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Sunday, April 19, 2015

Sesamoid Injury: Email Advice


Dear Dr. Blake,

     Firstly thank you for all of your support you give to this issue. When researching my condition I have found your website to be of great value. Mostly because I can relate to much to all of the other people dealing with such a tough issue.

     I was diagnosed with sesamoiditis about 8 months ago. I have tried every treatment I know of besides acupuncture, which I am putting my hopes in now as I have an appointment tuesday.

     I have a
bipartite sesamoid in my right foot. I had a hot spot in the bone scan followed by a CAT scan. Two doctors have agreed that from the scan that there is no fracture.
Dr Blake's comment: I always treat a positive bone scan as a stress fracture, since you have the treat the most serious problem, and CT scans and x-rays will not show the fracture itself (even when the bone is broken). 

    I have been in a boot for two months, tried rigorous icing and heat daily, anti-inflammatories (which I am not off for being on too long, plus they didn’t seem to do anything), dancer pads - minimal help, off the shelf and custom orthotics - little help there. Two cortisone shots - the second one worked for about 7 weeks. Then slowly back to square one.
Dr Blake's comment: The thing with orthotics and dancer's pads is that they have to shift the weight to the middle of your foot and off the sesamoid. If not, get them adjusted. Cortisone is to be shied away from because of the possibility that this is a stress fracture and cortisone can slow down the healing process. 

    I was a sub 3 hour marathoner and used to run ultra marathons and climb mountains for fun, so being stuck swimming laps is often a tough pill to swallow. Besides swimming and low impact activities and the once every two months a short run just keep sane- no long walks, no hiking, no mountaineering, very few casual runs. My podiatrist has stated that he is not convinced surgery is worth it yet and it may just heal.
Dr Blake's comment: I am glad your podiatrist is sane. At some point, get an MRI to see how much bone edema still exists in the sesamoid. If positive, then you also should be on a bone stimulator. It is great you are cross training and trying to create a pain free environment. 

    When discussing the idea he has brought up a partial sesamoidectomy stating that with my bipartite the offending bone is slightly smaller, so he should be able to take out half, hopefully leaving me with full function. He also stated under the preface “if you’re game” It would be an experiment, but trying a bone graft to join the two parts, but he wasn’t sure if this had been done or where he would take the bone from to graft it - does this sound feasible? Has anyone else done this?
Dr Blake's comment: If 6 months from now, only one of the two sesamoid pieces remained hot on MRI and you were still struggling, I would entertain a partial sesamoidectomy, but only then. Never heard about bone grafts across the fracture site. 

    I am also seeking a third opinion outside of the clinic which I go to. Is there a sesamoid specialist in the greater pacific northwest who has experience in this issue? It seems very difficult to find a podiatrist who has a great deal with sesamoid issues not that I don’t think they are out there, its just how to find them.
Dr Blake's comment: I typically recommend Dr Richard Bouche in the Seattle area, he is very smart and deals with athletes all the time. 

 My last question is the current surgeon I have been seeing has performed 50 or so sesamoidectomies, I have no idea if this is an adequate amount of experience? Is 50 a lot or a little...
Dr Blake's comment: After 3 or so you have good adequate experience, after that it helps fine tune the thought process on when to operate, and what to do post operatively. I hope this helps. 
If you’ve read this far, thank you for your time, any advice you can offer would be greatly appreciated. I would give anything to have my life back.

