligament if it turns out I have that as well?  

I'm anxious to get resolution to this ASAP.  I'm a physically active person and although this has not been a "debilitating" injury/symptom, its definitely hindered my abilities to do the things I enjoy pain free. 

Look forward to your response, thank you.

Dr Blake's response:

     Thank you so very much for your email. Plantar fasciitis rarely lasts this long, and can not be diagnosed by x ray. You would need a MRI. If you saw a podiatrist, or your family doc, a RX for Rearfoot MRI could be given to you and then you could call around to the hundreds of local facilities for their self pay rate. Without a diagnosis, and physical examination findings, it is hard to recommend anything to you right now. When you come to my facility, within Saint Francis Hospital, your current insurance will be charged an office visit and facility fee. Even with your deductible, your insurance will tell us what you owe. We can not do that. If it helps, my standard new patient office visit code is 99203. If it helps, you can go to the label section of the blog and open up the Playlist for Plantar Fasciitis.  Hope this helps. Rich

Achilles Pain: Possibly from the Low Back

Hello Dr. Blake.

 I attempted to post this as a comment in your blog, but I was unsuccessful. I hope that this email finds you well. I have been dealing with achilles pain since March. I believe it started because I was putting all of my weight on my heels when doing the elliptical, to avoid stressing an injury I have on my forefoot. I have tried PT and it did not work, the therapist kept telling me that all the exercises that make patients better were working the opposite on me-making me worse. The exercises included the type on your blog, the eccentric calf exercises. No negative heel drops. I am wondering if I have no relief because I have an over stretched tendon. The calf stretches and exercises replicate my pain, I have no relief from them. The pain that I get is exactly the pain created when I bring my entire foot upward toward my body (picture a negative heel stretch but without weight bearing). I had an MRI which showed a normal tendon, with some non specific swelling at the heel. The pain started bilaterally, but now, the right side is much worse and the left has improved. I have completely rested from all activity for months. Still nothing. Heel lifts work a little. I can't even sleep on my back because my own body weight is enough to cause pain on my heel. Could you please share some thoughts on treatment of an over stretched tendon? Thank you so much! You are an amazing resource.

Dr Blake's comment:

    You could have an overstretched tendon that the PTs should be able to measure, but it sounds like radiculopathy which is localized nerve pain below the low back. Stretching of the hamstrings and calf make radiculopathy worse. Sometimes, MRI of the back can help. I would see a chiro or physiatrist to help the PT develop a plan. When you held your heels back, you probably also could have hyperextended your knee causing the problem. Any postures, movements that effect the sciatic nerve can effect this problem. Try ice packs 2 times daily to the low back and neural flossing 3 times a day (seen on my blog), but avoid calf and hamstring stretches for the next 6 weeks. Keep me in the loop. Rich

Saturday, September 6, 2014

Never Say I Can't

Bunion/Metatarsal Help with Hapads

Please send me more info on your felt pads for arch support to aid bunions. Thank you 


Planning on Hiking this Fall/Winter with your Orthotics: Product for Waterproofing Orthotics!!

Another brilliant idea from my patient Dan!!!

External Hip Rotator Strengthening: A Great Help for Pronators and Patellar Tracking Problems

The video that follows is an example of the hip position for runners and walkers to strengthen the external hip rotators. These muscles, when weak, increase the internal rotation at the knee leading to patellar tracking problems like Runner's Knee, and increase the pronation force at the foot with all those problems. Like any exercise it must be done pain free and in the position of the activity to strengthen for that activity. This is a reason I do not like the Clam to strengthen the external rotators since the hip and knee are too flexed. This standing version can be done without the bands near the ankle, and can be done with less hip flexion and less knee flexion. If you have knee pain, and you want to strengthen the external hip rotators, try to have your knee as straight as possible. You do this exercise every other evening and 2 sets of 10 reps. When this gets easy, advance gradually over a 6 week period to two sets of 25 reps. I hope this helps. 

Wednesday, September 3, 2014

Bunion Surgery Complication: Hallux Varus

Dr. Blake, 

I had a bunionectomy 12 years ago when I was 18 and now have a rather prominent hallux varus on my RT big toe.
Dr Blake's comment: Hallux Varus is where the big toe points towards the other foot and away from the 2nd toe, and definitely a significant complication and shoe fit nightmare.

 I honestly didn't know that this was what my condition was called until recently and thought for years that the space was normal aftermath of some bunion surgeries. I am concerned now because I have recently noticed some friction while walking in between my 3rd and 4th toes and I am unsure if this is related or not.
Dr Blake's comment: Probably only related because the destabilization of the big toe joint is leading to changes in the rest of the foot. 

 Also, knowing that my condition is not necessarily a normal expectation from my surgery, I would also like to find out if I can do anything non-surgical to correct the problem given the time lapse since surgery. If you can provide me any suggestions or insight into what might benefit me, I would greatly appreciate it. 
Dr Blake's comment: Where you can not tape the first and second toes together (may function differently), you can try to develop the adductor hallucis muscle which pulls the big toe towards the second. Please review the metatarsal doming video, and send me a short 30 sec vid of you attempting this seen from in front of you. I can then instruct you on how to modify to get the adductor hallucis. 