Thank you,

Saturday, April 18, 2015

Peroneal Tendon Injury: Email Advice

Dear Dr. Blake,
I am in my late 50s and fractured my os peroneum bone into several pieces along with tearing my peroneus brevis and longus tendons making a sharp turn, walking in my office.  I did not twist my ankle...I was just walking.  I would greatly appreciate any advice you have for me.
I stupidly delayed treatment for 5 months, but have now completed 10 weeks in a short CAM walker including a) 10 weeks of wrapping sponge and Elastikon tape around my foot, in front of the ankle (yet covering the os peroneum) and b) 7 weeks of using the Exogen bone stimulator twice daily.  The new Xray shows slight new bone being deposited in the area.  I am just starting the process of gentle stretching and weaning out of the boot.  Your website has really helped me (and others I am sure) now understand good pain versus bad pain, and how to wean into a shoe.
Dr Blake's comment: Your injury does not make sense. How could you fracture a bone and tear two tendons without a significant fall/sprain? "Something is rotten in Denmark" borrowing from Shakespeare. But you did injure something, and did not get it treated for 5 months, so you placed yourself into the Immobilization Phase. I would only be convinced of a os peroneum injury with a positive bone scan, or bone edema on MRI. Please email me with other info you have. 
Thank goodness I no longer have the os peroneum syndrome sensation of stepping on sharp rocks.  If you have time, I would appreciate your answers and any treatment suggestions that you have for me:
1.      Have you successfully treated os peroneum fractures?
Dr Blake's comment: Our surgeons have had to remove several, and several just stopped hurting with orthotics, etc. I have seen so few that I do not have a great understanding. Several I thought were not injured, it was just the inflammation from the tendon injury that made the bone look inflamed. You did the right thing getting the bone stim.
2.      Do you think that I should continue to tape my foot?  If so, what tape brand and where would you recommend that I apply it?  The recommended Elastikon tape around my foot in front of my ankle in the shoe is bulky, even with the new extra wide sneaker with a wide base.
Dr Blake's comment: I love this tape you get at www.supportthefoot.com. Get the small size. 
3.      I have a naturally wide foot.  I feel pressure from the tied sneaker being pulled over the os peroneum area.  Should I cut a hole in the sneaker so that it doesn’t rub that area?
Dr Blake's comment: I am afraid that that would lead to some instability. Get some 1/4" adhesive felt from www.mooremedical.com and place on your foot in areas that take the pressure off the sore area. 
4.      My podiatrist wants to firmly press along the tendon and broken bone every time I see him.  I am worried about aggravating or slowing down the healing process.  Should I be?
Dr Blake's comment: No, that does not come close to weight bearing stress. However, soreness from this problem will remain for up to 1 year longer than the injury, as the healing continues. So, palpable soreness is a poor way of judging healing. Gradual improvement in function, or lack of improvement, is a better way. 
5.      Does the bone stimulator help?  Can it hurt if I use it too long?
Dr Blake's comment: Unsure if it helps, since I am not sure what you have, but if will do no harm. 
6.      When will it be OK for me to wear 1” wedge shoes again?  Before I went into the CAM walker, I found that a slight wedge shoe was actually more comfortable because it shifted the weight off of that area of my foot.
Dr Blake's comment: You are gradually moving from the Immobilization Phase, through the ReStrengthening Phase, and into the Recovery to Activity Phase. You said that you tore some tendons, are you doing something to get them strong? MRIs typically show peroneal tendon problems when they do not exist. I would need more info on those tendons. You should be doing peroneal tendon strengthening exercises, and gradually introducing various shoes to see what works (start with one hour at a time). You really do not know how healed you are right now. Go easy. 
7.      Other suggestions?
Dr Blake's comment: I love orthotics for this, but the doc/therapist/pedorthist has to know about stabilizing that half of your foot (lateral one half). See my blog posts on supination correction with orthotics to give you some idea. Definitely, continue icing and contrast bathing daily to control inflammation and increase healing with swelling control. Good luck!!
Dr. Blake, thank you for taking the time to get back to me.
Gratefully,

And the patient's response:

Dear Dr. Blake,

Thank you for all of your good advice and especially for the reminder to go easy. I needed that.

By way of background, I should have mentioned that an MRI confirmed the X-ray finding of a fractured  os peroneum which is now in many fragments.  For comparative purposes, an X-ray of my good foot showed an intact os peroneum.  It was a freak injury where I was walking quickly and took a quick turn.  It felt like someone hit me in the foot with a bat.  Two radiologists independently confirmed the fragmented os peroneum, severe partial tears of the perroneal brevis and longus tendons and that the distal peroneum tendon appears thinned. Besides intense pain flexing my foot away from my body, I had the sensation of stepping on sharp stones with every step and weakness/the inability to lift my heel and go up on my toes on the one bad foot.

You have me thinking now that there is something rotten in Denmark.  It has been about 8 years since my last bone scan, and maybe it is time for another.  I have been practicing yoga barefoot for about 10 years.  Would flexing my foot at 45 degrees in certain yoga lunges  or downward dog poses put added strain on the tendons simply because I have an os peroneum bone?  What causes a tendon to thin?  I sure welcome any insight you have to help prevent this from happening again.

Still grateful,

Dr Blake's comment: 
     Thank you for the response and confirmation that we are dealing with an Os Peroneum Fracture. The bone is so buried in your foot, I have a hard time understanding how it breaks in the first place without a history of a fall. A bone density screen is great. Again, the peroneals get thinned and look bad on most MRIs even when they do not hurt (more mystery). How is the tendon function? Are you strengthening the peroneus longus and brevis? Rich

Post Cortisone Shot in CRPS patient: Email Correspondance


Dr Blake's comment: This patient developed CRPS after a cortisone injection for a neuroma. She has had quite a journey with many ups and downs. Calmare Pain Therapy has been crucial in her treatment to quiet the nervous system. This email was followup to a cortisone shot I just gave her to shrink down a Morton's Neuroma left foot now that her symptoms are not systemic, but more local. We both realize that the neuroma was producing a chronic amount of neural tension in her body, and needed to be somehow addressed. 

Dear Dr Blake: 
It went very well! The pain stayed away all that day till 5 pm (shot given around 10 am was a mixture of local anesthetic 0.5% Sensorcaine and long acting Cortisone Kenalog 10).

Since then I have had some minor flare, but less flare than with any other shot in the past (including pre-CRPS shots)! Only a few cruel "zings" up the leg, and locally increased burning in a 2-inch diameter around the injection site, and also strong burning in 3rd and 4th toes. But completely tolerable.

I think the flare is calming down today and by this weekend I'll be completely in the "benefit" stage of it. I hope it allows me to walk longer/farther and increases my standing tolerance too.

From my lay-person experience, I recommend the combo of Synera patch 30 minutes before injection (placed on the top and bottom of her foot)and a single 5 mg dose of Valium for anyone who has CRPS or you think is at risk of CRPS—just to minimize the sympathetic activation around the experience. Maybe add 10 mg of Nortriptyline the night before and the night after, for even more suppression of nerve pain, so that the CRPS cycle doesn't get started.

Thank you so much for all your care and expertise. You are the only person I would ever let inject my foot!

Would you tell me what drugs/dose were in my shot? (see above--1 ml of each). I am considering an occipital nerve root block next week, and the doctor wants to know how much cortisone I got this week to make sure it's not too much in my body (even though in a totally different place).

I'll report in next week to let you know the longer-term benefits of the shot.

With much gratitude,

Further patient comment:

     Hi Dr. Blake,

I am doing well now.

It took about two and a half weeks for the flare from the shot to calm down! Longer than I expected. But the amplitude of the flare was not bad, so I was not in cruel agony like in past years. 

So now I will see if I can up my walking tolerance even more, and/or begin to wear a shoe. The Oesh brand shoes do seem really good for neuromas, you might want to check them out. But my foot is still hypersensitive enough that I dread wearing any shoe. Still, I know it is not ideal mechanics to walk in flip flops—there is some constant toe flexion to hold the shoe on—so it would be better if I could wear a closed shoe, or at least a sandal with a strap around the heel, if I could find one with a comfortably cushioned footbed.

I just met with one of the directors of the pain dept at Kaiser to see if I could get them to buy a Scrambler machine, but there are all the same obstacles there. I'll let you know if I make any progress on that front.

Hope you are well!

Tuesday, April 14, 2015

Possible Sesamoid AVN: Email Advice

Hi Dr. Blake,

     I have been reading your blog for the last month and viewed several of your videos which has spurred a few questions. 

     My 14 year old daughter was diagnosed with AVN in the left tibial sesamoid (this means avascular necrosis or dying bone secondary to poor blood supply).  A bit of background; she is a competitive Irish dancer and sadly due to this injury just had to sit out on the World Championships.  Last fall she dealt with some sesamoiditis in the right foot which we treated and it resolved.  Both feet have bipartite sesamoids (naturally occurring sesamoids in 2 pieces), we know from X-rays.  The left foot started aching in late November and then was really bad in early January after she started back from Christmas break.  She went into a boot 1/15 for 3 weeks at the time the DPM was treating as sesamoiditis, when she started to work out of the boot in wk 4 the pain was the same so we had an MRI on 2/11 and the AVN was noted.
Dr Blake's comment: You can get an idea of AVN from MRI, but CT Scan denoting bone fragmentation is the best test, just more radiation.

   The DPM immediately tried to arrange for a bone stimulator and she wanted her immobilized again.  We also sought a second opinion from a pediatric orthopedic because teachers and family felt it was important.  She understood by the time we saw the orthopedic that Worlds was out, and we saw the MRI pic ourselves (clearly it was not normal to our untrained eyes).  She asked him what she needed to do to heal.  He said a cast for 3 wks non-weight bearing, then a boot for another 2 wks non-weight bearing and start an Exogen unit.  She was allowed to start weight-bearing last Thursday but we were traveling for Worlds so I had her continue with a scooter.  She is now walking in the boot and is not having pain.  In addition, she has seen a chiropractor during this time who has done some ART (Active Release Technique) for her left calf and arch and right hip and foot since it was getting the brunt with the crutches.  We were supposed to go back to the orthopedic this week, but knew he would not do any X-rays or MRI yet so I called and she is to start PT this week.  The PT can release her from the boot, and she’ll go into a carbon fiber plate and at some point back to activity.  She is chomping at the bit to get back, but very concerned she do it correctly so she doesn’t re-injure it.  My questions are:

1.      When should we expect to re-do an MRI to know if the AVN is turning around?  And why do you say, as did the orthopedic, MRIs, X-rays are delayed in showing healing?
Dr Blake's comment: The earliest for a new MRI is 5/11/15 or 3 months from the first. I personally like to wait as long as possible while following symptoms as I move the patient from non weight bearing to weight bearing with boot to weight bearing without boot to return to activity. The Exogen bone stimulator is a 9 month course, so you want typically 6 months before an MRI or CT scan is done. Do you have that patience? Most not, so use the 3 month rule for some idea of healing. X-rays only reflect the amount of calcium in an area. If that area is healing, the water content of the area dramatically increases bringing in nutrients, like calcium, making the area appear to have less calcium, thus poor healing, when actually there is more calcium with healing. It is just a percentage reader. You can increase calcium for healing, but with the increase water, the area looks like it has avascular necrosis or at least is not healing. 
2.      What % of your young patients heal from AVN?  Should we expect it will re-occur due to her intense foot pounding activity?
Dr Blake's comment: Young patients rarely have AVN problems due to their great bone metabolism. Unless you do not create a pain free environment (0-2 pain levels) as you progress her back to full dance, unless she has some dietary issues negatively influencing healing, unless you can not control the swelling with icing and contrasts, or forget to use the Exogen, she should do just fine. 
3.      We plan to have her use dancer pads when she goes back, though it will be difficult and change how her dance shoes fit.  Should we also do the spica taping, though I’m afraid it will impair her range of motion for dancing and possibly mess something else up? 
Dr Blake's comment: You have to just try. I love dancer's padding and spica taping for this problem. Remember every day she has had restricted mobility it takes two days to get that mobility/activity back. So, it is important to calculate for her the injury date to return to activity date starting date. If that takes 100 days, it will take 200 days from that point to get everything back. You go slow, conservative, and it typically does fine. With some tears for sure. 
4.      What type of shoe should she be wearing outside of dance?  Is barefoot walking bad?
Dr Blake's comment: Barefoot is the worse for the next year. You want a stylish shoe that she wants to wear, that has room for a dancer's pad, and allows for 0-2 pain levels. 
5.      How do we get her foot mechanics evaluated to see if she needs to learn different walking/running mechanics outside of dance to help minimize added stress?
Dr Blake's comment: I used to treat the entire SF Ballet. It took me a few years to really understand that what they did outside of class had a big influence on the pain during class. So, typically with sesamoid injuries, you are not just adding dancer's pads and arch supports to her dancing shoes, but all shoes and activities need to be evaluated. When you are talking about someone who is at the level of World Competitions, you need top sports medicine advice on all her shoes and activities. 
6.      Have you had any of your patients do dry needling for sesamoid/tendon issues?
Dr Blake's comment: I love dry needling for circulation and nerve hypersensitivity. If you can get it, do it twice weekly. Does it help more than contrast baths nightly, I am not sure. But, if you do both, and add the Exogen bone stimulator, you are doing your best to heal this. 
7.      In your opinion, when could she start riding a stationary bike?  She has not only lost lots of muscle in her calf but her hamstring and quad as well with the extended inactivity.
Dr Blake's comment: OMG, she should do this the day she injured herself for up to an hour daily. You can lower the seat of the bike a little, and place your weight of pedal in your arch. I hope this advice helps her. Rich