Just to let you know a little about me. I am a healthy mom of 2 and not looking to or able to have surgery due to my children's ages at this time, but if that is a path that I may need to travel down in the future could you tell me what those indications might be as well. Thank you again.
Dr Blake's comment: I can not imagine someone attempting shoe buying with this, so perhaps yours is very very mild. Please send a weight bearing picture of both feet to see the difference. Rich

Amy (name changed due witness protection)

Forefoot Pain: Sesamoid or Nerve or Both

Hey Dr Blake, 

Through my despair yesterday I stumbled upon your blog and I must say I am so glad I did. I really wanted to e-mail you though, I hope you don't mind.

I'm a 23 year old female who hurt my foot 3 years ago! I literally stubbed the inside edge of my foot, just half an inch under my first metatarsal head. I never got an X-Ray but I was in agony for about 3 months, my local doctor told me it was just a "BAD bone bruise". If say the pain dissipated about half a year down the line and slowly but surely I got back into my fitness which I loved so dearly. 

For these 3 years pain in my big toe joint had been on and off, the pain itself is felt at the base of the head, sometimes on top but mostly behind but at the outer edge (there it is like a niggly/twingy pain that gets worse with activity) I get pain whenever my toe joint is in a bending push off position..and it ALWAYS clicks, that's recently got worse.
Dr Blake's comment: The niggly pain is nerve, as the biggest nerve in the front of your foot runs right there. It can develop into a condition called "Joplin's neuroma", but the nerve can be irritated and angry from simple internal swelling. The clicking means that there is swelling within the big toe joint, signifying some problem in that joint. 

I saw a private podiatrist about 2 years ago now who got me into Orthotics as she noticed I pronate and had "flexible flat feet". She disposed (diagnosed) me with Hallux Limitus. These helped somewhat, a lot.
Pain would go away for a couple months only to come back if I increased my activity or wore heels then I'd suffer with the pain and swelling for another month. 
Dr Blake's comment: Hallux Limitus is caused by many conditions, and you seem to have a very sensitive big toe joint. X-rays and MRIs are usually needed to help discover what you did to yourself 3 years ago. 

I went to see my doctor who thinks it's a sesamoid issue, so I get my X-Ray results on Fri. My podiatrist recently gave me acupuncture which kind of helped but I found the procedure painful. She also said I should go back in a month and we'll talk about seeing an Orthopaedic for a surgical outlook and also a steroid injection.
Dr Blake's comment: This is all right except I would avoid invasive (even shots) until I knew the diagnosis. Let me know what the x rays showed. 

My arches are also so tight and when I do strengthening exercises it hurts alot. The toe joint is really swollen, mostly on top but icing makes it so much worse, specifically that niggly feeling on the edge underneath, which makes me worry that it is a sesamoid issue. 
Dr Blake's comment: Nerves typically hate ice, so try some version of contrast bathing (see previous posts). Icing typically cools the joint, but does not move swelling out of an area like contrast bathing. Where the initial contact was sounds sesamoid. See if you can get the results of the x-rays to me, and possibly get an MRI. 

I'm just at my wits end because I'm so young and meant to be starting uni this year but exercise means, namely walking, but it hurts too much now and I seem to be compensating with my other foot and my other toes, I would swim but it flares up my acne and also makes my feet too cold which makes my toe sore.

Any advice would be grateful,

Sara (name changed to protect the innocence)

Multiple Sclerosis Patient: Email Advice

Good morning,

I just discovered your website. Thank you for offering an email to ask questions.

I am a 49 yr old female, diagnosed with MS exactly 1 year ago.   My main problem is spasticity in my legs.  Calves are the worst, very tight.   I tend to turn my left leg-foot outward slightly when I walk.  I don't believe I have foot drop.   Looking at my shoe pattern, I can't tell. Perhaps I could send a photo for you to view.

I found a website for a shoe designed for weak spastic legs and I was curious if you were familiar with it.   The website is outdated and options appear limited.  So I'm a little cautious but if their claims are valid, it might be my answer.

When I discussed footwear or brace options with my neurologist 6 months ago, she said she was more concerned about controlling the spasticity and if that was possible the feet wouldn't be so affected.  I consistently have high tone, hyper-reflexia and ankle clonus 4-5 beats.

I am trying different prescription strengths of baclofen but it's not very successful. So...I am due for a new pair of shoes and my legs, calves, and feet hurt enough that I decided to research my options.  I welcome your thoughts and advice.

Thanks again for your time.

Dr Blake's comment: 
     Thank you for you questions. No, I am not familiar, but I called the number and spoke with Curtis. He was very kind and explained the concept. The shoes on the website are all with the same heel height and rocker. The heel height is to bend the knee and get the weight moving forward (if you have a tendency to hyper-extend your knee). So, it is great if you have knee hyper-extension (too straight) than excessive knee flexion to begin. It does rob you of some of your proprioception (balance), so poles could help if you have some loss of sensation. He loves to work with physical therapists or physiatrists who seem to have the most knowledge on MS. They start you on 30S (see picture of the 30 style) with the open toe, because it can test the style, and is one of the best for a variety of shoe widths. He says he has a liberal return policy, so probably worth a trial. Even if it does not work, having a PT figure out why, can help in the selection of other shoe types. There has definitely been an explosion of variety!! Hope this helps some. Rich

Here is a post from a fellow sufferer of MS--I like his style.