I do like the DPM we have seen though she does not see lots of high level athletes and the orthopedic is good too but we are rushed in and out - it’s difficult to get questions asked and answered.  So thank you so much for your blog and sharing your experience.

Kind regards,

Sunday, April 5, 2015

Ollier's Disease and Calcaneal Apophysitis: Email Advice

From Wikipedia:
Ollier disease is a rare nonhereditary sporadic disorder where intraosseous benign cartilaginous tumors (enchondroma) develop close to growth plate cartilage. Prevalence is estimated at around 1 in 100,000. Normally, the disease consists of multiple enchondromas which usually develop in childhood. The growth of these enchondromas usually stops after skeletal maturation. The affected extremity is shortened (asymmetric dwarfism) and sometimes bowed due to epiphyseal fusion anomalies. Persons with Ollier disease are prone to breaking bones and normally have swollen, aching limbs.

Hi Dr. Blake,

I am truly at a loss for my son’s pain in his rt. Foot.  The pain is in his heel and it just isn’t getting any better.  A little history… my son has Ollier’s Disease and has had two surgeries on his Rt. Leg.  1st surgery was May 2011 femur fracture, rod placement.  2nd surgery was leg lengthening and corrective alignment of knee.  The leg lengthening wasn’t exactly a success as he was growing bone too quickly which forced us to double up on the amount of turns each day to avoid the bone from growing together.  This caused him to have severe nerve pain, that lasted about a year.  He was taking Neurontin to control this pain.  He also ended up with stress fractures once he could walk but it was the nerve pain in his foot that was the worst.  He ended up still being short in that leg and continues to be about an inch short.  During this time, his rt. Foot was 2 ½ sizes smaller than his left foot.  Today he is only about one size different. Rt. Shoe is a 3 left shoe is a 4.  He also has an internal lift in his rt shoe.  He still has trouble going down stairs, he takes them one at a time vs. a continue flow.  He recently had to have surgery on his left arm they actually did a salvage surgery to save his left forearm from amputation creating a one bone forearm in Sept. 2014. He again had nerve pain and was put on Neurontin which he is still taking.  

On March 15th he was playing with friends being very active (which he really hasn’t been able to do) for about 4 hours.  He ended up coming in basically crawling because he couldn’t walk and started complaining that his heel really hurt with some pain on the top of his foot but mostly just his heel. There was no swelling, no redness, but it hurt to touch it and move it.  They were doing a lot of jumping as they were trying to make a big look out nest on top of a very large snow pile.  We took him to our local urgent care, they took x-rays and said they looked ok that it was most likely a deep, deep bruise and to stay off of it and rest it. 


  Three days went by and he wasn’t getting a lot of relief from the ibuprofen he was taking around the clock, icing it helped somewhat, but he was still pretty miserable.  I ended up taking him to Children’s in Boston where he is followed by two ortho doctors. He saw a Dr. on call, they took more xrays, and placed him in a boot.  He couldn’t stand the boot, he said it made the pain worse, he tried to wear it for short periods of time but it just wasn’t working.  The pain was still the same and not getting any better.  We went back to Children’s and this time they put him in a cast.  The cast was better but it still didn’t provide enough relief.  He was asking for pain medicine around the clock so I started thinking that it might be more nerve related.  We went back to Children’s yesterday and they took off the cast.  When they took the cast off he was in a ton of pain and said it felt better in the cast.  UGH!!!!   So, they ended up making a bi-valve cast so he can remove it and I can massage his foot.  He is absolutely miserable still, he keeps saying he just doesn’t know what to do and frankly neither do I.  We are going to be seen by the pain clinic at Children’s tomorrow and I’m hoping that you can give me your thoughts based on the xrays and my description.  Sometimes another set of eyes can bring something else to light.  This pain wakes him up at night, he has trouble falling asleep, he just wants to be a normal boy!!! 

PLEASE, PLEASE, PLEASE share your insight with me.  I would be beyond grateful for any advice and can be reached by phone or email.

Thank you & Warmest Regards,

Dr Blake's comment: Thank you so very much for the email. The heel looks normal on xray, but the pain from calcaneal apophysitis (yes, a normal injury) can be intense. The treatment is ice soaking 20 minutes (heel in the ice bucket only, not the entire foot) 3-4 times a day since the pain is primarily inflammatory. These growth plates stay open in boys until 14, so he could have a few episodes. You ice 3 days longer than you need to with each episode. After 5 days of icing, let me know what is happening. You should be aware of Calmare Pain Therapy for nerve pain. Go on their website, I am not sure if there are age restrictions, but it can be used on any part of the body, and it non-invasive. Hope this helps some. Rich

Hallux Limitus Discussion: Dancer's Padding or Reverse Morton's Extensions

​Dear Dr. Blake,

     I am a senior podiatry student. I was just reading one of your blog posts (Sesamoid Fractures: Advice when not healing well) and I have a couple of questions I was hoping you could clarify for me.

     My questions actually have to do more with hallux limitus. I have been trying to understand the difference between offloading the 1st MPJ with a dancer's pad for conditions such as sesamoiditis versus using a reverse mortons extension for a hallux limitus. Essentially they seem to be the same pad? But how could one be offloading and relieving pressure while the other one is increasing plantarflexion of the 1st MPJ (and I assume that would be increasing pressure) to decrease the elevatus?
Dr Blake's comment: Dancer's pads and Reverse Morton's Extensions are one and the same. I would rather give credit to the French who in the 1770s while studying their ballet dancers came up with this unique pad for big toe joint pain. It was the time of the French Revolution, but also the time of this unique pad that was not placed over the sore area, but designed to transfer weight. A truly revolutionary idea!! A dancer's pad should transfer weight from the first metatarsal to the second through 5th metatarsals at push off. When this works, normal push off occurs with the first metatarsal being free to plantarflex for an active push off. When there is too much weight on the first metatarsal (say from over pronation of the foot), then functional jamming and pain can occur as the first metatarsal tries to plantarflex at push off but is being restricted. So, at push off you want normal plantarflexion of the first metatarsal, with normal to slightly less than normal plantar pressures. This can help a pain syndrome produced by that jamming force. And, push off is only one third of stance. Dancer's pads do eliminate a lot of pressure on the first metatarsal during the contact and midstance phases. So, all 3 phases of stance have less pressure on the first metatarsal with a dancer's pad, and active push off should be less restricted and therefore more powerful. Now, a structural met primus elevatus is best helped by a Morton's Extension. It brings the ground up to the first metatarsal and allows it to function normally. A functional met primus elevatus, caused by over pronation, is only elevated by the pronation jamming it upward. It needs arch support to decelerate pronation, shifting the weight in midstance to the middle of the foot, with a dancer's pad to free up the jammed big toe joint. Besides Dr Root, Dr Langer first discussed this concept in the 1980s. Drs Wernick, Langer and Dannenberg introduced the kinetic wedge with first ray cut outs to free up the first metatarsal to achieve wonderful push off. The basic concept was that some arch support, and some first ray freedom, would help the first ray push off. This is achieved in various orthotic modifications. I love adequate over pronation correction from the orthotic device, along with some dancer's pad to give extra freedom. Dancer's pads have been crucial in pain syndromes, and less necessary when there is no pain (although always an option to add). 

Also, If someone has a hallux limitus and a plantar plate tear of the second, would you recommend doing a spica taping to the first and the second toe simultaneously? Your instructional video on Youtube for this is excellent. My mom actually has this issue and I have been trying to research different taping methods since she does not want surgery. I bought her a morton's extension innersole but she also doesn't wear sneakers very often as she is a dancer. She is hypermobile so perhaps using a reverse mortons extension may help the joint align. However, I am worried to add pressure to the sesamoids because she also states she has pain there (hence my confusion on padding). I have included a photo of her foot and x-ray just in case my rambling doesn't make sense.
Dr Blake's comment: Even though you are only a student, you are asking great critical questions. The main treatment for a plantar plate tear is a Budin splint or spica tape to the 2nd/3rd toes (typically buddy tape to share the pressure). Look at the Hapad products. Start with an Extra-Small Longitudinal Medial Arch for the Hallux Limitus to shift weight more central. Add a Budin splint for the 2nd/3rd toes (Single loop opened up for both toes). You can trim the Budin splint plantar padding as much as you like, and you can even add an extra small metatarsal pad to the splint. 
Dr Blake's comment: The xrays point to that long first metatarsal that gets jammed at push off. This is typically initially a functional jamming (functional hallux limitus), which can become osteoarthritis (structural limitus or rigidus). Since you can not load the second met head, you have to support the arch to transfer weight from first to central. 

 She also has a strange lump on the medial 2nd digit. She was told by a podiatrist that it was just bursitis but I am not convinced since it is a hard lump- feels almost like an extension of the medial condyle of the prox phalynx...the x-ray just looks like a bit of increased density in the soft tissue. Have you ever seen something like that before?

Dr Blake's comment: With plantar plate tears, the second toe can start to deviate to the the loss of plantar ligament stability. Here you see the second toe proximal phalanx deviating towards the first toe. She may need that fixed surgically some day. And, today definitely needs to live with a Single loop Budin splint with the loop opened up enough to cover both the second and third toes. I sure hope this helps her and good luck with your career. Rich

I am going to have her start doing the joint mobilization that you recommend in your other blog post.