I also like the approach in the next link where closer to the ground is better.

Monday, September 1, 2014

Slomo: A Soul check for us all

     I have been asked why I write my blog for hours and hours on sunny days or late into the night. Part of the answer lies in this very well done video on a doctor that simplified his life to save his soul. This blog is more from my heart and soul than anything else I do in medicine, because it is pure. A pure gift without expectations of rewards. It allows me to get off my treadmill of chaos and deadlines, and just be with the act of giving.
     The video explains that this doctor had to save his soul or materialism and bitterness and depression would have got him. He had to do something big, but individual, and right for him. He had to do something "soulful" which always brings you peace, joy, and happiness. In the video, you can see the true joy he receives. Contrary to majority opinion, it is not escaping life, but living life robustly.
     I work hard, and have some materialistic tendencies I fight, but I try to find what brings me peace, joy, and happiness to stay centered. When I am not centered, I am unhappy. I have been centered enough in life, that I feel terrible when I am not.
     Some of you know I love basketball. It is a game I have played in 7 decades, so it is the only remaining activity of my long ago youth. Playing basketball, as I did this morning, makes my heart sing for joy, even when I am not wearing my iPod. I do not have to visualize my childhood, one or two dribbles and I am transported back 50 plus years ago.
     My best friend is my wife. Being in medicine, and working long long hours has not afforded me many long term friends. Alot is my fault, but in reality, it is really my choice. I have willingly chosen to dedicate my life to my best friend for the last 42 years. She is my soul mate, my companion, my heart and soul. I would rather be with her, or my children, than anywhere else.
     So, I will not start the San Francisco version of Slomo. But, I will take his incredible insights, and continue to find my soul, and keep my soul healthy. I will continue to ask when confronted by opportunities, is this something that will help my soul and bring more love and health and peace into this world? If the answer is yes, I may be adding a new skill.

Sesamoidits: Email Advice

Good morning Dr. Blake
Hope you are doing well . I wish I can travel to meet  with you as I know you re the most expert in these fields.
I have emailed you few month ago regarding my chronic ( 9month) sesamoiditis , maybe was a result of my hallux limitus.
That was later developed to algodystrophy (aka reflex sympathetic dystrophy).
I have waited for the MRi results so I can send you a better picture , I hope the pic below is fine. Sorry for the long email

Displaying photo.PNG

The Mri results mentions only two anormalities :
·         A small kyste synovial of 4 mm in second articulation metarso-phalagienne( sorry it’s in french I am trying to translate)
·         A small ostheophytose in the first arcticulation metarso-phalangienne.
·         The report mentions nothing regarding the sesamoid bones although I am in pain. ( can you please check the picture attacehd if they are fine coz one seems not that healthy for my eyes)
Dr Blake's comment: I agree that the sesamoids do not look perfect, but that would be accepted if you are getting some bone remoldeling with healing. It is the 2nd joint with the cyst plantarly and some soft tissue reaction that looks the most involved at present. Does it hurt on range of motion of the 2nd joint, or palpation of the 2nd metatarsal head? The sesamoid injury which started, developing the algodystrophy, may be healed by now. See if you can send the T2 image of the same view where the bone is dark and swelling shows up bright white. 

Here are my symptoms :  I have nothing of the usual algodystrophie symptoms you usually read online , such as changing in skin colors , nails droping or hair loss…ect
My bad foot even looks 98% as my good foot , don’t have any swelling or feeling of heat..
but I have sharp pain in my sesamoid after walking 10 min max without orthotics.
When I wear orthotics pain increase in my heel.  When I don’t pain incresae in the sesamoid area ( so basically I am lost here)
Dr Blake's comment: Why do you think the orthotics give heel pain? Can that be remedied? Maybe the orthotics need more padding in the heel or a slightly different design. This seems crucial to getting you well. Try if some Hannaford version can be made for you. I would have 5 different pairs with different qualities if needed to experiment since this is so crucial to you. It is not unreasonable to be in the orthotics full time for the next 2-3 years as the bone continues to heal the sesamoid. 
For the last two month or so I have been swimming or biking on daily basis ( biking with orthotics to avoid pressure on the sesamoid , I don’t know if you recommend)
Dr Blake's comment: Definitely, biking, swimming, elliptical, typically are great if you can avoid bend of the toe and excessive weight on the sesamoid. 

I appreciate your recommendation regarding my case , since I so down lately with this hard case.
Note that I cannot affoard a bone stimulator since it’s not covered by insurance here “ I don’t know if it’s needed”
Dr Blake's comment: If the sesamoid on the T2 image is still very white then a bone stimulator would be wonderful. Once you send me that image I will place on this post. 
I was considering buying used ones on Ebay but I am not sure which ones to pick and if they are good or have high counters.
Dr Blake's comment: I love Exogen from Bioventus!!

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