So sorry for the long e-mail. I really appreciate you taking the time to read this. I am looking forward to your response. 

Best Regards,

Heel Pain: Email Advice

Hi,
Ive got a question I have been seeing a local doctor and he has gave me a series of 3 cortisone shots in the side of my heal no spreading it around just a prick and done. Now he is telling me that he needs to go in and cut the fascia. I am not comfortable about this. Is there any other options???


Limping in Illinois

Dr Blake's comment: 
     Hey Limping, thank you so very much for the email. And, sorry you are limping!! With perhaps less than 1% of all plantar fasciitis cases needing surgery, I look at this with a bit (a lot) of caution. The plantar fascia is the 3rd supporting structure for your arch (after the ligaments and muscles/tendons), and there are cases of arches collapsing following surgical release (very small percentage also). However, that means you should consider plantar fascia release only if all the stones are turned over. Definitely get some other opinions, but do not tell anyone about what this doc wants to do. Only tell them what you have had done that has not worked so far, and what are your options. Cortisone is part of the Immobilization/Anti-Inflammatory Phase where you are trying to achieve that coveted pain free environment (0-2 level pain). While you are getting the shots (or physical therapy, or a home program of icing and contrast bathing and NSAIDs, or a combination of these things), you should be getting protected weight bearing inserts like orthotics. You may need a removable boot like an Anklizer (purchase online), or need to tape every day (www.supportthefoot.com). Until the pain is under control, I would avoid stretching the achilles and plantar fascia since you may have a plantar fascial tear. An MRI would be wonderful to see what is really going on. If you can not get a referral, you can check the AAPSM website for sports medicine podiatrists. It typically is a good source. 
     You may need surgery, but I would step back, get some opinions, and see what people say. I hope this helps you some. Rich

Recent Sesamoid Fracture: Email Advice

Greetings Dr. Blake,

First off, your blog is amazing! I learned more here about treating my tibial sesamoid fracture than I have any other sources combined together. My question is primarily regarding getting the proper treatment and when it's time to seek a 2nd opinion. I fractured my tibial sesamoid back in January of this year. I'm not one to rush to the doctor, so I waited 5 weeks from when the pain started to get treatment. The DPM I went to took X-rays that clearly showed an acute fracture of the tibial sesamoid resulting in a bipartite sesamoid. He said that the bones may never unify, however most cases heal with a fibrous union between the fractured pieces. He put me in a cam boot and sent me on my way with instructions to come back in 6 weeks. He also said to ice 3 times daily and take ibuprofen for pain.  I’m on week  5.  At week 3 I had really bad heel pain due to the boot and added a gel insole. That greatly helped the heel pain. Once that calmed down, I realized that I still had light pressure on my sesamoids. I did a sesamoid accommodation myself and that’s help alleviate the pressure on the sesamoids while wearing the boot.
Dr Blake's comment: Bravo!!!!!!!

Since the boot is almost impossible to sleep in, I was sleeping barefoot and was waking up in a lot of pain. I had a muscle spasm that jerked my big toe one night and was in a lot of pain after that. I dug more into your blog and learned to spica tape. That’s allowed me to sleep and shower much better.  I only walk outside the boot for just a few steps on the side of my foot to get to the bathroom that’s right outside my bedroom. I can do that pain free for the most part. Do toe jerks and things like that re-break the bone if fibrous tissue is trying to grow?
Dr Blake's comment: No, you could not generate enough force to re-break the bone or the fibrosis junction.

How easy is it to re-fracture and set back the healing?
Dr Blake's comment: It is very hard to re-break after about 6 weeks in the cam walker, when most of the consolidation occurs. However, after 6 weeks, there is the worry about avascularization of the bone with boney fragmentation. That is why I push when possible for daily contrast bathing, Exogen Bone Stimulators, pain free environments (0-2 pain level), weight bearing to tolerance, good diet with calcium and Vit D3, and icing when aggravated, for about 6 months. 

I am taking calcium and vitamin D3.

My 6 week appointment is next week. I don’t know if he’ll want to keep me in the boot another 6 weeks for a total of 3 months in the boot, or if he’ll try to wean me out of the boot. I’ll need help getting a good insert for my shoes with a sesamoid cutout for that to be the case. Should he be doing this with me in the office?
Dr Blake's comment: I am so impressed by your knowledge and questions. Orthotics can be done by a doctor, physical therapist, pedorthist, running shoe store. Ask your doctor where to get the right insert that off weights the sesamoid appropriately. It is crucial to begin a successful wean out of the boot, and can take several weeks to make, and several visits to adjust. 

What if he recommends custom orthotics? I hear about as much bad about custom orthotics as I do good. Seeing as I feel he didn’t give me the type of useful information I’ve found through your blog to really allow me to be mostly pain free there’s a question of trust which is making me leary of going through the time and expense of getting custom orthotics and they not working due to his office just not seeing many of these cases. I don't want to be rude and question him, but I want to be sure I'm getting the treatment I need.
Dr Blake's comment: Time is never enough in a medical office, it is one of the personal reasons I started my blog for my patients, because I do not have enough time either to talk about everything. So, if he did not discuss everything, it was because the Immobilization phase is a relatively simple phase without the need to go over everything. Custom orthotics are my life, I see the unbelievable changes they can make in someone's life, but I sure do not understand everything about them. The secret to every part of your rehabilitation is in execution of the subtleties. Any doctor is good with some things, and okay or poor with others. Medicine is too complex. I have no idea about your doc, but I would not be worried at this stage. Just ask good questions, without putting a wall between the two of you. He may need to send you to a place that really specializes in orthotics, or for any aspect of the treatment. Does this sort of make sense?

How do I know for sure that if he tells me to wean out of the boot that it’s really time? I still have pain and swelling. In normal healing how long is dealing with a lot of swelling normal?
Dr Blake's comment: Golden Rule of Foot: Keep the Pain Level between 0-2 and you will know you are maintaining a Healing Environment. So, Listen to your Body. And swelling can be part of the overall healing for the next year, and you should continue to work with it with icing and contrasts bathing, while paying attention to the pain level utmost. 

No MRI was done initially. I have a $3000 deductible, so we’re being a bit conservative before really getting into high-cost items like MRI scans and bone stimulators. Having said that, I want to get this healed.  Can you help me with some indicators of judging healing progress as well as what my DPM should be doing at this stage that might let me know if he’s on the right track or if it’s time to seek a 2nd opinion?  What if he does X-rays and the bones are further apart? Does that mean the fibrous tissue will never grow to unify the fracture and that surgery is the only option? If I was your patient, what would you recommend be done? When's it time to start a bone stimulator? Most insurances wants to wait 3 months from what I'm hearing.
Dr Blake's comment: The following is my protocol if I was to take over your treatment right now:
  • Not rely on x-rays at all, they are visually way behind the healing, and usually cloud the judgement rushing patients into surgery. But, not a reason to give up on a doc if this is what they are used to relying on.
  • Ask the patient to self pay for an Forefoot MRI without contrast at some imaging center (typically $500 or so). It may be a crucial baseline in 3-6 months down the line. 
  • Keep the patient in the cam walker for 3 total months (initial plan), and actively design inserts with dancer's pads and some arch support to off weight the sesamoid. It can be that by 8 weeks with the right off weighting insert, the weaning process can begin early.
  • Request 2 times daily ice pack 10-15 minutes, and evening contrast bathing to control inflammation and flush out bone swelling.
  • Make sure diet, calcium, Vit D3 are good. Consider Vit D3 blood test. 
  • Make sure patient is getting core, cardio, and lower extremity strength and flexibility work close to daily.
  • See if you can self pay for Exogen. If not, it is a judgement for the patient to wait and get another x ray 3 months from the first x ray documenting the delay healing for the insurance company. 
  • Have the patient learn how to spica tape (takes a few times to get good at it)
  • Look at their shoes and perhaps replace (how is the padding, flexibility, heel height, etc). It is at least good for the patients to look at Hoka One One, New Balance 928, carbon graphite plates from Otto Beck, etc.

Thanks for your time, I sincerely hope you can help guide me with an opinion of how to proceed.

Big Toe Joint Pain: Email Advice



Hi Dr Blake,


I've been a reader of your blog for a while now, just wanted to
thank you for putting all of this info out there, it is extremely
helpful.

So I'm hoping to get some feedback about a recent toe injury. About me:
I've been an avid tennis player for a few years (play 3-4 times a week)
and am currently 38.  

About 2 weeks ago, I noticed that after playing my left big toe felt a 
little tender, but the next day the tenderness was gone.  Then a few days 
later I played again and this time after playing this feeling came back 
but was worse, in addition to feeling tender now I noticed that there 
was some swelling/aching. When I pushed off on the left foot it was 
even a little painful. Not acute, just sort of a dull ache feeling.  Well 
this time the swelling didn't go away.  So I scheduled an appointment 
with my doctor (podiatrist) and he did some poking and prodding and 
said it seemed ok, that I should just rest. He even took some x-rays 
(from the top of the foot) and said nothing was broken, that the sesamoids 
were fine and the joint looked good, that I should just rest.

So for the past 1.5 weeks I haven't played tennis, I've just done swimming
and biking (biking I put the middle of my foot on the pedal so most of
the weight is near my arch).  I've also been icing 2-3 times a day and
really trying to immobilize the joint. The problem, is that the swelling /
tender feeling hasn't subsided. Not at all.  I especially notice an issue
when I put weight on the ball of my foot, it's not painful, but it feels
really tender.  It is even more obvious if I go up on my toes.  My toe
joint doesn't feel stiff, there is no bruising and I appear to have full
range of motion.  If I sit down and move the toe up and down without 
weight on it, no pain at all.

So given these symptoms, do you have any hunches about what the issue
might be?  Aside from continuing to ice and keep the joint immobile, is
there anything else I can do?  (I'm spica taping but that doesn't seem
to help much).

Regards,

Dr Blake's comment:
     Thank you so very much for your email. X-rays are poor indicators of anything serious within the joint, but it was the most appropriate test to do at that stage. You did well to get in to see someone so early. I love the 3 day rule: If pain does not go away after 3 days, you have to do something to try to change the course of the injury. Remember icing only controls swelling, never really gets rid of it. I love 2 times a day of 10 minute ice pack, but at least one time a day of straight contrast bathing to flush the tissue. 


You have to assume that you have a stress fracture because of the potential of overuse playing hard tennis 3-4 times a week, and how quickly this went from no pain to a lot of pain. Definitely check your shoes and make sure they are not worn out. Check the inserts in the shoes and see if there are holes in the area of pain. See if you can design a "dancer's pad" to take pressure off the area, probably will need it on both sides for balance as you start to go back to tennis. 


At this point in the injury typically more x-rays will not help. An MRI is normally recommended if 2-3 weeks pass with little or no improvement. Of course, if you were a Golden State Warrior, you probably would have already had 2 MRIs. So, if you are anxious, you can request it now. You can also treat the injury as a stress fracture, typically requiring a minimum of 6 weeks in an Anklizer Removable boot  (can be purchased online) with an accommodation for the big toe joint. 


So, make sure you are getting the calcium and Vit D3 you need. Avoid NSAIDs and cortisone shots if possible, since they can slow down bone healing. If you do not have custom orthotics, you may want to consider them to off weight the big toe joint, although some OTC inserts can be customized to do the same thing. 

I sure hope this helps point you in the right direction. It is never bad while you wait on a diagnosis (which you do not have), to continue to create a pain free (0-2 level pain) environment for proper healing whatever it takes. You are doing the correct thing with the bike pedal adjustment. Sometimes, you only need the boot for work when you do not want to think about it, and tennis shoes with dancer's pads for after work. Good luck, Rich





Thursday, March 26, 2015

Heel Pain/Plantar Fasciitis: Email Advice

I came across your website trying to find any other options for the heel pain / fasciitis that I may have. I am from Tennessee. My problems have been going on for 2 years. Both feet.

 About 3 months ago the right heel pain resolved. The left has not. I am seeing my second podiatrist. I have the custom hard inserts I keep in my shoes.
Dr Blake's comment: This is the time to critically evaluate each treatment avenue/modality and possibly make changes. The orthotic goal for patients with heel pain is to transfer the weight into the arch and cushion/float the heel. Do you feel this is being accomplished? If not, see if they can be altered or remade. This is called protective weight bearing and every step you take can be used to make the heel better if done right. 

 I have had my heel injection 3 times by the second podiatrist this year. Helps some but seems to "wear" off and return to pain. 2 times the year before with absolutely no relief which is why it took me a year to finally go again. 
Dr Blake's comment: Cortisone shots can be crucial if there is heel bursitis, but it is a mixed bag with plantar fasciitis. You really do not want to inject the plantar fascia itself, so you have to inject under it (and gravity actually pulls the cortisone away from the fascia) limiting its effectiveness. 

Wears a night splint but not all time because I didn't feel like it was making a difference.
Dr Blake's comment: If you have the classic morning soreness from from plantar fasciitis, the night splints should do wonders if the plantar fascia is tight. When there is minimal results with the night splint, you either do not have plantar fasciitis, your fascia is just not tight, or it is the wrong type of splint (I like the ones where the heel is enclosed and the toes are not bent up). 

 Can't take antiinflammatory long. They hurt my stomach.
Dr Blake's comment: You can use celebrex which is milder on the stomach with or without cytotec. Or, you can use topical Voltaren 1.3% gel or flector patches. Any anti-inflammatory drug, no matter the application, should be done on a 5 day on 2 day off routine, or 10 day on 4 day off routine, to rest the body and prevent some of the side-effects. You typically have to ice more on the days you are not using the medication. 

 Oral steroids may help a little but I know I cant always take them.
Dr Blake's comment: I love an 8 day Prednisone burst to knock out inflammation. See my blog post on that. It is especially good in chronic situations, or acute flares. But, it can also be very diagnostic when it works or does not work. It is for inflammation, but does not help the mechanical or neuropathic aspects of the pain. 

 Have been in a walking boot for 6 weeks. That didn't help any.
Dr Blake's comment: This is where I would need more info. When you were in the boot, were you 100% pain free. Plantar fasciitis feels great in the boot, plantar heel bursitis may hurt more in the boot. The problem with boots and heel pain is that your heel stays down longer than normal walking, thus increasing the normal pressure on the heel. But, the boots allow you to roll through, not bending the toes at push off, and thus not irritating the plantar fascia. I guess you can see that success or failure with any of these treatments can help us fine tune what is going on and how to fix it. 

 Have used heel cups. Good shoes that are known for stability. Have heel Spurs to both feet. But as a nurse practitioner I understand it is not the spur itself causing the pain. I have wore straps around my ankles that allowed me to strap my foot.
Dr Blake's comment: Does the strapping help? Typically works well with plantar fasciitis. And yes, the spur does not cause pain!!! 

  I do work 6 days a week for the most part with one to two of those days 12 hours.
Dr Blake's comment: I do not have to tell you that working that much can decrease your immune system's ability to heal. Have you had a workup on your ability to heal? Are there other problems that have been slow at healing? Are you always fatigued or have other systemic signs/symptoms?

 I am so frustrated that I cannot make this resolve and wondered if you might have any suggestions on what to do. I would love to be able to walk from the time that I get up til bedtime with no pain. I want to be able to walk run and I cannot. My feet get so sore and it is difficult to walk. Once I get walking it will settle some but will be even worse when I sit or sleep. I am suppose to visit the podiatrist again Monday to consider a 4th injection. Thank you again for any comments you may can give
Dr Blake's comment: I would suggest no more shots until you get an MRI. You could have a slight tear in the plantar fascia that cortisone can make worse. Even if you have to self pay for a Rearfoot MRI without contrast, it would be worth it. Hope this helps you in some way. 

Helen (name changed)
Tennessee

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